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).

Answer and Explanation

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.

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Correct Answer is A

Explanation

The correct answer is choice A. Ask the client direct questions about the hallucination.

Choice A rationale:

Asking direct questions about the hallucination helps the nurse understand the client’s experience and assess the content and intensity of the hallucinations. This approach also allows the nurse to provide appropriate support and interventions.

Choice B rationale:

Acting as if the hallucination is real can reinforce the client’s distorted perception of reality, which is not therapeutic. The nurse should acknowledge the client’s experience without validating the hallucination as real.

Choice C rationale:

Telling the client to go to their room and that the hallucinations should go away is dismissive and does not address the client’s immediate needs. It is important to engage with the client and provide support rather than dismiss their experience.

Choice D rationale:

Instructing the client to argue with the voices can increase the client’s distress and is not a recommended therapeutic approach. Instead, the nurse should help the client find ways to cope with and manage the hallucinations.

A. A room without a window. B. A room containing personal belongings. C. A room adjacent to the nursing station. D. A room with dim lighting.

Correct Answer is B

Explanation

The correct answer is choice B. A room containing personal belongings.

Choice A rationale:

A room without a window would likely be isolating and could contribute to feelings of confusion and disorientation in a cognitively impaired individual. Natural light from windows helps regulate the circadian rhythm and provides a sense of time, which is crucial for maintaining a therapeutic environment.

Choice B rationale:

A room containing personal belongings is the correct choice. Familiar items from home can provide comfort and a sense of familiarity, reducing anxiety and agitation in cognitively impaired individuals. These belongings can act as cues for memory recall and assist in maintaining a connection to their personal identity.

Choice C rationale:

A room adjacent to the nursing station might lead to increased noise and disruption for the client. Cognitively impaired individuals often benefit from a quiet and calm environment, which would not be ensured in a room close to a potentially busy nursing station.

Choice D rationale:

A room with dim lighting can exacerbate confusion and disorientation in cognitively impaired individuals. Adequate lighting is essential for maintaining a safe and structured environment, as poor lighting can lead to falls and increased disorientation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client diagnosed with schizophrenia and is experiencing hallucinations. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is taking care of a client who is cognitively impaired. The nurse recognizes that which of the following rooms will provide a therapeutic environment for this client?

Correct Answer is B

Explanation

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?

A nurse in a mental health facility is caring for a client who is upset about the loss of privileges due to repetitive negative behavior. Which of the following statements by the nurse demonstrates the effective use of assertive communication?

A nurse is caring for a client diagnosed with a mental illness on a psychiatric unit. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?

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