Practice Question
The nurse is performing a mental status examination and asks an adult client to interpret a familiar proverb. When the client is unable to interpret the proverb, the nurse repeats the instructions and the client is still unable to accurately interpret it. Which action should the nurse implement?
Answer Choices:
Correct Answer:
Document client's difficulty with abstract reasoning.
Rationale:
🟦 Interpreting a proverb is a standardized method used during a mental status examination (MSE) to assess the client’s ability to use abstract reasoning, a higher-level cognitive skill.
🟦 If the client cannot interpret a proverb even after the nurse clarifies instructions, this indicates a deficit in abstract thinking, not a misunderstanding of directions.
🟦 Abstract reasoning is commonly impaired in conditions such as dementia, schizophrenia, intellectual disability, or acute confusion.
🟦 The nurse’s responsibility during the MSE is to objectively record findings, not teach or coach the client into a correct answer.
🟦 Therefore, documenting the client’s difficulty with abstract reasoning is the appropriate and clinically accurate action.
❌ Incorrect Options Explained
Explain the meaning and ask the client to repeat it
— This teaches the client and invalidates the assessment; it no longer measures cognitive ability.
Provide a different proverb
— If they cannot interpret the first proverb, another proverb will likely not change the result and only prolongs the assessment.
Reschedule the exam
— There is no indication of fatigue, confusion, or illness that would justify delaying the test.
— The inability is a finding, not a timing issue.
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This question is from Fall 2025-BSN -246 RN Health Assessment which contains 59 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: Health Assessment
- Answer Choices: 4