While the nurse is taking the history of a 68-year-old patient ...

[deesands]

While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of a(n):
 
  a. Great sense of humor.
  b. Uncooperative behavior.
  c. Inability to understand questions.
  d. Decreased level of consciousness.

Question 2

To test for gross motor skill and coordination of a 6-year-old child, which of these techniques would be appropriate? Ask the child to:
 
  a. Hop on one foot.
  b. Stand on his head.
  c. Touch his finger to his nose.
  d. Make funny faces at the nurse.

[stano32]

Answer to Question 1

ANS: D
A change in consciousness may be subtle. The nurse should notice any decreasing level of consciousness, disorientation, memory loss, uncooperative behavior, or even complacency in a previously combative person. The other responses are incorrect.

Answer to Question 2

ANS: A
Normally, a child can hop on one foot and can balance on one foot for approximately 5 seconds by 4 years of age and can balance on one foot for 8 to 10 seconds at 5 years of age. Children enjoy performing these tests. Failure to hop after 5 years of age indicates incoordination of gross motor skills. Asking the child to touch his or her finger to the nose checks fine motor coordination; and asking the child to make funny faces tests CN VII. Asking a child to stand on his or her head is not appropriate.

[deesands]

Thanks for the timely response, appreciate it

[mcabuhat]

TYSM