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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Lithium is a commonly used medication for treating bipolar disorder, and therapeutic drug monitoring is crucial to ensure its effectiveness and prevent potential toxicity. Monitoring the client's lithium levels in the blood is important because lithium has a narrow therapeutic range, meaning that levels that are too low might not provide the desired therapeutic effect, while levels that are too high can lead to toxicity.
B) "This medication is addictive, so you will need to discontinue it in six months."
Lithium is not considered addictive. It's important to provide accurate information about the nature of the medication to avoid unnecessary concerns.
C) "Weight gain should be reported to your provider as an indication of lithium toxicity."
While weight gain can be a side effect of some medications, it's not a specific indicator of lithium toxicity. Lithium toxicity is characterized by a range of symptoms including tremors, confusion, nausea, vomiting, and excessive thirst, among others.
D) "Your provider may prescribe a diuretic if you have trouble urinating while taking lithium."
Diuretics are generally not recommended with lithium because they can increase the risk of lithium toxicity. Lithium can affect kidney function, and using diuretics may exacerbate this effect. The client should be advised not to use diuretics without consulting their healthcare provider.
Correct Answer is C
Explanation
While offering female assistive personnel for personal hygiene care is one option, it doesn't necessarily address the larger concern of the client's discomfort with a male nurse in her care team. The nurse manager's response should address the client's overall care and interactions.
B) "Your doctor is a man, so it seems like this should not be a problem."
Comparing the client's situation to the gender of the doctor might not be perceived as sensitive or supportive. The client's comfort with different members of the care team can vary, and it's important to address her concerns directly.
C) "I can review the assignments and arrange for a female nurse to care for you."
Explanation:
Respecting a patient's preferences and comfort is an important aspect of patient-centered care. If the female client expresses discomfort with a male nurse providing care due to her traumatic experience, it's appropriate for the nurse manager to accommodate her request if feasible. Changing the assignment to ensure that a female nurse provides care respects the client's wishes and helps create a more supportive and comfortable environment.
D) "The nurse assigned to care for you is very capable and cares for other women in this situation."
While it's important to emphasize the capabilities of the nurse, this response does not directly address the client's expressed discomfort with a male nurse. It's crucial to prioritize the client's feelings and concerns in this situation.
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