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.
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Correct Answer is D
Explanation
Choice A Reason:
In the orientation phase is false. The orientation phase is focused on establishing rapport, building trust, and identifying the patient's needs and goals. It is too early to discuss termination during this phase.
Choice B Reason:
On the working phase is false. The working phase involves active problem-solving, goal attainment, and skill development. While progress is being made, it is not the appropriate time to introduce the topic of termination.
Choice C Reason:
When the patient brings up the topic is false. While it's important to be responsive to the patient's concerns, addressing the issue of termination solely based on the patient's initiation may not provide a comprehensive and planned discussion. The nurse should guide the conversation about termination at the appropriate time, considering the progress made in therapy.
Choice D Reason:
The termination phase is the final phase of the therapeutic relationship, and it involves discussing and planning for the conclusion of the therapeutic alliance. It provides an opportunity for the nurse and patient to reflect on the progress made, revisit goals, and discuss strategies for maintaining gains after the conclusion of the formal therapeutic relationship.
Correct Answer is ["3.5"]
Explanation
He has been prescribed Fluphenazine decanoate 87.5 mg intramuscularly every 3 weeks to treat his schizophrenia. The nurse checks the medication order and the vial label. The vial contains Fluphenazine decanoate 25 mg per milliliter. To calculate the amount of medication to administer, the nurse uses the formula:
dose ordered / dose available = mL to administer
Substituting the values, the nurse gets:
87.5 mg / 25 mg/ml = 3.5 ml
Therefore, the nurse will administer 3.5 milliliters of Fluphenazine decanoate for this dose.
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