Author Question: A nurse assesses a client's recent memory. Which client statement confirms that the client's remote ... (Read 81 times)

tatyanajohnson · **on:** Jun 25, 2018

A nurse assesses a client's recent memory. Which client statement confirms that the client's remote memory is intact?

a. A young girl wrapped in a shroud fell asleep on a bed of clouds.
b. I was born on April 3, 1967, in Johnstown Community Hospital.
c. Apple, chair, and pencil are the words you just stated.
d. I ate oatmeal with wheat toast and orange juice for breakfast.

Question 2

A nurse plans care for a client who has a hypoactive response to a test of deep tendon reflexes. Which intervention should the nurse include in this client's plan of care?

a. Check bath water temperature with a thermometer.
b. Provide the client with assistance when ambulating.
c. Place elastic support hose on the client's legs.
d. Assess the client's feet for wounds each shift.

trog · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: D
Asking clients about recent events that can be verified, such as what the client ate for breakfast, assesses the client's recent memory. The client's ability to make up a rhyme tests not memory, but rather a higher level of cognition. Asking clients about certain facts from the past that can be verified assesses remote or long-term memory. Asking the client to repeat words assesses the client's immediate memory.

Answer to Question 2

ANS: B
Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and coordination, predisposing the client to falls. The nurse should plan to provide the client with ambulation assistance to prevent injury. The other interventions do not address the client's problem.