The nurse is assessing a client’s neurological status. The c…

The nurse is assessing a client’s neurological status. The client is in his room talking with his wife about the current television show they are watching. When asked, the client is aware of where he is, but does not know his name or the current year. How would the nurse document this finding?

The nurse is performing her shift assessment on a client who…

The nurse is performing her shift assessment on a client who was admitted after falling from a rooftop. During the assessment the nurse notes that upon stimulation, the client flexes her upper arms, wrists, and fingers toward the thorax of the body and internally rotates their lower extremities. What type of posturing would this be considered?