Author Question: A nurse is performing a mental status examination and asks an adult patient what the statement Don't ... (Read 35 times)

vicotolentino · **on:** Jul 22, 2018

A nurse is performing a mental status examination and asks an adult patient what the statement Don't cry over spilled milk means. Which area is the nurse assessing?

a. Long-term memory
b. Abstract thinking
c. Recent memory
d. Knowledge

Question 2

A teen female patient reports intermittent abdominal pain for 12 hours. No dysuria is present. Which action will the nurse take when performing an abdominal assessment?

a. Assess the area that is most tender first.
b. Ask the patient about the color of her stools.
c. Recommend that the patient take more laxatives.
d. Avoid sexual references such as possible pregnancy.

elyse44 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: B
For an individual to explain common phrases such as A stitch in time saves nine or Don't cry over spilled milk requires a higher level of intellectual function or abstract thinking. Knowledge-based assessment is factual. Assess knowledge by asking how much the patient knows about the illness or the reason for seeking health care. To assess past (long-term) memory, ask the patient to recall the maiden name of the patient's mother, a birthday, or a special date in history. It is best to ask open-ended questions rather than simple yes/no questions. Patients demonstrate immediate recall (recent memory) by repeating a series of numbers in the order in which they are presented or in reverse order.

Answer to Question 2

ANS: B
Abdominal pain can be related to bowels. If stools are black or tarry (melena), this may indicate gastrointestinal alteration. The nurse should caution patients about the dangers of excessive use of laxatives or enemas. There is not enough information about the abdominal pain to recommend laxatives. Determine if the patient is pregnant, and note her last menstrual period. Pregnancy causes changes in abdominal shape and contour. Assess painful areas last to minimize discomfort and anxiety.