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The nurse is caring for an older adult client who has recently been admitted and is performing a physical assessment. What test can the nurse perform to obtain a baseline cognitive function?
- A. Mini-Cog
- B. Neurovascular assessment
- C. Cardiovascular assessment
- D. Pupillary response
Correct Answer: A
Rationale: When performing a physical assessment for an older client, ascertain a baseline cognitive function level at onset of interview. The Mini-Cog is a quick and simple four-question method. Neurovascular and cardiovascular assessment and pupillary response are not specific assessment techniques to assess cognitive function.
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Which of the following are statements clients make about how they feel?
- A. Objective data
- B. Cultural data
- C. Cognitive data
- D. Subjective data
Correct Answer: D
Rationale: Subjective data include statements clients make about what they feel. Objective data are facts obtained through observation, physical examination, and diagnostic testing. Cultural data include cultural background and health beliefs.
The nurse is completing a physical examination on a client who reports abdominal pain. Which are facts the nurse will obtain during the physical examination?
- A. Symptoms
- B. Objective data
- C. Subjective data
- D. Complaints
Correct Answer: B
Rationale: Objective data are facts obtained through observation, physical examination, and diagnostic testing. Feelings related to subjective data are symptoms. Subjective data are statements clients make about what they feel. Complaints are reasons the client is seeking care.
Questions about current and past use of prescription medications would probably be part of which of the following?
- A. The client's past health history
- B. The client's history of present illness
- C. The client's chief complaint
- D. The functional assessment
Correct Answer: A
Rationale: The client's past health history includes identifying childhood diseases and prior hospitalizations. History of present illness is gathered when the nurse asks the client to describe all present problems, including the onset, frequency, and duration of symptoms. A chief complaint is the current reason the client is seeking care. A functional assessment determines how well the client can perform activities of daily living.
The nurse provides a comprehensive initial assessment on a newly admitted client. What is the benefit to establishing this database from the client?
- A. It will help determine wh
- B. It will inform the healthcare team about what medications are best for the client.
- C. It will give the healthcare team all of the information about the client.
- D. It will be a yardstick for measuring effectiveness of care.
Correct Answer: D
Rationale: Findings from this comprehensive initial assessment establish a database that gives all team members relevant client information and becomes a yardstick for measuring effectiveness of care. The physician will make the determination about what unit the client will require according to the acuity of care. The physician will determine what medications are best for the client. The information obtained will not be conclusive, and further assessment of the client's condition and information will be obtained during the hospital stay.
The nurse is performing a functional assessment for a client who has had a mild stroke and will be discharged in 2 days from the hospital. What question would be important to ask when conducting this assessment?
- A. Do you have enough money to pay for the medications that you will be taking at home?'
- B. Do you have friends that will come and visit and take you out to socialize?'
- C. How will you obtain transportation to return to see the physician in 1 week?'
- D. Do you understand that your medication can cause bleeding tendencies?'
Correct Answer: C
Rationale: A functional assessment determines how well the client can manage activities of daily living (ADLs). ADLs include self-care activities, such as walking moderate distances, bathing, and toileting, and instrumental activities, such as preparing meals, obtaining transportation, and dialing the phone. This assessment component is particularly important when assessing older adults or physically challenged clients of any age. The ability to pay for medications or socialize and the side effects of the medication do not pertain to ADLs.