AND VERIFIED ANSWERS YEAR 2024/2025
RN uses MMSE when assessing a client for admission to an
assisted living facility. Which finding is the RN assessing when
requesting the client to count by 7s?
A Recall of information
B Orientation to Surroundings
C Attention to Details
D Ability to follow complex commands - C Attention to details
Counting by 7s evaluates the ability to do simple calculations
and is specific to the clients attention to details. ABD are all
parts of MMSE but they evaluate orientation and cognitive
function.
RN palpates a weak pedal pulse in the client's right foot. Which
assessment findings should the RN document that are
consistent with diminished peripheral circulation? (select all that
apply.)
A Diminished hair on legs
B Bruising on extremities
C Skin cool to touch
D Capillary refill less than 3 seconds
E Darkened skin on extremities - A, C
Diminished hair on the legs A and skin is cool to touch C are
symptoms of decreased arterial blood flow. BDE are not
indicators for impaired peripheral circulation
Which action should the RN implement to complete an
assessment for a client while using an interpreter?
, A Ask closed-ended questions with the assistance of the
interpreter
B Maintain eye contact with the client while listening to the
translation
C Instruct interpreter to answer questions from the interpreter's
point of view
D Protect the client's privacy by asking a limited number of
questions - B Maintain eye contact with the client while listening
to the translation
When completing an assessment the RN should maintain eye
contact with the client B to gather additional information from
the client's nonverbal cues. ACD do not use both verbal and
nonverbal communication techniques to gather data during an
assessment
A client with progressive hearing loss appears distressed when
RN ask open-ended questions about the client's health history.
Which forms of communication should the RN use? (Select all
that apply.)
A Face the client so the client can see the RN's mouth
B increase one's speech volume when interacting with the
client
C Repeat information to client if misunderstood
D Check if the client's hearing aides are working properly
E Reduce environmental noise surrounding the client - A,D,E
A client with hearing loss can develop the ability to read "lips,"
so facing the client during conversation A allows visualization of
the lips and directs the sound towards the client. Inspection of
the hearing aide device's functionality is a vital step in
communication D. Hearing aides magnify all surround noise, so
it is imperative to reduce outside environmental noise during
the interview process E. Speaking clearly with enunciation and
in a regular tone is easier for a client to understand than
increasing the volume of speech B. If a client shows signs of