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

Answer and Explanation

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.

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Correct Answer is ["B","C","D"]

Explanation

A. "Are you able to feed yourself?": This question relates to basic activities of daily living (ADLs), not instrumental activities of daily living (IADLs).

B. "Do you do your own laundry?": This question assesses the ability to perform IADLs, which include tasks like laundry, managing household chores, and other tasks beyond basic self-care.

C. "Do you shop for groceries?": This question evaluates the client’s ability to perform IADLs, such as shopping for groceries.

D. "Do you manage your own money?": This question is also relevant for assessing IADLs, which include financial management.

A. VII B. XII C. V D. II

Correct Answer is A

Explanation

A. VII: The Facial nerve (VII) is responsible for taste sensation in the anterior two-thirds of the tongue. An inability to taste in this area indicates a dysfunction in this nerve.

B. XII: The Hypoglossal nerve (XII) controls tongue movements but does not involve taste sensation.

C. V: The Trigeminal nerve (V) provides sensation to the face and mouth but is not responsible for taste.

D. II: The Optic nerve (II) is involved in vision, not taste.

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Naxlex Comprehensive Predictor Exams

During a health history, which of the following can the nurse ask to determine an older adult client's abilities to conduct instrumental activities of daily living? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

A patient is unable to taste in the 2/3 anterior of his tongue. Which cranial nerve is affected?

Correct Answer is A

Explanation

Cranial nerves involved in eye movements are:

When assessing for appendicitis, what signs might the nurse look for? (Select all that apply.)

During the cardiac cycle, heart sounds correlate with events of the cycle. Which is being associated with systole?

The nurse suspects an older adult client has congestive heart failure. Which of the following did the nurse most likely assess in the client?

Data collection occurs where in the nursing process?

The nurse is conducting a health history with a female client who reports upper back and jaw pain. In order to assess the client's risk for a cardiac event, which question should the nurse ask first?

During a physical assessment, the nurse should implement which actions initially when determining if a client's radial pulse is irregular? (Select all that apply.)

When planning care for a client with an inner ear infection, the nurse will need to include interventions for which of the following potential problems?