Which of the following do you assess when asking questions about a patient’s orientation?
Determining the client’s pain level is an important part of an assessment but does not provide information as to the client’s orientation to time, place, and person.
Personal hygiene.
Mental state.
Family medical history.
The Correct Answer is C
Choice A reason: Pain level assessment is important but unrelated to orientation, which evaluates mental state via time, place, and person questions. Assuming pain assesses orientation risks missing cognitive deficits, delaying diagnosis of delirium or dementia, critical for tailoring care and interventions in patients with altered mental status.
Choice B reason: Personal hygiene reflects self-care ability, not orientation to time, place, or person, which assesses mental state. Assuming hygiene evaluates orientation misguides assessment, risking oversight of cognitive impairments, essential for diagnosing conditions like Alzheimer’s or acute confusion, requiring targeted interventions in clinical practice.
Choice C reason: Orientation questions assess mental state, evaluating cognitive function through awareness of time, place, and person. This detects impairments in conditions like delirium or dementia, guiding care planning. Accurate assessment ensures timely interventions, critical for managing cognitive decline and supporting patient safety and communication in healthcare settings.
Choice D reason: Family medical history provides genetic context but doesn’t assess orientation, which targets mental state. Assuming history evaluates orientation risks missing cognitive issues, delaying diagnosis of acute or chronic cognitive impairments, critical for implementing cognitive support or pharmacological interventions in patients with suspected mental status changes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Head protrusions are not expected in older adults; they may indicate abnormal growths or trauma, requiring investigation. Thinning hair is a normal aging change. Assuming protrusions are expected risks missing serious conditions like tumors, delaying diagnosis and treatment critical for ensuring safety in elderly patients.
Choice B reason: Asymmetry of facial features is not a normal aging variation; it may suggest stroke or Bell’s palsy, needing urgent evaluation. Thinning hair is expected due to hormonal changes. Assuming asymmetry is normal risks overlooking neurological issues, delaying interventions critical for older adults’ health and functional outcomes.
Choice C reason: Thinning hair is an expected aging variation, resulting from reduced hair follicle activity and hormonal changes in older adults. Unlike vertigo or asymmetry, it’s benign and doesn’t require intervention unless cosmetic. Recognizing this ensures accurate assessment, focusing on abnormal findings like vertigo that need medical attention in elderly patients.
Choice D reason: Vertigo is not an expected aging variation; it may indicate inner ear disorders or neurological issues, requiring evaluation. Thinning hair is a normal change. Assuming vertigo is expected risks delaying diagnosis of treatable conditions like BPPV, compromising safety and quality of life in older adults.
Correct Answer is B
Explanation
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.
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