Which assessment action should the nurse use when performing a cognitive ability exam?

Evaluate ability to brush and floss teeth.

Ask client to describe reactions in a difficult situation.

Observe physical grooming and hygiene.

Tell the client to repeat a phrase that was said earlier.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Evaluate ability to brush and floss teeth: Assessing the ability to perform personal hygiene activities evaluates functional status and motor skills, not specifically cognitive ability. It reflects activities of daily living (ADLs) rather than direct cognitive processing.

B. Ask client to describe reactions in a difficult situation: Asking about reactions assesses judgment and emotional response but not cognitive functions like memory, attention, or orientation, which are the primary focus in a cognitive ability exam.

C. Observe physical grooming and hygiene: Observing grooming and hygiene helps assess self-care and possibly hints at cognitive decline if hygiene is poor, but by itself, it does not directly measure specific cognitive abilities such as memory or recall.

D. Tell the client to repeat a phrase that was said earlier: Asking the client to recall and repeat a previously stated phrase directly assesses short-term memory, an important component of cognitive ability. This action is a standard part of evaluating memory retention and cognitive functioning.

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Correct Answer is A

Explanation

Rationale:
A. Axillary nodes feel soft and fatty: In older adults, lymph nodes often become smaller, softer, and more fatty due to age-related atrophy of lymphatic tissue. Soft, fatty nodes in the axillary area are considered a normal finding and generally do not indicate infection or malignancy unless associated with other concerning symptoms.

B. Inguinal nodes are enlarged and warm to the touch: Enlarged and warm lymph nodes suggest acute infection or inflammation. This is not a normal finding at any age and would warrant further evaluation to rule out infectious processes, malignancy, or systemic disease.

C. Nodes feel ropey and rubbery: Ropey and rubbery lymph nodes can indicate abnormal conditions such as lymphoma or chronic infection. While texture can vary, this description is more consistent with pathological changes and not considered normal in a healthy older adult.

D. Nodes are nonpalpable: While nonpalpable lymph nodes can be normal, especially if small and deep, some lymph nodes—like inguinal or axillary nodes—can still be felt even in healthy individuals. Therefore, the presence of soft, fatty nodes is a more typical normal finding rather than complete nonpalpability.

A. Hematocrit. B. Serum calcium. C. Hemoglobin. D. Serum prealbumin.

Correct Answer is D

Explanation

Rationale:
A. Hematocrit: Hematocrit measures the proportion of red blood cells in the blood and helps assess for anemia or dehydration, but it does not directly reflect short-term changes in nutritional status or protein stores.

B. Serum calcium: Serum calcium levels assess electrolyte balance and bone health but are not specific indicators of overall nutritional status. Calcium levels can be maintained even when nutritional intake is poor.

C. Hemoglobin: Hemoglobin evaluates oxygen-carrying capacity and can suggest anemia, which may indirectly reflect poor nutrition, but it is not as sensitive a marker for acute or current nutritional status as prealbumin.

D. Serum prealbumin: Serum prealbumin is a sensitive marker of recent nutritional intake and protein status, reflecting short-term changes in nutrition. It is the most important laboratory value to assess when evaluating a client for malnutrition, especially in the setting of appetite loss and generalized malaise.

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Which assessment action should the nurse use when performing a cognitive ability exam?

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Naxlex Comprehensive Predictor Exams

The nurse has just completed palpation maneuvers for lymph nodes on an older adult female client. Which findings are considered normal for this older adult client?

Correct Answer is A

Explanation

An older adult client is admitted to the medical unit because of a loss of appetite and generalized malaise. To analyze the client's general nutritional status, which laboratory value is most important for the nurse to review?

Correct Answer is D

Explanation

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