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.

Answer and Explanation

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 C

Explanation

Choice A Reason:

"Your husband is making really good progress" This statement assumes a positive or negative judgment about the husband's progress without first understanding the spouse's concerns. It may not address the spouse's immediate emotional needs or allow them to express their feelings.

Choice B Reason:

"Crying helps us let things out and we feel better". While this statement acknowledges the act of crying as a way to express emotions, it doesn't directly address the specific concerns of the spouse or invite further communication about the issues causing distress.

Choice C Reason:

"Tell me what is concerning you. “This is a therapeutic nursing response because it encourages the spouse to express their concerns and share their feelings. It opens up communication and allows the nurse to better understand the specific issues or worries that the spouse is experiencing. This response demonstrates active listening and a genuine interest in the spouse's perspective, fostering a supportive and empathetic therapeutic relationship.

Choice D Reason:

"Did your husband say something to upset you?" This question assumes that the spouse's distress is solely related to something the husband said. It may not be the most open-ended or empathetic way to encourage the spouse to share their concerns and might direct the focus too narrowly.

A. Coordinate the implementation of the nursing care plan and documents. B. Provide and maintain a safe and therapeutic environment in collaboration with others. C. Apply current knowledge to assess the patient's response to medication. D. Give anticipatory guidance to prevent or reduce menta illness and enhance mental health.

Correct Answer is B

Explanation

Choice A Reason:

Coordinating the implementation of the nursing care plan and documents is inappropriate. This choice is more related to general nursing responsibilities and care coordination. Milieu therapy specifically focuses on creating a therapeutic environment rather than coordinating care plans and documents.

Choice B Reason:

Providing and maintaining a safe and therapeutic environment in collaboration with others is appropriate. Milieu therapy involves creating a therapeutic environment that promotes the patient's mental health and well-being. This includes ensuring safety, providing structure, and creating a supportive atmosphere for patients. The nurse, in collaboration with the healthcare team, is responsible for establishing and maintaining this therapeutic milieu.

Choice C Reason:

Applying current knowledge to assess the patient's response to medication is inappropriate.

Assessing the patient's response to medication is an important nursing responsibility, but it is not the primary focus of milieu therapy. Milieu therapy is more concerned with the overall environment and its impact on the patient's mental health.

Choice D Reason:

Giving anticipatory guidance to prevent or reduce mental illness and enhance mental health is inappropriate. While anticipatory guidance is important in nursing care, it may not capture the essence of creating and maintaining a therapeutic environment, which is the core of milieu therapy. This choice is more related to health education and preventive measures rather than the overall therapeutic environment.

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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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