A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination. What should the nurse expect during this patient's tests of cognitive function?

May show evidence of some clouding of his level of consciousness.

Will be oriented to place and person, but the patient may not be certain of the date.

Disruptive behavior

Will state, "I am so relieved to be out of intensive care."

Answer and Explanation

The Correct Answer is B

A. May show evidence of some clouding of his level of consciousness: While patients who have been in intensive care for an extended period may experience some clouding of consciousness or altered mental status, it is not a universal finding. This option implies a more significant alteration in consciousness than typically expected in a patient transitioning to a medical-surgical unit.

B. Will be oriented to place and person, but the patient may not be certain of the date: This is a common expectation for patients who have been in an intensive care setting for a prolonged period. They may maintain orientation to person and place due to their familiarity with the environment and staff, but they might have difficulty recalling the date due to the stress of hospitalization and changes in routine.

C. Disruptive behavior: While some patients may exhibit changes in behavior after a long stay in intensive care, it is not a standard expectation. Many patients may be more subdued and fatigued rather than disruptive.

D. Will state, "I am so relieved to be out of intensive care": While this response might occur, it is not guaranteed. Patients may have mixed emotions about their transition from intensive care, including anxiety or confusion. Therefore, this statement is not a definitive expectation during the mental status examination.

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Correct Answer is C

Explanation

A. Bell palsy: Bell palsy is characterized by sudden, unilateral facial weakness or paralysis, usually affecting one side of the face. While it can impact sensation, the inability to differentiate between sharp and dull stimuli on both sides of the face suggests a more systemic issue rather than just Bell palsy.

B. Scleroderma: Scleroderma is a systemic autoimmune disease that affects connective tissue, leading to skin thickening and changes in blood flow. While it can cause skin changes and discomfort, it does not specifically result in the loss of the ability to differentiate sharp and dull sensations in a localized manner.

C. Damage to the trigeminal nerves: The trigeminal nerve (cranial nerve V) is responsible for sensory perception in the face, including the ability to differentiate between sharp and dull sensations. Damage to this nerve can lead to loss of sensation or altered sensation in the facial region. The bilateral nature of the symptoms suggests a central or systemic cause affecting the trigeminal pathways.

D. Frostbite with resultant paresthesia to the cheeks: Frostbite typically causes localized tissue damage and would more likely present with symptoms specific to the affected areas, such as numbness, discoloration, or blistering. While frostbite can lead to sensory changes, it would not typically result in a generalized inability to differentiate sensations on both sides of the face.

A. Whisper a set of random numbers and letters, and then ask the patient to repeat them. B. Shield the lips so that the sound is muffled. C. Stand approximately 6 feet away to ensure that the patient can really hear at this distance. D. Ask the patient to place his or her finger in their ears to occlude outside noise.

Correct Answer is A

Explanation

A. Whisper a set of random numbers and letters, and then ask the patient to repeat them: The whispered voice test is a simple and reliable screening method for hearing loss. The nurse stands about 2 feet behind the patient, whispers a series of random numbers or letters, and asks the patient to repeat them. This helps assess high-frequency hearing loss.

B. Shield the lips so that the sound is muffled: While the test is performed without the patient seeing the nurse’s lips to prevent lip reading, deliberately muffling the sound is unnecessary and may alter the accuracy of the assessment.

C. Stand approximately 6 feet away to ensure that the patient can really hear at this distance: The whispered voice test is conducted at a standard distance of about 2 feet, not 6 feet. Increasing the distance may make the test unreliable.

D. Ask the patient to place his or her finger in their ears to occlude outside noise: The test should be performed in a quiet environment, but instructing the patient to occlude their ears is unnecessary. Instead, the nurse tests one ear at a time by covering the opposite ear.

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A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination. What should the nurse expect during this patient's tests of cognitive function?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. What does the nurse suspect?

Correct Answer is C

Explanation

In performing a voice test to assess hearing, which of these actions would the nurse perform?

Correct Answer is A

Explanation

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