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 D
Explanation
The correct answer is Choice D.
Choice A rationale: This statement reflects anger and frustration, which are characteristic of the anger stage of grief. The individual is expressing disbelief in the doctor's competence but is not denying the reality of their diagnosis.
Choice B rationale: This statement indicates acceptance and acknowledgment of the physical effects of the disease. The client recognizes their lack of energy but is not denying their condition, suggesting they are in a more advanced stage of the grieving process.
Choice C rationale: This statement reflects acceptance of the situation and gratitude towards the doctor. The client acknowledges the efforts made by the medical team and recognizes the inevitability of their condition, indicating they are in the acceptance stage of grief.
Choice D rationale: This statement indicates denial as the client doubts the doctor's prognosis and believes the doctor is exaggerating. Denial is a common initial reaction where the individual struggles to accept the reality of their diagnosis, instead choosing to believe it is not as severe.
Correct Answer is D
Explanation
Choice A rationale:
Administering medication to sedate the client is not the appropriate initial action. The client's confusion and restlessness could be due to various factors, and administering sedative medication without identifying the cause of these symptoms could lead to adverse effects or mask underlying issues.
Choice B rationale:
Calling the family to stay with the client might provide emotional support, but it doesn't directly address the client's safety needs. The client's increasing confusion and restlessness require a more immediate intervention to ensure their safety.
Choice C rationale:
Applying wrist and leg restraints should be a last resort and is not the appropriate initial action in this situation. Restraints should only be used if less restrictive interventions have failed and the client's safety is at risk. Restraints can lead to complications such as decreased mobility, skin breakdown, and increased agitation.
Choice D rationale:
Correct Choice Moving the client to a room closer to the nurses' station is the most appropriate action in this scenario. This intervention helps to increase the client's visibility and proximity to nursing staff, making it easier to monitor and address their needs promptly. It also promotes a safer environment while allowing the healthcare team to assess the underlying causes of the restlessness and confusion.
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