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 D

Explanation

A. This may involve using a stethoscope to auscultate the apical pulse, as it might be more easily heard than felt, especially in individuals with significant muscle mass or other anatomical variations. This approach ensures that a thorough cardiac assessment is conducted.
B. Dimming the lights would not impact the ability to palpate or auscultate the apical pulse. Lighting adjustments are generally more relevant for visual examinations rather than for palpation or auscultation of heart sounds. This action would not address the issue of locating the apical pulse.
C. While steroid use can affect cardiovascular health, such as potentially causing changes in heart size or function, questioning the client about steroid use is not the immediate priority if the apical pulse cannot be palpated. The priority should be to ensure a correct assessment and use proper techniques to locate the pulse.
D. Positioning the client in high Fowler's position (sitting up at a 60-90 degree angle) can help in various cardiac assessments and might make it easier to detect the apical pulse, especially if the client has a high muscle mass. This position can improve access to the chest and potentially facilitate better auscultation of heart sounds.

Correct Answer is ["20"]

Explanation

The standard distance for a visual acuity test using the Snellen chart is 20 feet. This distance allows for an accurate assessment of how well a person can see the details of the letters on the chart, which is a common method used by eye doctors to measure visual acuity.

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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

When assessing a 24-year-old body-builder, the nurse is unable to palpate an apical pulse. Which action should the nurse implement?

Correct Answer is D

Explanation

The nurse is assessing the visual acuity of a client who reports changes in vision. How many feet away from the Snellen chart should the client stand? (Enter a whole number only.)

Correct Answer is ["20"]

Explanation

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