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:

"I pray when I begin to breathe fast". This technique is inappropriate. Using prayer as a coping mechanism can provide emotional support and a sense of comfort for many individuals.

Choice B Reason:

"Exercise when my neck is tense". This technique is inappropriate. Physical activity, such as exercise, is a well-established and effective stress management technique, promoting the release of endorphins and reducing muscle tension.

Choice C Reason:

"Journal when I find it difficult to talk". This technique is inappropriate. Writing in a journal can be a therapeutic way to express thoughts and emotions, providing an outlet for self-reflection and stress reduction.

Choice D Reason:

"Fix myself a pot of coffee when I get anxious" This technique is appropriate. The least effective stress management technique among the options is fixing oneself a pot of coffee. While caffeine might provide a temporary boost in alertness and mood, excessive consumption of caffeinated beverages, especially during times of anxiety, can contribute to increased heart rate, restlessness, and may exacerbate feelings of anxiety. In the long run, relying on caffeine as a coping mechanism may not be the healthiest or most effective approach to managing stress.

Choice A Reason:

Formulating a nursing diagnosis is incorrect. This occurs after a comprehensive assessment of the patient's needs, and it helps guide the planning and implementation of nursing care.

Choice B Reason:

Planning for continued care is incorrect. Once the nursing diagnosis is formulated, the nurse can develop a plan of care, including interventions and goals for the patient.

Choice C Reason:

Promoting patient's insight is incorrect. This is a part of the ongoing therapeutic process and involves helping the patient gain self-awareness and understanding of their thoughts, feelings, and behaviors. It typically occurs after the initial assessment and planning.

Choice D Reason:

Examining personal biases is correct. In the nurse-patient relationship, examining personal biases is a foundational and essential step that should happen first. It involves the nurse being self-aware and acknowledging any personal biases or prejudices that might affect the therapeutic relationship. Recognizing and addressing personal biases is crucial for providing unbiased and patient-centered care.