To assess for cranial nerve XI, we would instruct the client to:

Choice A reason: Pain rating is considered a subjective vital sign, assessed via patient self-reporting, often on a 0-10 scale. It reflects neurological and emotional status, guiding pain management. Including it as a vital sign is a valid clinical practice, making this choice a correct use.

Choice B reason: In less stable clients, vital signs should be checked more frequently than once daily, often every few hours, to monitor deteriorating conditions like sepsis or shock. This statement inaccurately suggests infrequent monitoring, which is not a standard use of vital signs, making it the correct answer.

Choice C reason: Vital signs assess circulatory (blood pressure, pulse), respiratory (respirations, pulse oximetry), neurological (via pulse and responsiveness), and endocrine (temperature) systems. They provide critical data on physiological function, making this a valid use of vital signs in comprehensive health assessments.

Choice D reason: Vital signs include temperature, pulse, respirations, blood pressure, and pulse oximetry, which measure thermoregulation, cardiovascular, and respiratory status. This is a standard definition in clinical practice, accurately reflecting the components of vital sign assessment, making it a correct use.

Choice A reason: Dementia is a progressive condition causing memory decline and impaired daily activities, as seen in Alzheimer’s or vascular dementia. This definition aligns with clinical criteria, guiding diagnosis and care like cognitive therapy or medications. Accurate recognition ensures proper support, critical for improving quality of life in affected patients.

Choice B reason: Assuming false is incorrect, as dementia accurately describes progressive cognitive and functional decline. Misidentifying this risks misunderstanding the condition, potentially delaying diagnosis or interventions like cholinesterase inhibitors. Recognizing dementia’s definition ensures timely care planning, essential for managing symptoms and supporting patients and families in chronic cognitive disorders.