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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Vitamin K is not the antidote for heparin. It is used to reverse the effects of warfarin, which is a vitamin K antagonist.
Choice B rationale
Iron is not related to the reversal of heparin. It is a mineral that is crucial for many bodily functions, including the transport of oxygen in the blood.
Choice C rationale
Glucagon is a hormone that raises the level of glucose in the blood. It is not used as an antidote for heparin.
Choice D rationale
Protamine is the correct choice. Protamine sulfate is a drug that reverses the anticoagulant effects of heparin by binding to it and forming a stable complex, thereby neutralizing its anticoagulant activity.
Correct Answer is A
Explanation
The correct answer is Choice A
Choice A rationale: Ensuring that the mother calls and the nurse takes the baby to the room maintains security and safety protocols. It prevents unauthorized individuals from handling the infant, thus minimizing the risk of abduction or harm.
Choice B rationale: Showing photo identification alone is not sufficient to ensure the safety of the newborn. The nurse should directly handle the transfer of the baby to maintain strict security measures and verify the proper identification in the process.
Choice C rationale: Allowing someone to push the baby in a wheeled bassinet without proper authorization and identification verification does not adhere to safety protocols. The nurse should always verify and manage the transfer to ensure the infant’s security.
Choice D rationale: Carrying the grandchild to the room without adequate identification verification and authorization does not follow safety protocols. The nurse should always be involved in the transfer to prevent any security breaches and ensure the infant’s safety.
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