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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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.

A. Inspection. B. Percussion. C. Palpation. D. Auscultation.

Correct Answer is A

Explanation

A. In the context of detecting papilledema, "inspection" refers to using an ophthalmoscope to examine the optic disc for swelling. Papilledema, which is swelling of the optic disc due to increased intracranial pressure, can only be observed through this direct examination of the eye’s interior. This technique is the most appropriate and accurate for confirming papilledema as it allows the nurse to visually inspect the optic disc for signs of swelling or other abnormalities.
B. Percussion involves tapping on the body to assess underlying structures and is commonly used in evaluating lung and abdominal sounds. It is not used for assessing the optic nerve or papilledema. Therefore, percussion is not relevant for confirming the presence of papilledema.
C. Palpation involves feeling the body’s surface to assess for abnormalities such as swelling or
tenderness. It is used for evaluating various parts of the body but does not apply to detecting papilledema. Papilledema involves changes to the optic nerve head, which cannot be assessed through palpation.
D. Auscultation involves listening to internal body sounds using a stethoscope, such as heartbeats, lung sounds, or abdominal sounds. This technique is not used to assess the optic disc or detect papilledema. It is not relevant for the diagnosis of conditions affecting the optic nerve.

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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

A male client reports the onset of a burning sensation in his hands and legs. How should the nurse document this finding in the electronic medical record (EMR)?

Correct Answer is B

Explanation

Which assessment technique should the nurse use to confirm the presence of papilledema in a client with a rapidly decreasing level of consciousness?

Correct Answer is A

Explanation

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

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