A nurse is performing a mental status examination of a client. Which of the following questions should the nurse ask the client to assess their cognition?
"What did you have for dinner last night?"
"Do you hear voices speaking to you?"
"Do you ever think about harming yourself?"
"What do you do to relieve stress?"
The Correct Answer is A
Choice A reason:
This question assesses recent memory, which is a key component of cognition. Cognition includes orientation, attention, memory, language, and executive functioning. Asking about recent events helps the nurse evaluate the client’s ability to recall information and process experiences accurately.
Choice B reason:
This question assesses perception, specifically the presence of auditory hallucinations. Hallucinations are related to thought content and sensory perception rather than cognition, making this option incorrect.
Choice C reason:
This question assesses suicide risk and thought content. While critically important for safety, it does not evaluate cognitive functioning such as memory, attention, or orientation.
Choice D reason:
This question assesses coping mechanisms and stress management strategies. It provides insight into behavior and emotional regulation, not cognition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Sleeping only 4 hours is common during mania and contributes to exhaustion, but it is not immediately life-threatening.
Choice B reason: Refusing to shower reflects poor self-care, which is expected in mania, but it does not pose an acute medical risk.
Choice C reason: Eating half a snack shows reduced intake but is not as urgent as fluid refusal.
Choice D reason: Refusing fluids is the priority because dehydration can quickly lead to severe complications such as electrolyte imbalance, cardiac dysrhythmias, and renal impairment. This requires immediate intervention.
Correct Answer is D
Explanation
Choice A reason: Referring the client to the provider dismisses the client’s immediate concern and does not foster therapeutic communication. While providers can give medical details, the nurse’s role is to explore feelings and provide support. This response blocks communication.
Choice B reason: Telling the client not to worry minimizes their concern and invalidates their feelings. Clients with anorexia nervosa often have significant anxiety about their health and body image. This response is non-therapeutic and does not encourage further discussion.
Choice C reason: Asking “Why” questions can make the client feel defensive and pressured to justify their feelings. Therapeutic communication avoids “Why” phrasing because it can hinder open dialogue.
Choice D reason: Reflecting the client’s concern by restating it in a supportive way acknowledges their fear and invites them to elaborate. This therapeutic response validates the client’s feelings and opens the door for further discussion about their health and emotional state.
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