The patient presents to the clinic with a family member. The family member states that the patient has been wandering around the house and mumbling. What is the first assessment the nurse should do?
a. Ask the patient why she has been wandering around the house.
b. Introduce self and ask the patient her name.
c. Take the patient's blood pressure, pulse, temperature, and respiratory rate.
d. Immediately do a complete head-to-toe neurologic assessment.
ANS: B
Introduce self and engage the patient by asking her name to assess orientation; ask the patient why she is visiting the clinic today. Continue the assessment with vital signs and a complete workup, including a neurologic assessment.
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