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?"
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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Related Questions
Correct Answer is B
Explanation
A. This term suggests a problem with blood flow, which could potentially cause symptoms such as numbness or tingling. However, it does not specifically address the sensation of burning. Using this term might lead to an incorrect or incomplete assessment of the client's condition.
B. Paresthesia is a term used to describe abnormal sensations in the skin, such as burning, tingling, or prickling. The client's report of a burning sensation in the hands and legs aligns well with the definition of paresthesia. Documenting it as "paresthesia reported" accurately reflects the nature of the symptoms and is a medically precise way to describe the abnormal sensory experience.
C. This documentation uses colloquial language ("on fire") to describe the client's symptoms. While it conveys the intensity of the sensation, it is not a standardized medical term and may not be as clear or useful for clinical documentation.
D. Inflammation refers to the body's response to injury or infection, which often involves redness, swelling, heat, and pain. The term "inflammation" does not specifically describe the sensation of burning reported by the client.
Correct Answer is A
Explanation
A. A mental status exam is a comprehensive assessment tool used to evaluate various aspects of cognitive function, including orientation, memory, attention, language, and higher cognitive functions. Given that the client is confused, a mental status exam is highly relevant to understand the scope of the confusion, identify possible underlying issues, and provide a baseline for further evaluation and treatment.
B. Eliciting a pain response is typically used to assess responsiveness in patients who are not fully conscious or are unresponsive. Since the client is described as alert and ambulatory, attempting to elicit a pain response is not the most appropriate next step. This action is more suited for assessing levels of consciousness in patients who are less responsive or in coma-like states.
C. The Babinski reflex is a neurological test where the sole of the foot is stroked to assess the presence of an abnormal reflex response. In adults, the presence of the Babinski reflex may indicate neurological damage. This test is more specialized and less relevant for a general assessment of confusion.
D. Assessing pupillary accommodation involves checking how well the pupils adjust to changes in light and focus. While this is an important part of a neurological assessment, it is not the most direct approach to addressing confusion. Pupillary responses are generally assessed alongside other neurological evaluations but do not specifically address the cognitive or confusion aspects of the mental status.
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