A nurse is admitting an older adult client to the unit who has a suspected cognitive disorder. Which of the following inventories should be included as part of the admission assessment?
Brief Patient Health Questionnaire (Brief PHQ).
Scale for Assessment of Negative Symptoms (SANS).
Mental status examination (MSE).
Abnormal Involuntary Movements Scale (AIMS).
The Correct Answer is C
Choice A rationale:
The Brief Patient Health naire (Brief PHQ) is primarily used for assessing the presence and severity of depressive symptoms and not specifically for cognitive disorders. It consists of nine items that assess the frequency of specific symptoms over the past two weeks.
Choice B rationale:
The Scale for Assessment of Negative Symptoms (SANS) is a tool used to assess negative symptoms in schizophrenia and other related psychotic disorders. It includes items related to affective blunting, alogia, anhedonia, and avolition, which are not directly relevant to the assessment of cognitive disorders.
Choice C rationale:
The Mental Status Examination (MSE) is a comprehensive assessment of cognitive function, including orientation, memory, attention, language, and executive function. It provides valuable information about the client's cognitive abilities and can aid in diagnosing cognitive disorders such as dementia or delirium.
Choice D rationale:
The Abnormal Involuntary Movements Scale (AIMS) is used to assess the presence and severity of tardive dyskinesia, a movement disorder commonly associated with the use of antipsychotic medications. It is not relevant to the assessment of cognitive disorders.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
When dealing with an angry and aggressive client, using clarification is an essential communication technique. It involves asking open-ended questions to better understand the patient's emotions and concerns, which can help defuse the situation and provide insight into the underlying issues.
Choice B rationale:
Maintaining constant eye contact can be interpreted as confrontational or aggressive behavior, potentially escalating the client's aggression. It's important to maintain a respectful distance and avoid behaviors that could exacerbate the situation.
Choice C rationale:
Moving the patient to a private area is a reasonable approach if the environment is contributing to the patient's agitation. However, the primary concern should be the safety of both the patient and the staff. Privacy can be important, but it shouldn't compromise safety.
Choice D rationale:
Speaking to the patient with an authoritative voice and asking "why" questions can escalate the situation further. It may come across as confrontational and provoke a defensive reaction from the patient. Open-ended questions that encourage the patient to express their feelings can be more effective in de-escalation.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale:
Impulsive behaviors, such as sudden excessive spending, risky sexual encounters, or reckless driving, are common manifestations of manic behavior in individuals with bipolar disorder. These behaviors can result from the heightened energy and impulsivity associated with a manic episode.
Choice B rationale:
Dressing in black or grey clothing is not indicative of manic behavior. Mania is characterized by heightened mood, excessive energy, and impulsivity, rather than specific clothing choices.
Choice C rationale:
Talking in rapid, continuous speech, also known as pressured speech, is a classic symptom of manic episodes. Individuals may talk rapidly, switch topics frequently, and have difficulty allowing others to interject or participate in the conversation.
Choice D rationale:
Interacting with others in a flirtatious way can be a manifestation of manic behavior. During manic episodes, individuals may exhibit increased sociability, reduced inhibitions, and engage in behaviors that are out of character, including flirtatious interactions.
Choice E rationale:
Sleeping for long periods of time is not consistent with manic behavior. Manic episodes are often associated with decreased need for sleep, and individuals may experience insomnia or only require minimal sleep during these episodes.
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