A patient has been in the intensive care unit for 10 days. He has ...

[silviawilliams41]

A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination. During the tests of cognitive function, the nurse would expect that
 
  he:
  a.
  May display some disruption in thought content.
  b.
  Will state, I am so relieved to be out of intensive care.
  c.
  Will be oriented to place and person, but the patient may not be certain of the date.
  d.
  May show evidence of some clouding of his level of consciousness.

Question 2

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 that:
 
  a.
  She probably does not have any problems.
  b.
  She is only trying to shock people and that her dress should be ignored.
  c.
  She has a manic syndrome because of her abnormal dress and grooming.
  d.
  More information should be gathered to decide whether her dress is appropriate.

[Christopher]

Answer to Question 1

ANS: C
The nurse can discern the orientation of cognitive function through the course of the interview or can directly and tactfully ask, Some people have trouble keeping up with the dates while in the hospital. Do you know today's date? Many hospitalized people have trouble with the exact date but are fully oriented on the remaining items.

Answer to Question 2

ANS: D
Grooming and hygiene should be notedthe person is clean and well groomed, hair is neat and clean, women have moderate or no makeup, and men are shaved or their beards or moustaches are well groomed. Care should be taken when interpreting clothing that is disheveled, bizarre, or in poor repair because these sometimes reflect the person's economic status or a deliberate fashion trend.

[silviawilliams41]

Excellent

[shailee]

TYSM