VERIFIED Q&A | DETAILED RATIONALES | NURSING EXAM
PREP | GUARANTEED PASS
A NURSE ASSESSES AN OLDER ADULT PATIENT BROUGHT TO THE EMERGENCY DEPARTMENT BY
A FAMILY MEMBER. THE PATIENT WAS WANDERING OUTSIDE, SAYING, "I CAN'T FIND MY WAY
HOME." THE PATIENT IS CONFUSED AND UNABLE TO ANSWER QUESTIONS. WHAT IS THE
NURSE'S BEST ACTION TO PROVIDE EFFECTIVE NURSING CARE?
A. DOCUMENT THE PATIENT'S MENTAL STATUS. OBTAIN OTHER ASSESSMENT DATA FROM THE
FAMILY MEMBER.
B. RECORD THE PATIENT'S ANSWERS TO QUESTIONS ON THE NURSING ASSESSMENT FORM.
C. ASK AN ADVANCED PRACTICE NURSE TO PERFORM THE ASSESSMENT INTERVIEW.
D. CALL FOR A MENTAL HEALTH ADVOCATE TO MAINTAIN THE PATIENT'S RIGHTS.
CORRECT ANS: A. DOCUMENT THE PATIENT'S MENTAL STATUS. OBTAIN OTHER
ASSESSMENT DATA FROM THE FAMILY MEMBER.
A NURSE ASKS A PATIENT, "IF YOU HAD FEVER AND VOMITING FOR 3 DAYS, WHAT WOULD YOU
DO?" WHICH ASPECT OF THE MENTAL STATUS EXAMINATION IS THE NURSE ASSESSING?
A. BEHAVIOR
B. COGNITION
C. AFFECT AND MOOD
D. PERCEPTUAL DISTURBANCES
CORRECT ANS: B. COGNITION
AN ADOLESCENT ASKS A NURSE CONDUCTING AN ASSESSMENT INTERVIEW, "WHY SHOULD I
TELL YOU ANYTHING? YOU'LL JUST TELL MY PARENTS WHATEVER YOU FIND OUT." WHAT IS THE
NURSE'S BEST REPLY REGARDING PATIENT CONFIDENTIALITY?
, A. "THAT IS NOT TRUE. WHAT YOU TELL US IS PRIVATE AND HELD IN STRICT CONFIDENCE. YOUR
PARENTS HAVE NO RIGHT TO KNOW."
B. "YES, YOUR PARENTS MAY FIND OUT WHAT YOU SAY, BUT IT IS IMPORTANT THAT THEY KNOW
ABOUT YOUR PROBLEMS."
C. "WHAT YOU SAY ABOUT FEELINGS IS PRIVATE, BUT SOME THINGS, LIKE SUICIDAL THINKING,
MUST BE REPORTED TO THE TREATMENT TEAM."
D. "IT SOUNDS AS THOUGH YOU ARE NOT REALLY READY TO WORK ON YOUR PROBLEMS AND
MAKE CHANGES."
CORRECT ANS: C. "WHAT YOU SAY ABOUT FEELINGS IS PRIVATE, BUT SOME THINGS, LIKE
SUICIDAL THINKING, MUST BE REPORTED TO THE TREATMENT TEAM."
A NURSE ASSESSING A NEW PATIENT ASKS, "WHAT IS MEANT BY THE SAYING, 'YOU CAN'T JUDGE
A BOOK BY LOOKING AT THE COVER'?" WHICH ASPECT OF COGNITION IS THE NURSE
ASSESSING?
A. MOOD
B. ATTENTION
C. ORIENTATION
D. ABSTRACTION
CORRECT ANS: D. ABSTRACTION
WHEN A NURSE ASSESSES AN OLDER ADULT PATIENT, THE PATIENT'S ANSWERS SEEM VAGUE OR
UNRELATED TO THE QUESTIONS. THE PATIENT ALSO LEANS FORWARD AND FROWNS, LISTENING
INTENTLY TO THE NURSE. WHAT WOULD BE AN APPROPRIATE QUESTION FOR THE NURSE TO
ASK IN THIS SITUATION?
A. "ARE YOU HAVING DIFFICULTY HEARING WHEN I SPEAK?"
B. "HOW CAN I MAKE THIS ASSESSMENT INTERVIEW EASIER FOR YOU?"
C. "I NOTICE YOU ARE FROWNING. ARE YOU FEELING ANNOYED WITH ME?"