As the nurse assesses vital signs, he notices the client is shaking. The nurse notes a change in the client's tone and in a loud voice the hospitalized client insists, "You're not my wife. How did you get into my house?" Based upon the client's behavior, which assessment will the nurse now focus upon?
Mental
Physical
Spiritual
Interpersonal
The Correct Answer is A
A. Mental: The client's disorientation and altered perception suggest a need for a mental health assessment to evaluate cognitive function, potential delirium, or other psychiatric conditions.
B. Physical: While the client's shaking is noted, the primary concern in this scenario is the client's altered mental state, rather than physical health alone.
C. Spiritual: The client's behavior does not directly indicate a need for a spiritual assessment.
D. Interpersonal: Although the client’s behavior may impact interpersonal interactions, the immediate need is to assess the mental status due to the confusion and altered perception.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Tuning fork: A tuning fork is used in auditory assessments, such as hearing tests, to evaluate hearing loss and bone conduction.
B. Stethoscope: While a stethoscope is essential for auscultation of heart and lung sounds, it is not used for examining the ears.
C. Ophthalmoscope: An ophthalmoscope is used for examining the eyes, not the ears.
D. Tongue depressor: A tongue depressor is used for examining the mouth and throat, not the ears.
Correct Answer is B
Explanation
A. Focused: A focused assessment targets specific concerns or symptoms rather than including a complete health history and physical examination.
B. Comprehensive: A comprehensive assessment includes both a detailed health history and a thorough physical assessment, providing a complete picture of the patient’s health.
C. Ongoing: Ongoing assessments are periodic evaluations to monitor changes or progress in a patient’s condition, not necessarily encompassing a full health history and physical examination.
D. Emergency: Emergency assessments are conducted quickly to address immediate life-threatening issues, not to gather a full health history or perform a comprehensive physical exam.
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