A nurse is admitting an elderly patient suspected of having a cognitive disorder.
What inventories should be included as part of the admission assessment?
Scale for Assessment of Negative Symptoms (SANS)
Mental status examination (MSE)
Abnormal Involuntary Movements Scale (AIMS)
Mini-Mental State Examination (MMSE) .
The Correct Answer is B
Choice A rationale
The Scale for Assessment of Negative Symptoms (SANS) is a tool used to assess negative symptoms in schizophrenia and is not typically used in the assessment of cognitive disorders.
Choice B rationale
The Mental Status Examination (MSE) is a key part of the clinical assessment process in psychiatric practice. It is a structured way of observing and describing a patient’s current state of mind, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight, and judgement.
Choice C rationale
The Abnormal Involuntary Movements Scale (AIMS) is a rating scale that measures involuntary movements known as tardive dyskinesia (a side effect of long-term use of antipsychotic drugs). It is not typically used in the assessment of cognitive disorders.
Choice D rationale
The Mini-Mental State Examination (MMSE) is a commonly used test for complaints of memory problems or when a diagnosis of dementia is being considered. However, in this case, the MSE would be a more comprehensive tool.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Phenytoin is an antiepileptic medication used to control seizures. It’s important for the patient to understand that they should not switch brands of this medication without consulting their healthcare provider. Different brands of phenytoin can have different effects, and switching could potentially lead to changes in seizure control.
Choice B rationale
Regular dental appointments are important for patients taking phenytoin. This medication can cause gum overgrowth (gingival hyperplasia), so good oral hygiene and regular dental check- ups are essential.
Choice C rationale
It’s crucial for patients to notify their doctor before taking any other medications. Phenytoin can interact with many other drugs, altering their effectiveness or increasing side effects.
Therefore, the patient’s statement indicates an understanding of the need for caution when considering additional medications.
Choice D rationale
Phenytoin is a long-term medication for controlling seizures. It’s not something that patients can stop taking once they feel better. Abruptly stopping the medication can lead to withdrawal
seizures. Therefore, the patient’s statement, “I’ll be glad when I can stop taking this medicine,” indicates a need for further teaching about the importance of continuing the medication as prescribed.
Correct Answer is D
Explanation
If there is a delay in receiving the new TPN solution from the pharmacy, the nurse should infuse Dextrose 10% in water until the next TPN solution is available. This is because stopping TPN abruptly can cause hypoglycemia. Dextrose 10% in water can provide a source of glucose to prevent hypoglycemia.
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