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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Ethmoid: The ethmoid sinuses are located between the eyes and are not typically accessible for palpation during a physical examination. Instead, tenderness in this area is assessed through inspection and indirect methods rather than direct palpation.
B. Maxillary: The maxillary sinuses are located in the cheeks and are accessible for palpation. The nurse can assess for tenderness or swelling in this area, which can indicate sinusitis or infection. Palpating the maxillary sinuses is a standard part of the examination for patients with cold and sinus pain.
C. Mastoid: The mastoid process is located behind the ear and contains air cells, but it is not directly involved in sinus pain associated with cold symptoms. While mastoid tenderness may indicate a different type of infection (such as mastoiditis), it is not part of the sinus assessment.
D. Sphenoid: The sphenoid sinuses are located deep within the skull, behind the nasal cavity, and are not accessible for palpation during a physical examination. Any issues with the sphenoid sinuses would typically be assessed through imaging studies rather than physical palpation.
Correct Answer is ["B","C","E","F"]
Explanation
A. Forlani: No known clinical test named "Forlani" is used to assess the acoustic nerve (cranial nerve VIII). Standard assessments for hearing and vestibular function do not include this test, making this an incorrect option.
B. Rinne: The Rinne test evaluates conductive versus sensorineural hearing loss by comparing air conduction and bone conduction using a tuning fork. Normally, air conduction should be greater than bone conduction, but in conductive hearing loss, bone conduction is either equal to or greater than air conduction. It helps assess cranial nerve VIII function and differentiate between middle and inner ear pathology.
C. Weber: The Weber test is another tuning fork test used to differentiate between conductive and sensorineural hearing loss. The tuning fork is placed on the midline of the forehead, and sound should be heard equally in both ears. If sound lateralizes to one ear, it suggests conductive hearing loss in that ear or sensorineural loss in the opposite ear, aiding in the evaluation of cranial nerve VIII.
D. Kinecki: No known clinical test named "Kinecki" is used to assess the acoustic nerve. The main tests for hearing assessment involve tuning forks, spoken-word tests, and audiometry, none of which include a test by this name, making this option incorrect.
E. Whisper Test: The Whisper Test is a simple screening method to assess hearing by whispering words or numbers behind the patient and having them repeat what was heard. This test evaluates the function of cranial nerve VIII by determining whether the patient can perceive soft sounds at a standard distance, providing a quick but effective measure of hearing acuity.
F. Audiogram (formal hearing test): An audiogram is a comprehensive, formal test that measures hearing ability at different frequencies and intensities. It provides detailed information about sensorineural and conductive hearing loss by assessing how well different pitches and volumes are detected, making it one of the most accurate methods for evaluating cranial nerve VIII function.
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