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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
A patient who states "I have no one who cares about me. "This statement relates more to the need for belonging and love, which is a lower level on Maslow's hierarchy.
Choice B Reason:
A patient who states "I have never met my career goals." This statement relates to self-esteem and self-actualization needs, which are higher-level needs in Maslow's hierarchy.
Choice C Reason:
A patient who exhibits hostile and angry behaviors is correct. Maslow's hierarchy of needs places safety and security needs above other needs. The patient exhibiting hostile and angry behaviors may pose a threat to their own safety, the safety of others, or the overall therapeutic environment. Addressing safety concerns and de-escalating aggressive behaviors takes precedence in this situation.
Choice D Reason:
A patient upset that his family can only visit during visiting hours. This situation is related to social needs and may not be as immediate a concern as the hostile and angry behaviors described in option C.
Correct Answer is B
Explanation
Choice A Reason:
Facing reality and developing standards for responsible behavior is inappropriate. This goal aligns more with reality therapy or choice theory, which focuses on helping individuals take responsibility for their behavior and make choices that lead to responsible actions.
Choice B Reason:
Examining irrational beliefs and eliminating self-defeating behaviors is appropriate. Beck's cognitive-behavioral therapy (CBT) is based on the premise that thoughts influence feelings and behaviors. The goal of CBT is to identify and change irrational or distorted thoughts that contribute to negative emotions and behaviors. This process involves examining irrational beliefs and challenging cognitive distortions to promote more realistic and adaptive thinking.
Choice C Reason:
Developing satisfactory relationships, maturity, and relative freedom from anxiety is inappropriate. This goal may align with psychodynamic or humanistic approaches that emphasize personal growth, self-awareness, and improvement in relationships.
Choice D Reason:
Reducing body tension through biofeedback training is inappropriate. This goal is more aligned with behavioral approaches that use techniques like biofeedback to address physiological symptoms.
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