While making a home visit, the spouse of an older client tells the nurse the client is becoming increasingly confused about past events and has started forgetting to all pain dictation for osteoarthritis in the knees. Which assessment should the nurse initially perform to evaluate the client's memory?

Ask the client to recall what was consumed for lunch and breakfast

Ask the spouse how often the pain medication is to be taken

Request for the spouse to write down the things the client forgets

Observe client ability to perform activities of daily living (ADLs)

Answer and Explanation

The Correct Answer is A

Choice A Reason:
Asking the client to recall what was consumed for lunch and breakfast is appropriate. Asking the client to recall recent events, such as what was consumed for lunch and breakfast, helps assess their short-term memory. Difficulty recalling recent events or recent medication doses may indicate emery impairment or cognitive decline, which could be contributing to the reported confusion and forgetfulness. This assessment provides valuable information about the client's ability to retain and recall recent information, which is pertinent to understanding the extent of memory impairment.
Choice B Reason:
Asking the spouse how often the pain medication is to be taken is inappropriate. While asking the spouse about the pain medication regimen provides information about the client's medication schedule, it does not directly assess the client's memory. Additionally, relying solely on the spouse's report may not accurately reflect the client's memory abilities or recall of medication instructions.
Choice C Reason:
Request for the spouse to write down the things the client forgets is inappropriate. Asking the spouse to write down forgotten items may help track memory lapses but does not directly assess the client's memory during the home visit. It also does not provide real-time information about the client's ability to recall recent events or medication instructions.
Choice D Reason:
Observing client ability to perform activities of daily living (ADLs) is inappropriate. Assessing the client's ability to perform activities of daily living (ADLs) is important for evaluating overall functional status but may not specifically target memory assessment. While memory impairment can impact ADL performance, it is not the most direct assessment for evaluating memory specifically during the home visit.

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Correct Answer is D

Explanation

Choice A Reason:
Appears confused and depressed is incorrect. This option includes subjective interpretations ("confused" and "depressed") that may not accurately reflect the observed behavior. It's important to avoid subjective assessments and stick to objective descriptions of the client's behavior and mental status.
Choice B Reason:
Demonstrates signs of early dementia is incorrect. This option jumps to a diagnostic label ("early dementia") based on the observed behavior, which is not appropriate without further assessment and evaluation by a healthcare provider specializing in geriatric care or neurology. It's crucial to avoid diagnosing conditions based solely on observations without proper evaluation.
Choice C Reason:
While the client is ambulatory, the term "disoriented to place" is an assumption that has not been explicitly confirmed through an assessment. The documentation should be based on observable facts rather than assumptions.
Choice D Reason:
This statement is accurate, objective, and based on observable behaviors. "Wandering behavior" describes the client's aimless walking, and "flat affect" refers to the blank expression. This documentation does not make assumptions about the client's mental state beyond what is directly observable.

A. Palpate the client's dorsalis pedis pulses. B. Ask If the client often feels weak or hungry. C. Compare the range of motion of both legs. D. Measure the client's capillary glucose.

Correct Answer is A

Explanation

Choice A Reason:
Palpating the client's dorsalis pedis pulses is appropriate because shiny lower legs with no hair growth are characteristic findings of peripheral arterial disease (PAD), which commonly occurs in individuals with diabetes mellitus. Palpating the client's dorsalis pedis pulses allows the nurse to assess peripheral arterial perfusion. Weak or absent dorsalis pedis pulses may indicate decreased blood flow to the feet and lower extremities, supporting the diagnosis of PAD.
Choice B Reason:
Asking if the client often feels weak or hungry is less relevant to the assessment findings of shiny lower legs with no hair growth. While it is important to assess for symptoms of hypoglycemia in clients with diabetes mellitus, such as weakness or hunger, these symptoms do not directly correlate with the observed peripheral vascular changes.
Choice C Reason:
Comparing the range of motion of both legs is less relevant to the assessment findings of shiny lower legs with no hair growth. Range of motion assessment is important for assessing joint function and mobility but does not provide information specifically related to peripheral vascular status.
Choice D Reason:
Measuring the client's capillary glucose is less relevant to the assessment findings of shiny lower legs with no hair growth. While it is important to monitor blood glucose levels in clients with diabetes mellitus, capillary glucose measurement does not provide information specifically related to peripheral vascular status or the observed findings of PAD.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes an older adult client walking aimlessly in the hallway and staring straight ahead with a blank expression. How should the nurse enter documentation of this finding in the client's electronic medical record (EMR)?

Correct Answer is D

Explanation

The nurse observes that the lower legs of a client with diabetes mellitus are shiny with no hair growth. To obtain additional data to support these findings, which assessment should the nurse perform?

Correct Answer is A

Explanation

While assessing a client, the nurse notices that the client's legs are asymmetrical. Which additional physical data should the nurse collect?

During the admission assessment, a male client admitted with chest pain states he has no breathing problems and no trouble sleeping at night. To obtain further data regarding possible orthopnea, which action should the nurse take?

The nurse notes an enlarged, visible lymph node on the client's neck. Which action should the nurse take next?

The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

In assessing a client's level of consciousness, what should the nurse assess first?

A client reports experiencing stomach pain and it is localized in the middle section of the abdomen below the xiphoid process. The nurse should describe the pain as occurring in which region of the abdomen?

The primary nurse asks another nurse to assist in checking a client for an apical-radial pulse deficit. One nurse counts an apical pulse of 72 beats/minute while the other nurse counts a radial pulse of 88 beats/minute. Which action should the primary nurse take?