Evaluating a client’s judgment?

1. While performing a mental status examination, which question should the nurse ask when attempting to evaluate a client’s judgment?

 

A. “What is the difference between a hamster and a rabbit as a pet?”

B. “Should someone who lives in a glass house throw stones?”

C. “Do you write checks if you know the bank account is overdrawn?”

D. “Can you recall the date the Twin Towers in New York were destroyed?

 

2. An older male client reports to the nurse that his feet are cold. Before covering the client’s
feet, which assessments should the nurse complete? (SATA)

a. Observe color of the feet and toes.
b. Palpate dorsal surface of feet for warmth.
c. Assess volume of the pedal pulses.
d. Measure skin elasticity around the ankles.
e.  Test feet for a positive Babinski reflex.

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