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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Technical expert is correct. In Peplau's Interpersonal Relations in Nursing theory, the emphasis is on the interpersonal and psychosocial aspects of nursing. While technical expertise is crucial in nursing practice, it is not specifically identified as a distinct role according to Peplau. The theory focuses more on the nurse's role in facilitating the patient's growth and development through the therapeutic relationship.
Choice B Reason:
Resource is incorrect. Peplau identified the nurse as a resource, emphasizing the nurse's role in providing information, support, and guidance to the patient. This aligns with the concept of the nurse as a source of knowledge and assistance for the patient.
Choice C Reason:
Surrogate is incorrect. The surrogate role in Peplau's theory reflects the nurse's ability to act on behalf of the patient, representing their best interests, especially in situations where the patient may be unable to advocate for themselves. The nurse serves as a substitute or stand-in for the patient in certain circumstances.
Choice D Reason:
Guardian is incorrect. The guardian role in Peplau's theory emphasizes the nurse's responsibility to protect the patient's rights and advocate for their well-being. The nurse acts as a guardian of the patient's interests, ensuring they receive appropriate care and support.
Correct Answer is B
Explanation
Choice A Reason:
Limited the role of the nurse to medication administration and documentation is inappropriate. Peplau's theory goes beyond medication administration and documentation. It emphasizes the interpersonal aspect of nursing, focusing on the therapeutic relationship between the nurse and the patient.
Choice B Reason:
Included both an interpersonal theory and a definition of nursing roles is appropriate. Peplau's Interpersonal Theory of Nursing focuses on the nurse-patient relationship and includes both an interpersonal theory and a definition of nursing roles. Peplau emphasized the importance of the nurse's therapeutic use of self in the relationship with the patient.
Choice C Reason:
Depended on moral theory linked to gender is inappropriate. Peplau's theory is not specifically linked to moral theory or gender. It is more focused on the dynamics of interpersonal relationships in the healthcare context.
Choice D Reason:
Defined the role of the nurse in the mental health setting as an extension of the psychiatrist is inappropriate. While Peplau's theory is applicable to mental health settings, it doesn't define the role of the nurse as merely an extension of the psychiatrist. It highlights the nurse's unique role in building therapeutic relationships and assisting patients in their psychosocial needs.
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