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 C
Explanation
Choice A reason: Selective inattention occurs in moderate anxiety, where the client begins to block out or ignore certain stimuli due to difficulty focusing. It is not characteristic of mild anxiety, where awareness is still intact.
Choice B reason: Urinary frequency is a physical manifestation of severe anxiety due to autonomic nervous system activation. It is not expected in mild anxiety.
Choice C reason: Sharpened perceptions are characteristic of mild anxiety. The client is more alert, attentive, and able to focus better on the environment. Mild anxiety can enhance problem-solving and concentration.
Choice D reason: Voice tremors are associated with moderate to severe anxiety, where physiological symptoms become more pronounced. They are not typical of mild anxiety.
Correct Answer is B
Explanation
Choice A reason: Telling the client to stop the behavior and dismissing their fear is non-therapeutic. It invalidates the client’s feelings and does not encourage communication.
Choice B reason: Acknowledging the difficulty of the client’s compulsion and inviting them to talk about their feelings is therapeutic. It validates their experience, reduces anxiety, and opens the door for supportive dialogue. This is the correct response.
Choice C reason: Suggesting the client is seeking attention is judgmental and non-therapeutic. It undermines trust and may increase agitation.
Choice D reason: While recognizing the client’s need to expend energy is partially supportive, shifting the focus to anger does not address the client’s expressed fear. It risks misinterpreting the client’s concern and does not directly validate their anxiety.
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