A nurse is admitting an older adult client 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)
Abnormal Involuntary Movements Scale (AIMS)
Mental status examination (MSE)
Scale for Assessment of Negative Symptoms (SANS)
The Correct Answer is C
A. Brief Patient Health Questionnaire (Brief PHQ):
The Brief PHQ is a screening tool used to assess symptoms of depression. While it may be relevant to assess mood and emotional well-being, it is not specific to evaluating cognitive functioning or cognitive disorders.
B. Abnormal Involuntary Movements Scale (AIMS):
The AIMS is used to assess involuntary movements, particularly in individuals taking antipsychotic medications. It is not directly related to assessing cognitive disorders.
C,. Mental status examination (MSE)
Explanation:
When admitting an older adult client with a suspected cognitive disorder, including a mental status examination (MSE) as part of the assessment is crucial. The MSE is a structured assessment of a client's current cognitive functioning, emotional state, and thought processes. It helps to evaluate memory, attention, language, perception, orientation, mood, and other cognitive and emotional domains.
D. Scale for Assessment of Negative Symptoms (SANS):
The SANS is used to assess negative symptoms in individuals with schizophrenia. It focuses on features such as affective blunting, alogia, anhedonia, and other negative symptoms. While it may provide important information about a client's mental state, it is not primarily used to assess cognitive disorders.
Assessing cognitive function is a key component when evaluating older adult clients for cognitive disorders such as dementia or other cognitive impairments. The MSE provides valuable information to guide diagnosis and treatment planning for these conditions.
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Related Questions
Correct Answer is A
Explanation
A. Identify the client's nutritional status.
Explanation:
Given the significant weight loss and the client's distorted belief about her body image (believing she is fat despite losing weight), it is crucial to assess the client's nutritional status first. Rapid weight loss and distorted body image are characteristic features of an eating disorder, such as anorexia nervosa. The nurse needs to determine the extent of malnutrition and potential medical complications related to inadequate nutrition. This assessment will guide the subsequent interventions.
Why the other choices are incorrect:
B. Provide a structured environment for the client.
While providing a structured environment can be important in managing eating disorders, such as anorexia nervosa, it is not the first priority. Understanding the client's nutritional status and medical condition takes precedence.
C. Plan a therapeutic diet for the client.
Planning a therapeutic diet may be part of the client's care plan, but without understanding the underlying nutritional status and potential eating disorder, creating a diet plan may not be effective or appropriate.
D. Request a mental health consult.
While a mental health consult is important for addressing the client's distorted body image and potential eating disorder, it should follow the assessment of nutritional status. The nutritional assessment provides critical information for both medical and psychological interventions.
Correct Answer is D
Explanation
A) Maturational crisis:
This type of crisis arises from normal life transitions, such as entering a new stage of development (adolescence, midlife crisis, etc.). It involves a struggle to adapt to new roles and responsibilities. The client's situation does involve a life transition due to the death of his wife, but the sudden nature of the event and the resulting distress suggest a situational crisis.
B) Adventitious crisis:
Adventitious crises are caused by extraordinary events that are external to the individual's usual experience, such as natural disasters, accidents, or crimes. While the sudden death of the client's wife is an unexpected and tragic event, it's not an adventitious crisis because it involves personal loss rather than a large-scale or external event.
C) Developmental crisis:
Developmental crises are associated with specific stages of life and the challenges and changes that come with them. This crisis doesn't seem to fit the developmental category as it is more tied to the specific event of the wife's sudden death.
D) Situational crisis
Explanation:
A situational crisis is a type of crisis that arises from a specific event or situation that disrupts an individual's normal functioning and coping abilities. In this case, the sudden death of the client's wife is the triggering event that has led to his feeling paralyzed and overwhelmed in his ability to cope with work and family responsibilities. Situational crises are often unexpected and can lead to a temporary state of disorganization and distress.
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