The nurse is preparing to assess a client's mental status within the general survey. Which of the following should the nurse use to assess this status?
1. Note the number of times the client looks to significant other while answering interview questions.
2. Ask the client to describe elements of his health history.
3. Study the client's clothing selections.
4. Notice the client's ability to make eye contact during the examination.
2
Rationale 1: Observing the client walking into the examination room would help assess mobility.
Rationale 2: The general survey is composed of four major categories of observation: physical appearance, mental status, mobility, and client behavior. Asking the client to describe elements of his health history would help assess mental status.
Rationale 3: Studying the client's clothing selections would help assess physical appearance.
Rationale 4: Noticing the client's ability to make eye contact would help assess client behavior.
You might also like to view...
A nurse is working with a group of older adult clients at a community health center. Several clients report growing concerns about their dental health
They state they need to have dental work done despite continuing the same hygiene habits they have employed for years. They inquire about the underlying cause for these changes. Based on this data, which response by the nurse is the most appropriate? A) "It is common for dental health to decline with aging." B) "Aging increases saliva production, which increase exposure of the tooth's enamel to corrosive agents." C) "A decrease in bone density is associated with aging, which can result in tooth decay and breakage." D) "Metabolic changes in aging contribute to dental destruction."
Health promotion activities the nurse could suggest to a community group for Huntington's disease include
a. Eating foods high in omega-3 fatty acids. b. genetic screening for high-risk individuals. c. limiting exposure to heavy metals. d. taking 400 International Units of vitamin E daily.
The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil. How should the nurse interpret this?
a. Eye trauma b. Brain death c. Severe brainstem damage d. Neurosurgical emergency
A patient is having difficulty having a bowel movement on the bedpan. What is the physiologic reason for this problem?
A) It is painful to sit on a bedpan. B) The position does not facilitate downward pressure. C) The position encourages the Valsalva maneuver. D) The cause is unknown and requires further study.