The nurse is assessing orientation in a 79-year-old patient.
Which of these responses would lead the nurse to conclude that this patient is oriented?
"I know that my name is John. I am at the hospital in Evergreen. I cannot tell you what date it is, but I know that it is April 2025.”.
"I know my name is John. I cannot tell you where I am. I think it is 2010.”.
"I know that my name is John, but to tell you the truth, I get kind of confused about the date.”.
"I know that my name is John; I guess I'm at the hospital in Evergreen. No, I do not know the date.”.
The Correct Answer is A
Choice A rationale
Orientation to person, place, and time is a fundamental component of cognitive assessment, indicating intact neurological function. Knowing one's full name demonstrates personal orientation. Recognizing the hospital and its location signifies place orientation. Providing the correct month and year, even without the exact day, suggests a reasonable grasp of temporal orientation, reflecting adequate higher cortical processing.
Choice B rationale
The inability to state one's location and an incorrect year indicate significant deficits in both place and time orientation. This suggests impaired cognitive function, potentially due to delirium, dementia, or other neurological issues affecting memory and executive functions. Such a response would warrant further comprehensive cognitive evaluation.
Choice C rationale
While knowing one's name indicates personal orientation, confusion about the date points to a deficit in time orientation. This partial disorientation suggests some level of cognitive impairment, necessitating further assessment to determine the underlying cause and extent of the confusion.
Choice D rationale
Hesitation regarding location and complete inability to state the date demonstrate significant disorientation to both place and time. This pattern of response is indicative of impaired cognitive function and necessitates a thorough neurological and cognitive workup to identify potential etiologies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The posterior tibial pulse is located in the groove between the medial malleolus (inner ankle bone) and the Achilles tendon. Palpating this pulse requires a gentle but firm touch to identify the arterial pulsations. It is a common site for assessing peripheral circulation and is essential for evaluating lower extremity perfusion.
Choice B rationale
The inguinal area is the anatomical region of the groin, where the femoral pulse is located. The femoral pulse is palpable just below the inguinal ligament, midway between the anterior superior iliac spine and the pubic symphysis. This is a central pulse site, distinct from the posterior tibial pulse.
Choice C rationale
The top of the foot is where the dorsalis pedis pulse is located. This pulse is found lateral to the extensor hallucis longus tendon, over the metatarsal bones. It is another important site for assessing lower extremity perfusion but is different from the posterior tibial pulse.
Choice D rationale
Behind the knee is the location for palpating the popliteal pulse. This pulse is more difficult to assess due to its deep location within the popliteal fossa. It requires the patient's knee to be slightly flexed to relax the muscles and facilitate palpation.
Correct Answer is A
Explanation
Choice A rationale
A bruit is an abnormal vascular sound, typically a loud, whooshing, or blowing murmur, caused by turbulent blood flow through a narrowed or partially obstructed artery. It is best auscultated with the bell of the stethoscope, which is more effective at detecting low-pitched sounds due to its larger surface area and ability to transmit vibrations from a broader area of contact. The turbulence creates vibratory patterns indicative of compromised blood flow.
Choice B rationale
A high-pitched tinkling sound is not characteristic of a bruit and is more commonly associated with bowel sounds in cases of intestinal obstruction, indicating fluid and gas movement within the bowel. The diaphragm of the stethoscope is indeed used for high-pitched sounds, but this specific sound quality does not align with the pathophysiology of a vascular bruit.
Choice C rationale
A soft, trickling, pulsatile sound does not describe a bruit. While pulsatile, the "soft, trickling" quality suggests a very low-flow state or venous hum rather than the turbulent arterial flow responsible for a true bruit. The bell is appropriate for low-pitched sounds, but the character of the sound is inconsistent with a bruit.
Choice D rationale
A low gurgling sound is generally associated with gastrointestinal motility, such as normal bowel sounds, and is not indicative of a vascular bruit. While low-pitched sounds can be detected with the bell, the diaphragm is used for higher-pitched sounds, and the "gurgling" description is inappropriate for arterial turbulence.
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