Health Assessment Jarvis Ch 5 Practice Questions - with rationales

A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. The nurse concludes: ANS: that more information should be gathered to decide whether her dress is appropriate. Grooming and hygiene should be noted. The person is clean and well groomed, hair is neat and clean, women have moderate or no makeup, men are shaved or their beards or moustaches are well groomed. Use care in interpreting clothing that is disheveled, bizarre, or in poor repair because these sometimes reflect the person's economic status or a deliberate fashion trend. A 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of the fluid and electrolyte imbalance. For the mental status examination, the nurse should first assess the patient's: ANS: level of consciousness and cognitive abilities. Delirium is a disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention. It is not an alteration in mood, affect, or language abilities. A 23-year-old patient in the clinic appears anxious. Her speech is rapid, and she is fidgety and in constant motion. Which of these questions or statements would be most appropriate for the nurse to use in this situation to assess attention span? ANS: "Please pick up the pencil in your left hand, move it to your right hand, and place it on the table." Attention span is evaluated by assessing the individual's ability to concentrate and complete a thought or task without wandering. Giving a series of directions to fol