A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE) the nurse should include which of the following data? (Select all that apply)
Coping skills
Ability to perform calculations
Recall ability
Long-term memory
Level of orientation.
Correct Answer : B,C,D,E
Choice A Reason:
The coping skills (Choice A) may be observed and assessed as part of the broader clinical picture, but they are not typically specific components of a formal Mental Status Examination.
Choice B Reason:
Ability to perform calculations. This assesses the client's cognitive abilities, specifically related to mathematical reasoning and problem-solving.
Choice C Reason:
Recall ability. Assessing recall ability helps evaluate the client's short-term memory, which can be impaired in individuals with dementia.
Choice D Reason:
Long-term memory. Evaluating long-term memory provides insights into the client's ability to recall information from the distant past, which is another aspect of cognitive function.
Choice E Reason:
Level of orientation. Assessing orientation to time, place, and person is crucial in understanding the client's awareness of their surroundings and current circumstances, which can be affected in dementia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Engaging in friendly interactions with the client is correct. Developing a therapeutic relationship involves creating a supportive and empathetic connection with the client. Engaging in friendly interactions helps build trust and rapport. This approach fosters a positive environment for communication and collaboration.
Choice B Reason:
Instructing the client on how he should behave is incorrect. Instructing the client on how to behave can be perceived as directive and may hinder the development of a collaborative and trusting relationship.
Choice C Reason:
Setting limits for the relationship is incorrect. While setting boundaries is important, using the term "limits" can convey a sense of restriction. It's crucial to establish appropriate boundaries, but the term "limits" may not promote the openness needed in a therapeutic relationship.
Choice D Reason:
Promoting the use of transference by the client is incorrect. Promoting transference involves encouraging the client to project feelings from past relationships onto the nurse. This is generally not considered a therapeutic approach and may lead to misunderstandings in the therapeutic relationship.
Correct Answer is D
Explanation
Choice A Reason:
"Your provider usually recommends a diaphragm and spermicidal cream." This response prescribes a specific method without considering the client's preferences, health history, or individual needs. It's important to involve the client in the decision-making process and discuss various contraceptive options.
Choice B Reason:
"It's your choice, of course, but birth control pills are the most reliable." This response might pressure the client toward a specific method and may not consider other factors such as the client's preference, medical history, or potential side effects. It's essential to provide information and support rather than directing the client to a particular choice.
Choice C Reason:
"I’d consider an intrauterine device. You won't have to worry about pregnancy. “Similar to the first option, this response recommends a specific method without a thorough discussion of the client's preferences, health considerations, or individual needs. It's important to explore various options collaboratively with the client.
Choice D Reason:
"Let's talk about the available options and go from there. “This response is patient-centered and encourages collaborative decision-making. It allows the nurse to discuss various contraceptive methods, considering the client's preferences, health history, and individual needs. It supports shared decision-making between the nurse and the client.
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