During an interview with an older adult client, the nurse notes ...

[moongchi]

During an interview with an older adult client, the nurse notes the client is confused as to day and time. The nurse documents this finding as an indicator of which item?
 
  1. Affect and mood.
  2. Orientation.
  3. Cooperation.
  4. Level of anxiety.

Question 2

The nurse is assessing an adult client. Which observations should the nurse include when documenting the general survey of this client?
 
  Select all that apply.
  1. Blood pressure 112/68, pulse 68, 98.6 F, respiratory rate 16.
  2. Thin, well-nourished male client, appears younger than stated age.
  3. Client moves about exam room without difficulty.
  4. Abdomen flat, nondistended, bowel sounds present, nontender on palpation.
  5. Pain rating of 3 on a 0 to 10 scale.

[Meganchabluk]

Answer to Question 1

Correct Answer: 2

Client's ability to state name, location, and the date and time of day assesses orientation to person, place, and time. The client's affect and mood are revealed through speech, body language, and facial expression. The client was not uncooperative, but rather confused to day and time. Like affect and mood, the client's level of anxiety is revealed through speech, body language, and facial expression.

Answer to Question 2

Correct Answer: 2, 3

The general survey is composed of four major categories of observation: physical appearance, mental status, mobility, and behavior of the client. The documentation thin, well-nourished male client, appears younger than stated age reflects the client's physical appearance, one of the components of the general survey. The documentation client moves about exam room without difficulty describes the client's overall mobility, another component of the general survey. The vital signs are objective information, but not part of the actual general survey. The documentation abdomen flat, nondistended, bowel sounds present, nontender on palpation is specific to the abdominal assessment and not part of the general survey. A pain assessment is included when assessing the client's vital signs.

[moongchi]

TYSM

[Joy Chen]

Excellent