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 D

Explanation

Rationale:
A. Multiple yellow lesions with a grainy surface: These may represent seborrheic keratoses, which are common, benign skin growths seen especially in older adults. They typically do not require urgent medical intervention unless changing rapidly or showing signs of malignancy.

B. Large, flat, dark red irregular area on the neck: This finding likely represents a port-wine stain, a type of vascular birthmark. While noticeable, it is generally benign and would not usually necessitate immediate reporting unless there are associated complications or sudden changes.

C. Multiple silver striae on the abdomen: Silver striae (stretch marks) are common and typically result from rapid changes in body size, such as during pregnancy, weight gain, or growth spurts. They are benign and do not require healthcare provider notification unless accompanied by concerning symptoms.

D. Bluish discoloration of the nailbeds: Cyanosis, indicated by bluish nailbeds, suggests decreased oxygenation or possible cardiovascular or pulmonary compromise. It is a significant clinical finding that warrants immediate reporting to the healthcare provider for further evaluation and management.

A. Localized sternal border pain intensified by palpation. B. Chest pain that intensifies upon chest excursion. C. Anterior thorax pain that radiates between the scapulae. D. Pain in the neck, jaw, or medial side of the left arm.

Correct Answer is D

Explanation

Rationale:
A. Localized sternal border pain intensified by palpation: Pain that worsens with palpation suggests musculoskeletal causes such as costochondritis rather than cardiac ischemia. Cardiac chest pain is usually deep, pressure-like, and not reproducible with touch.

B. Chest pain that intensifies upon chest excursion: Pain that worsens with breathing movements often points to pleuritic causes such as pulmonary embolism or pleurisy, not myocardial infarction. Cardiac chest pain is generally constant and unaffected by breathing patterns.

C. Anterior thorax pain that radiates between the scapulae: Pain radiating between the scapulae is more characteristic of aortic dissection rather than a typical acute myocardial infarction, though some cardiac conditions can cause atypical pain patterns.

D. Pain in the neck, jaw, or medial side of the left arm: Referred pain to the neck, jaw, or inner left arm is classic for an acute myocardial infarction. This pattern reflects nerve pathways from the heart and is a hallmark symptom that strongly indicates myocardial ischemia.

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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

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Explanation

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Correct Answer is D

Explanation

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