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 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.

A. Notify the healthcare provider. B. Observe for eye opening to a painful stimulus. C. Check the pupillary response to light. D. Ask the client to open his eyes.

Correct Answer is B

Explanation

A. While notifying the healthcare provider is important if there are significant changes in the client's level of consciousness, it should not be the immediate next step. Before alerting the provider, the nurse needs to perform additional assessments to determine the extent of the client's unresponsiveness and gather more information about their neurological status.
B. Observing for eye opening in response to a painful stimulus is a critical step in assessing the depth of unconsciousness. This response helps determine the client's level of consciousness and can provide information about the severity of their condition.
C. Checking the pupillary response to light is important in evaluating neurological function and can provide information about brainstem activity and potential neurological deficits. However, it is secondary to checking for responses to stimuli like painful stimuli if the client is not opening their eyes spontaneously. Pupillary response should be assessed as part of a comprehensive neurological exam.
D. Asking the client to open his eyes might not be effective if the client is unresponsive or has impaired consciousness. If the client is not responding spontaneously, it is likely that verbal commands will also be ineffective. This step is less useful when assessing levels of consciousness compared to more objective assessments like responses to painful stimuli.

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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 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

In assessing a male client's level of consciousness, the nurse determines that the client does not open his eyes spontaneously. Which should the nurse do next?

Correct Answer is B

Explanation

The nurse reorients a male client to the correct time, day, date, and location, but he is only able to remember his name and where he is. Based on these findings, which should the nurse document?

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

The nurse is assessing a client with type 2 diabetes mellitus and observes an abnormal response when using a monofilament. Which finding should the nurse document that is consistent with an abnormal finding?

The nurse is completing an assessment for a client with uncontrolled diabetes mellitus (DM) who came to the clinic reporting frequent, painful urination. Which screening test should the nurse perform first?

While the nurse is taking a health history, the client announces, "I don't have time for this. This is a waste of time. I need treatment." Which response is best for the nurse to provide?

When assessing an adult client, the nurse notes that the client has unequal lung expansion. Which conclusion regarding this finding is most likely to be accurate?

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