Topic Resources The patient’s attention span is assessed first; an inattentive patient cannot cooperate fully and hinders testing. Any hint of cognitive decline requires examination of mental status ( see
Examination of Mental Status
Examination of Mental Status
Orientation to time, place, and person Attention and concentration Memory Verbal and mathematical abilities Judgment Reasoning
Loss of orientation to person (ie, not knowing one’s own name) occurs only when obtundation, delirium Delirium Delirium is an acute, transient, usually reversible, fluctuating disturbance in attention, cognition, and consciousness level. Causes include almost any disorder or drug. Diagnosis is clinical... read more , or dementia Dementia Dementia is chronic, global, usually irreversible deterioration of cognition. Diagnosis is clinical; laboratory and imaging tests are usually used to identify treatable causes. Treatment is... read more is severe; when it occurs as an isolated symptom, it suggests malingering.
The patient is asked to do the following:
Follow a complex command that involves 3 body parts and discriminates between right and left (eg, “Put your right thumb in your left ear, and stick out your tongue”)
Name simple objects and parts of those objects (eg, glasses and lens, belt and belt buckle)
Name body parts and read, write, and repeat simple phrases (if deficits are noted, other tests of aphasia Diagnosis are needed)
Spatial perception can be assessed by asking the patient to imitate simple and complex finger constructions and to draw a clock, cube, house, or interlocking pentagons; the effort expended is often as informative as the final product. This test may identify impersistence, perseveration, micrographia, and hemispatial neglect.
Praxis (cognitive ability to do complex motor movements) can be assessed by asking the patient to use a toothbrush or comb, light a match, or snap the fingers.
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A nurse is collecting data about a client’s respiratory system. Which of the
following breath sounds should the nurse expect to hear over the periphery
of the major lung fields?
A: Vesicular (Vesicular sounds are soft and low-pitched)
A nurse employs a thorough, systematic method for obtaining OBJECTIVE
data about a client. Which of the following methods should the nurse us to
collect this information?
A: Physical Examination (Physical findings are objective and the nurse should
collect this information in a systematic way.
A nurse is assisting a provider with performing thoracentesis to remove
pleural fluid. How should the nurse position the client?
A: Leaning forward over a pillow.
A nurse is preparing to insert an NG tube for a client who requires enteral
feedings. Which of the following instructions should the nurse give the client
before beginning the procedure?
A: “Raise your index finger if you need to pause during the insertion.”
A nurse is performing a mental-status exam for a client who has
manifestations of dementia. Which of the following directions should the
nurse give the client when evaluating the client’s ability to think abstractly?
A: Discuss the meaning of a common proverb. (Evaluates clients ability to
think abstractly.)
A nurse is presenting an in-service session about nutrition. Which of the
following simple sugars should the nurse identify as the carb found in milk?
A: LACTOSE (Sugar found in milk)
A nurse is assisting with teaching a newly licensed nurse about pain
management in clients age of 65 and older. Which of the following pieces of
information should the nurse include?
A: Clients who are 65 or older are reluctant to report pain. (Might not want to
bother or anger caregivers and might believe that pain is expected.)
A nurse in an oncology clinic is collecting data for a client who is undergoing
treatment for ovarian cancer. Which of the following statements by the client
indicate she is experiencing psychological distress?
A: “I keep having nightmares about my upcoming surgeries.”
A nurse is assisting with the admission of a client to the medical unit and
asks if he has advance directives. The client states “I have a document with
me that names someone who can make health care decisions for me if i am
not able.” The nurse should identify that the client is referring to which of the
following documents?A: Durable Power of Attorney Document (names a