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:
Safety needs is correct. In this scenario, the individual's safety is compromised both at work (due to the potential layoff) and at home (due to intimate partner violence). Safety needs, which include physical and emotional security, are fundamental in Maslow's hierarchy and take precedence over other needs in this situation.
Choice B Reason:
Physiological needs is incorrect. While a possible layoff can impact financial stability, it may not directly threaten immediate access to basic physiological needs like food, water, and shelter. The immediate safety concern takes precedence.
Choice C Reason:
Love and belonging needs is incorrect. Although witnessing intimate partner violence can strain relationships and affect the sense of belonging, the primary concern in this scenario is the immediate threat to safety.
Choice D Reason:
Esteem needs is incorrect. The threat of a layoff and exposure to domestic violence can impact self-esteem, but the more critical issue at the moment is ensuring physical safety.
Correct Answer is D
Explanation
Choice A Reason:
"I’m so sad and I feel I haven't accomplished much in my life." This statement may relate more to feelings of despair and a sense of unfulfilled purpose, which could be associated with Erikson's stage of Integrity vs. Despair (late adulthood).
Choice B Reason:
"I’m so anxious, can't seem to trust anyone. “This statement may indicate difficulties with trust and may be more aligned with Erikson's stage of Trust vs. Mistrust (infancy).
Choice C Reason:
"I'm so tired after work that I just want to watch TV and be alone. “This statement may reflect fatigue or a desire for solitude and may not directly represent the identity development struggles associated with Erikson's Identity vs. Role Confusion stage.
Choice D Reason:
"I'm so confused about what my goals are.” Erikson's phase of Identity vs. Role Confusion occurs during adolescence, and individuals in this stage are exploring and forming their own identity. The statement "I'm so confused about what my goals are" suggests a struggle with establishing a clear sense of identity and future direction, which is characteristic of the challenges faced during this developmental stage.
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