A nurse assesses a 70-year-old patient’s recent memory. Which would the nurse ask the patient to recall?

Can you name the past four presidents?

What are the names of your children?

Please tell me your mother’s maiden name

What did you have for breakfast this morning?

Answer and Explanation

The Correct Answer is D

Choice A reason: Naming the past four presidents tests remote memory, as it involves recalling historical facts learned years ago. Recent memory involves events from hours or days, so this question does not assess the patient’s short-term memory capacity effectively.

Choice B reason: Recalling children’s names typically involves long-term memory, as these are familiar, well-established facts. While personal, this information is not recent and does not evaluate the patient’s ability to retain new information, making it unsuitable for recent memory assessment.

Choice C reason: A mother’s maiden name is a long-term memory fact, often memorized years ago. It does not test recent memory, which focuses on newly acquired information, making this question inappropriate for assessing short-term memory in the elderly patient.

Choice D reason: Asking about breakfast this morning tests recent memory, as it involves recalling an event from hours ago. This is ideal for assessing short-term memory function in older adults, as it evaluates the ability to retain and recall new information accurately.

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Correct Answer is C

Explanation

Choice A reason: Intelligence cannot be assessed in a 3-month-old, as cognitive abilities are not yet developed enough for evaluation. Sucking and grasping are innate behaviors driven by reflexes, not conscious thought, making this an incorrect assessment focus.

Choice B reason: Cerebral cortex function is immature in a 3-month-old, and sucking and grasping are primarily brainstem-mediated reflexes. These actions do not directly assess higher cortical functions like memory or reasoning, making this an incorrect choice.

Choice C reason: Sucking and grasping in a 3-month-old are primitive reflexes (sucking reflex and palmar grasp reflex), mediated by the brainstem. Assessing these evaluates normal neurological development, making this the correct focus of the nurse’s inquiry.

Choice D reason: While sucking involves Cranial Nerves V, VII, IX, and XII, and grasping involves spinal reflexes, the nurse is assessing the presence of these reflexes, not the cranial nerves directly. Reflex assessment is the primary focus, making this less precise.

A. Appendix B. Spleen C. Gallbladder D. Spine

Correct Answer is A

Explanation

Choice A reason: Tenderness in the right lower quadrant on light palpation is a classic sign of appendicitis, as the appendix is located in this region. Inflammation causes localized peritoneal irritation, leading to pain, which may be accompanied by rebound tenderness or guarding, making this the correct structure.

Choice B reason: The spleen is located in the left upper quadrant, not the right lower quadrant. Tenderness in the right lower quadrant does not correspond to splenic pathology, such as splenomegaly or rupture, making this an incorrect structure for the described finding.

Choice C reason: The gallbladder is in the right upper quadrant, where tenderness might suggest cholecystitis. Right lower quadrant tenderness does not align with gallbladder pathology, as its anatomical location is distinct, making this an incorrect structure for the observed symptom.

Choice D reason: The spine is a midline structure, and tenderness in the right lower quadrant is unrelated to spinal pathology. Spinal issues typically cause back or radicular pain, not localized abdominal tenderness, making this an incorrect choice for the finding.

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A nurse assesses a 70-year-old patient’s recent memory. Which would the nurse ask the patient to recall?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While obtaining a health history of a 3-month-old infant from the mother, the nurse asks about the infant’s ability to suck and grasp the mother’s finger. What is the nurse assessing?

Correct Answer is C

Explanation

During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse recognizes this finding could indicate a problem with what structure?

Correct Answer is A

Explanation

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