A nurse is conducting a mental status examination on a client who has been admitted for psychiatric evaluation.

Which question should the nurse ask to assess the client's orientation?

"What is your name and date of birth?"

"Do you know where you are and why you are here?"

"What day of the week and month of the year is it?"

"Do you have any thoughts of harming yourself or others?"

Answer and Explanation

The Correct Answer is C

"What day of the week and month of the year is it?"

Rationale: Orientation is the awareness of one's personal identity, location, and time. Asking the client what day of the week and month of the year it is can help to assess the client's orientation to time.

Incorrect options:

A) "What is your name and date of birth?" - This question can help to assess the client's orientation to person, but not to location or time.

B) "Do you know where you are and why you are here?" - This question can help to assess the client's orientation to place, but not to person or time.

D) "Do you have any thoughts of harming yourself or others?" - This question can help to assess the client's suicidal or homicidal ideation, but not their orientation.

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Correct Answer is C

Explanation

Blood pressure of 90/60 mmHg

Rationale: A blood pressure of 90/60 mmHg indicates hypotension, which is a sign of septic shock and requires immediate intervention. Hypotension results from vasodilation and fluid loss due to the systemic inflammatory response to infection.

Incorrect options:

A) Temperature of 38.5°C (101.3°F) - This is a sign of fever, which is a common symptom of sepsis, but not as urgent as hypotension.

B) Heart rate of 110 beats per minute - This is a sign of tachycardia, which is a compensatory mechanism to maintain cardiac output in sepsis, but not as urgent as hypotension.

D) Respiratory rate of 22 breaths per minute - This is within the normal range for adults and does not indicate respiratory distress.

A. A brown mole with a smooth border and symmetrical shape B. A red macule with a flat surface and well-defined edges C. A black nodule with an irregular border and asymmetrical shape D. A yellow papule with a raised surface and round edges

Correct Answer is C

Explanation

A black nodule with an irregular border and asymmetrical shape

Rationale: A black nodule with an irregular border and asymmetrical shape is consistent with the ABCDE criteria for melanoma, which are: Asymmetry, Border irregularity, Color variation, Diameter greater than 6 mm, and Evolving or changing appearance.

Incorrect options:

A) A brown mole with a smooth border and symmetrical shape - This is a normal finding that does not indicate malignancy.

B) A red macule with a flat surface and well-defined edges - This is likely a benign vascular lesion, such as a cherry angioma or petechiae.

D) A yellow papule with a raised surface and round edges - This is likely a benign sebaceous lesion, such as a sebaceous cyst or milia.

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A nurse is conducting a mental status examination on a client who has been admitted for psychiatric evaluation. Which question should the nurse ask to assess the client's orientation?

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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A nurse is conducting a mental status examination on a client who has been admitted for psychiatric evaluation.

Which question should the nurse ask to assess the client's orientation?