A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse's best course of action?
a. Perform a complete mental status examination.
b. Refer him to a psychometrician.
c. Plan to integrate the mental status examination into the history and physical examination.
d. Reassure his wife that memory loss after a physical shock is normal and will soon subside.
ANS: A
Performing a complete mental status examination is necessary when any abnormality in affect or behavior is discovered or when family members are concerned about a person's behavioral changes (e.g., memory loss, inappropriate social interaction) or after trauma, such as a head injury.
You might also like to view...
The nurse knows that initial verification of a nasogastric placement is important. Which method is considered the only reliable method to determine enteral tube placement?
a. Auscultation of air bolus b. Measurement of pH of the aspirate c. Radiographic image d. Aspirate contents to visually inspect appearance
The nurse would expect to find which of the following symptoms when assessing a 38-year-old patient diagnosed with multiple sclerosis?
A) Vision changes B) Absent deep tendon reflexes C) Tremors at rest D) Flaccid muscles
During an assessment, a patient's tongue deviates markedly to the right side. What is the patient most likely exhibiting?
A. Sluggish oculomotor response B. Absence of the Homans sign C. Abnormal hypoglossal nerve response D. First cranial nerve (CN I) damage
You are working evenings on an orthopedic floor. One of your patients, J.O., is a 25-year-old man who was
a new admission on day shift. He was involved in a motor vehicle accident during a high-speed police chase on the previous night. His admitting diagnosis is status post (S/P) open reduction internal fixation (ORIF) of the right femur, multiple rib fractures, sternal bruises, and multiple abrasions. He speaks some English but is more comfortable with his native language. He is under arrest for narcotics trafficking, so one wrist is shackled to the bed and a guard is stationed inside his room continuously. He says a drug dealer told him he is "coming to get him." Hospital security is aware of the situation. Your initial assessment reveals stable vital signs (VS) of 116/78, 84, 16, 98.6° F. His only complaint is pain, for which he has a patient-controlled analgesia (PCA) pump. Lungs are clear to auscultation. His abdomen is soft and nontender. He has a nasogastric tube connected to intermittent low wall suction. He is receiving IV D5LR through the proximal port of a left subclavian triple-lumen catheter at 75 mL/hr; the remaining two ports are locked. The right femur is connected to 10 pounds of skeletal traction. The dressing is dry and intact over the incision site. J.O. has not had a cigarette since the accident. He is irate because the day nurse would not let him smoke. Do you think J.O. would be a good candidate for a nicotine patch? State your rationale.