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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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Skin turgor assesses skin elasticity and hydration, which is more indicative of general hydration status rather than specific types of insufficiency. While poor skin turgor might be observed in various conditions, it does not specifically differentiate between venous and arterial ulcers.
B. The location and appearance of the ulcer can provide significant clues about its etiology. Venous ulcers often appear on the lower legs, particularly around the medial malleolus (inside of the ankle), and tend to have irregular, shallow, and often wet or weepy edges.
C. Changes in color upon movement can provide insight into the type of insufficiency. For arterial ulcers, the leg may appear pale or blanched when elevated and may develop a reddish or purple color when lowered due to poor blood flow.
D. Measuring joint range of motion assesses flexibility and mobility rather than the type of ulcer. While joint mobility issues can be associated with various conditions, including those affecting the vascular system, it does not directly help in distinguishing between venous and arterial insufficiency ulcers.

A. Wrist - able to bend wrist back toward forearm B. Elbow - only able to straighten joint 30 degrees

Correct Answer is {"A":{"answers":"D"},"B":{"answers":"B"}}

Explanation

Wrist: Able to bend wrist back toward forearm

Flexion: When the wrist bends back toward the forearm, it is an example of flexion. Flexion decreases the angle between the wrist and the forearm.

Elbow: Only able to straighten joint 30 degrees

Extension: The ability to straighten the elbow is indicative of extension. In this case, the client is only able to straighten the elbow to 30 degrees, which reflects limited extension.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of either venous or arterial insufficiency. Which assessment technique should the nurse use to differentiate the pathophysiology causing the ulcer?

Correct Answer is B

Explanation

Patient Data Exhibits

Correct Answer is {"A":{"answers":"D"},"B":{"answers":"B"}}

Explanation

In assessing a client's nailbeds, the nurse notes that the angle between the nail and the nailbed is 200 degrees. Which action should the nurse take?

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