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. Inspect the external ear canals: Muffled hearing, especially if unilateral, may be due to cerumen impaction, swelling, or other obstructions in the external auditory canal. Visual inspection is a quick, non-invasive first step that can help identify mechanical causes of hearing difficulty before pursuing more complex diagnostic tests.

B. Ask client if he has tinnitus: Tinnitus refers to ringing or buzzing in the ears and is often associated with sensorineural hearing loss rather than conductive hearing loss, which is more likely when hearing is muffled. While relevant for a full hearing evaluation, it does not address the immediate symptom of muffled hearing.

C. Determine ability to maintain balance with eyes closed: Balance issues are more related to inner ear dysfunction, particularly involving the vestibular system. Since the client's primary complaint is muffled hearing and not dizziness or balance problems, this assessment is not the most appropriate first step.

D. Differentiate ability to hear high and low pitched sounds: Differentiating pitch perception helps assess for specific types of sensorineural hearing loss. However, before conducting specialized auditory discrimination tests, it is more appropriate to first check for any external, easily correctable issues such as blockage or infection.

A. Request a 24-hour dietary recall. B. Question her about thoughts of self harm. C. Ask the teen if she is sexually active. D. Inquire about the use of illicit drugs.

Correct Answer is B

Explanation

Rationale:
A. Request a 24-hour dietary recall: Gathering a dietary history can help assess nutritional intake and obesity management. However, given the significant behavioral changes—excessive sleeping, weight loss, and amenorrhea—the immediate concern is not nutrition but potential underlying psychological distress, which requires urgent attention.

B. Question her about thoughts of self-harm: Sudden weight loss, excessive sleep, amenorrhea, and behavioral withdrawal in adolescents can signal depression, which carries a risk for self-harm and suicide. Screening for suicidal ideation is a priority to ensure the teen's immediate safety and determine if emergency intervention is necessary.

C. Ask the teen if she is sexually active: While assessing sexual activity is important, especially with menstrual irregularities, it is secondary in priority compared to assessing for life-threatening psychological conditions. Sexual history can be explored after ensuring the adolescent is not in immediate psychological danger.

D. Inquire about the use of illicit drugs: Substance use can contribute to mood changes, weight loss, and altered sleep patterns, but it is not the primary concern given the combination of depressive symptoms. Safety screening for self-harm or suicidal ideation takes precedence before evaluating for substance abuse.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is evaluating a client's hearing who reports hearing best in the left ear although words are muffled during conversation at a social gathering. Based on this finding, which assessment should the nurse implement?

Correct Answer is A

Explanation

A mother brings her obese adolescent daughter to the clinic because for the last 6 months her daughter sleeps every day after school, has lost weight, and has not had a period for 3 months. After sending the mother to the waiting room, which assessment is most important for the nurse to implement?

Correct Answer is B

Explanation

Which method should the nurse use to assess response to painful stimuli for a client with a marked reduction in the level of consciousness (LOC)?

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The nurse is performing a health interview for a client who does not speak fluent English and has obtained an interpreter. Which action should the nurse implement?

While percussing the abdomen of an adult male client, the nurse encounters a musical high-pitched sound. Which does this finding indicate?

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

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

The nurse assesses a client with a sleep pattern disturbance. While developing a plan of care (POC), which assessment data should the nurse obtain first?