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 ["68"]
Explanation
Step 1 is: Add the ordered units of Humulin NPH and Humulin R insulin.
Step 2 is: 52 units + 16 units = 68 units. Answer: The nurse will administer 68 units. (Shade SYRINGE #3 to the 68-unit mark).
Correct Answer is ["75"]
Explanation
Step 1 is 1.5 L × 1000 mL/L = 1500 mL.
Step 2 is 1500 mL ÷ 20 hours = 75 mL/hour.
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