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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Related Questions
Correct Answer is D
Explanation
Choice A Reason:
To provide support for the patient is not appropriate. While providing support is important in therapeutic communication, the nurse's statement is more focused on bringing attention to an inconsistency rather than offering direct emotional support.
Choice B Reason:
To redirect the patient to an important idea is not appropriate. The nurse's statement is not aimed at redirecting the patient to a specific idea. Instead, it's about highlighting a potential incongruence between the patient's verbal and nonverbal expressions.
Choice C Reason:
To provide a suggestion for coping strategies is not appropriate. The nurse's statement is not directly offering suggestions for coping strategies. It is more focused on helping the patient recognize and explore the discrepancy in their expressed emotions.
Choice D Reasons:
To bring inconsistencies into awareness is appropriate. This therapeutic communication technique is aimed at helping the patient recognize and explore any inconsistencies between their verbal and nonverbal expressions. By pointing out the discrepancy between the patient's statement of feeling sad and the observed behavior of smiling, the nurse encourages the patient to reflect on and explore their emotions more deeply. This can contribute to increased self-awareness and a better understanding of the patient's emotional state.
Correct Answer is C
Explanation
Choice A Reason:
"Now that we've discussed your reasons for being here and how often we will meet, I'd like to talk about what we will do at the time of your discharge." This option seems to introduce the topic of termination prematurely, especially if the client's issues and goals haven't been adequately addressed yet.
Choice B Reason:
"You are being discharged today, so I'd like to bring up the subject of termination, which includes discussing your time here and summarizing what coping skills you have attained."This option presents termination at the time of discharge without prior discussion or collaboration with the client.
Choice C Reason:
"Now that we are working on your problem-solving skills and the behaviors you'd like to change, I'd like to bring up the issue of termination." In therapeutic relationships, termination is an essential phase that involves discussing the ending of the relationship and summarizing the progress made. Bringing up the topic of termination when actively working on the client's goals and issues is appropriate. It allows for a collaborative discussion about the achievements, future plans, and coping strategies that the client has developed during the therapeutic process.
Choice D Reason:
"I haven't met my new patient yet, but am working through my feelings of anxiety in dealing with a parent who wanted to kill herself." This statement is not related to the discussion of termination in the ongoing nurse-patient relationship.
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