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A Nurse Assesses An Older Adult Patient Brought To The Emergency Department By A Family
Member. The Patient Was Wandering Outside, Saying, "I Can't Find My Way Home." The Patient
Is Confused And Unable To Answer Questions. What Is The Nurse's Best Action To Provide
Effective Nursing Care?
A. Document The Patient's Mental Status. Obtain Other Assessment Data From The Family
Member.
B. Record The Patient's Answers To Questions On The Nursing Assessment Form.
C. Ask An Advanced Practice Nurse To Perform The Assessment Interview.
D. Call For A Mental Health Advocate To Maintain The Patient's Rights.
ANSWER>> A. Document The Patient's Mental Status. Obtain Other Assessment Data From The
Family Member.
A Nurse Asks A Patient, "If You Had Fever And Vomiting For 3 Days, What Would You Do?"
Which Aspect Of The Mental Status Examination Is The Nurse Assessing?
A. Behavior
B. Cognition
C. Affect And Mood
D. Perceptual Disturbances
ANSWER>> B. Cognition
An Adolescent Asks A Nurse Conducting An Assessment Interview, "Why Should I Tell You
Anything? You'll Just Tell My Parents Whatever You Find Out." What Is The Nurse's Best Reply
Regarding Patient Confidentiality?
, A. "That Is Not True. What You Tell Us Is Private And Held In Strict Confidence. Your Parents Have
No Right To Know."
B. "Yes, Your Parents May Find Out What You Say, But It Is Important That They Know About
Your Problems."
C. "What You Say About Feelings Is Private, But Some Things, Like Suicidal Thinking, Must Be
Reported To The Treatment Team."
D. "It Sounds As Though You Are Not Really Ready To Work On Your Problems And Make
Changes."
ANSWER>> C. "What You Say About Feelings Is Private, But Some Things, Like Suicidal Thinking,
Must Be Reported To The Treatment Team."
A Nurse Assessing A New Patient Asks, "What Is Meant By The Saying, 'You Can't Judge A Book
By Looking At The Cover'?" Which Aspect Of Cognition Is The Nurse Assessing?
A. Mood
B. Attention
C. Orientation
D. Abstraction
ANSWER>> D. Abstraction
When A Nurse Assesses An Older Adult Patient, The Patient's Answers Seem Vague Or Unrelated
To The Questions. The Patient Also Leans Forward And Frowns, Listening Intently To The Nurse.
What Would Be An Appropriate Question For The Nurse To Ask In This Situation?
A. "Are You Having Difficulty Hearing When I Speak?"
B. "How Can I Make This Assessment Interview Easier For You?"
C. "I Notice You Are Frowning. Are You Feeling Annoyed With Me?"
D. "You're Having Trouble Focusing On What I'm Saying. What Is Distracting You?"