While performing a mental status examination, which question should the nurse ask when attempting to evaluate a client's judgment?

"Can you recall the date the Twin Towers in New York were destroyed?"

"What is the difference between a hamster and a rabbit as a pet?"

"Should someone who lives in a glass house throw stones?"

"Do you write checks if you know the bank account is overdrawn?"

Answer and Explanation

The Correct Answer is C

A.   This question assesses a client's recent memory, not their judgment.
B.   This question assesses a client's knowledge and understanding of animals, not their judgment.
C.   This question evaluates a client's judgment by assessing their ability to make sound decisions based on hypothetical situations. It requires the client to consider potential consequences and make a logical inference.
D.   This question assesses a client's financial knowledge and decision-making skills, but it doesn't directly evaluate their judgment in a hypothetical situation.

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Correct Answer is D

Explanation

A. This may involve using a stethoscope to auscultate the apical pulse, as it might be more easily heard than felt, especially in individuals with significant muscle mass or other anatomical variations. This approach ensures that a thorough cardiac assessment is conducted.
B. Dimming the lights would not impact the ability to palpate or auscultate the apical pulse. Lighting adjustments are generally more relevant for visual examinations rather than for palpation or auscultation of heart sounds. This action would not address the issue of locating the apical pulse.
C. While steroid use can affect cardiovascular health, such as potentially causing changes in heart size or function, questioning the client about steroid use is not the immediate priority if the apical pulse cannot be palpated. The priority should be to ensure a correct assessment and use proper techniques to locate the pulse.
D. Positioning the client in high Fowler's position (sitting up at a 60-90 degree angle) can help in various cardiac assessments and might make it easier to detect the apical pulse, especially if the client has a high muscle mass. This position can improve access to the chest and potentially facilitate better auscultation of heart sounds.

A. Numeric pain intensity scale. B. Apical-radial pulse deficit. C. Anteroposterior (AP) chest diameter. D. Body temperature.

Correct Answer is A

Explanation

A. The numeric pain intensity scale is a direct and effective method to assess the level of pain a patient is experiencing. If a client is splinting their chest, it’s essential to evaluate their pain level to determine the severity and guide appropriate pain management strategies. This is likely the most relevant and immediate follow-up assessment in this scenario.
B. An apical-radial pulse deficit measures the difference between the apical pulse (heart rate auscultated at the apex of the heart) and the radial pulse (heart rate palpated at the wrist). This assessment is used to detect conditions such as atrial fibrillation or other arrhythmias and is not directly related to the client’s chest splinting. Therefore, it is not the most relevant follow-up assessment in this context.
C. The anteroposterior (AP) chest diameter assessment is used to evaluate conditions such as barrel chest, which can be associated with chronic respiratory conditions. While this measurement can be important for assessing chronic respiratory issues, it is not directly related to the immediate concern of chest splinting, which is more likely associated with acute pain or discomfort.
D. Measuring body temperature is important for assessing the presence of fever or infection, but it does not directly address the client’s immediate complaint of chest pain or discomfort. While an elevated temperature might be relevant if an infection is suspected, it is not the most direct or immediate follow- up assessment for the observed behavior of splinting the chest.

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While performing a mental status examination, which question should the nurse ask when attempting to evaluate a client's judgment?

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Naxlex Comprehensive Predictor Exams

When assessing a 24-year-old body-builder, the nurse is unable to palpate an apical pulse. Which action should the nurse implement?

Correct Answer is D

Explanation

When entering a male client's room, the nurse observes that he is splinting his chest with a pillow. Which follow-up assessment should the nurse complete?

Correct Answer is A

Explanation

The nurse examines a client's abdomen. Which finding indicates an abnormal response when palpating the spleen?

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The nurse is assessing a client for goiter and is unable to observe the thyroid gland. Which action should the nurse take?

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

While assessing a client, the nurse observes that the client has a frequent productive cough. What follow-up assessment should the nurse evaluate first?