A 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. When conducting the mental status examination for this patient, what should the nurse assess first?

Question

Quizplus · Accepted Answer

The sequence of steps for a mental status examination forms a hierarchy in which the most basic functions (consciousness, language) are assessed first. The first steps must be assessed accurately to ensure validity for the steps that follow (i.e., if consciousness is clouded, the person cannot be expected to have full attention and to answer accurately or cooperate with new learning).

A 20-Year-Old Construction Worker Has Been Brought into the Emergency