loses track of time, then place, and lastly person. Ori-
entation returns in the reverse order: first, the person
knows who he or she is, then realizes place, and finally
time.
Disorientation is not synonymous with confu-
sion. A confused person cannot make sense of his or
her surroundings or figure things out even though he
or she may be fully oriented.
MEMORY
The nurse directly assesses memory, both recent and
remote, by asking questions with verifiable answers.
For example, if the nurse asks, “Do you have any mem-
ory problems?” the client may inaccurately respond
“no,” and the nurse cannot verify that. Similarly if the
nurse asks, “What did you do yesterday?” the nurse
may be unable to verify the accuracy of the client’s re-
sponses. Hence questions to assess memory generally
include ones such as:
- What is the name of the current president?
- Who was the president before that?
- In what county do you live?
- What is the capital of this state?
- What is your social security number?
ABILITY TO CONCENTRATE
The nurse assesses the client’s ability to concentrate
by asking the client to perform certain tasks such as:
- Spell the word “world” backward.
- Begin with the number 100, subtract seven,
subtract seven again, and so on. This is
called “serial sevens.” - Repeat the days of the week backward.
- Perform a three-part task such as, “Take a
piece of paper in your right hand, fold it in
half, and put it on the floor.” (The nurse
should give the instructions at one time.)
ABSTRACT THINKING AND
INTELLECTUAL ABILITIES
When assessing intellectual functioning, the nurse
must consider the client’s level of formal education.
Lack of formal education could hinder performance
in many tasks in this section.
The nurse assesses the client’s ability to use ab-
stract thinking,which is to make associations or
interpretations about a situation or comment. The
nurse usually can do so by asking the client to inter-
pret a common proverb such as “a stitch in time saves
nine.” If the client can explain the proverb correctly,
his or her abstract thinking abilities are intact. If the
client provides a literal explanation of the proverb
and cannot interpret its meaning, abstract think-
ing abilities are lacking. When the client continually
gives literal translations, this is evidence of concrete
thinking.For instance:- Proverb:A stitch in time saves nine.
Abstract meaning:If you take the time to fix
something now, you’ll avoid bigger problems
in the future.
Literal translation:Don’t forget to sew up
holes in your clothes (concrete thinking). - Proverb: People who live in glass houses
shouldn’t throw stones.
Abstract meaning:Don’t criticize others for
things you also may be guilty of doing.
Literal translation:If you throw a stone at a
glass house, it will break (concrete thinking).
The nurse also may assess the client’s intellectual
functioning by asking him or her to identify the simi-
larities between pairs of objects: for example, “What is
similar about an apple and an orange?” or “What do
the newspaper and the television have in common?”
Sensory-Perceptual Alterations
Some clients experience hallucinations(false sen-
sory perceptions, or perceptual experiences that do
not really exist). Hallucinations can involve the five
senses and bodily sensations. Auditory hallucinations
(hearing voices) are the most common; visual halluci-
nations (seeing things that don’t really exist) are the
second most common. Initially clients perceive hallu-
cinations as real experiences, but later in the illness
they may recognize them as hallucinations.Judgment and Insight
Judgmentrefers to the ability to interpret one’s en-
vironment and situation correctly and to adapt one’s
behavior and decisions accordingly (Chow & Cum-
mings, 2000). Problems with judgment may be evi-
denced as the client describes recent behavior and ac-
tivities that reflect a lack of reasonable care for self or
others. For example, the client may spend large sums
of money on frivolous items when he or she cannot af-
ford basic necessities such as food or clothing. Risky
behaviors such as picking up strangers in bars or un-
protected sexual activity also may indicate poor judg-
ment. The nurse also may assess a client’s judgment
by asking the client hypothetical questions such as,
“If you found a stamped, addressed envelope on the
ground, what would you do?”
Insightis the ability to understand the true na-
ture of one’s situation and accept some personal re-
sponsibility for that situation. The nurse frequently
can infer insight from the client’s ability to describe re-
alistically the strengths and weaknesses of his or her
behavior. An example of poor insight would be a client
who places all blame on others for his own behavior,8 ASSESSMENT 163