Ans: d. Before testing, the nurse would assess the patient's mental status and ability to follow directions.
During the taking of the health history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: “He can’t even remember how to button his shirt.” When assessing his sensory system, which action by the nurse is most appropriate?
a. The nurse would not test the sensory system as part of the examination because the results would not be valid.
b. The nurse would perform the tests, knowing that mental status does not affect sensory ability.
c. The nurse would proceed with an explanation of each test, making certain that the wife understands.
d. Before testing, the nurse would assess the patient's mental status and ability to follow directions.
Explanation: The nurse should ensure the validity of the sensory system testing by making certain that the patient is alert, cooperative, comfortable, and has an adequate attention span. Otherwise, the nurse may obtain misleading and invalid results.
Nursing
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