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)

Choice A Reason:

Wife/mother is incorrect. The wife/mother expresses that she is not skillful in conflict resolution, but her concerns are related to her own abilities rather than exhibiting specific problematic behaviors that are disruptive or distressing to the family system.

Choice B Reason:

Daughter is correct. The daughter, who is rebellious and in academic trouble, is most likely to be listed as the "identified patient" because her behavior is presenting visible challenges and concerns. In family systems therapy, addressing and understanding the dynamics surrounding the identified patient can provide insights into the broader family issues and interactions.

Choice C Reason:

Son is incorrect. The son is conflicted about where to attend college, which is a common developmental decision. While it may cause some family stress, it doesn't necessarily indicate the presence of disruptive or problematic behavior warranting the label of "identified patient."

Choice D Reason:

Husband/father is incorrect. The husband/father is skeptical of the idea that talking can be helpful, but skepticism or reluctance to engage in therapy does not necessarily make him the identified patient. His behavior doesn't present as a disruptive symptom within the family.

Choice A Reason:

Grooming is correct. Grooming assesses the client's personal care and hygiene, providing insight into their ability to perform self-care activities.

Choice B Reason:

Long-term memory is correct. Evaluating long-term memory helps assess the client's ability to recall past events and information, which can be affected in individuals with dementia.

Choice C Reason:

Support systems is incorrect. While support systems are crucial in the overall care of individuals with dementia, they are not typically assessed in a traditional MSE.

Choice D Reason:

Affecting is correct. Affect refers to the client's emotional expression. Assessing affect helps in understanding the client's emotional state, which can be important in diagnosing and managing dementia.

Choice E Reason:

Presence of pain is incorrect. While assessing pain is essential in clinical care, it may be more pertinent to a physical assessment than a mental status examination specifically focused on cognitive functioning.