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.
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Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Differentiation is incorrect. Differentiation refers to the ability of family members to maintain their individuality while remaining emotionally connected. It is not directly related to involving a third person in conflicts.
Choice B Reason:
Scapegoating is incorrect. Scapegoating involves blaming one family member for the family's problems. While this can be a dysfunctional family dynamic, it is not specifically about involving a third person in conflicts.
Choice C Reason:
Double Binding is incorrect. Double binding involves conflicting messages that create a no-win situation for the recipient. It does not specifically involve the inclusion of a third person in conflicts as observed in the given scenario.
Choice D Reason:
Triangulation is correct. Triangulation in family systems therapy occurs when a third person, often a child, is involved in the conflicts between two other family members. In this scenario, Kate is venting her frustrations to her younger son, which creates a triangle or three-person dynamic in the family system. Triangulation can serve as a way for family members to stabilize their relationships by shifting the focus or tension onto a third party.
Correct Answer is A
Explanation
Choice A Reason:
"People in the mental health category of the continuum do not experience stress." This statement indicates a misunderstanding about the mental health continuum. Mental health does not imply the absence of stress; rather, it is about one's overall psychological well-being. Even individuals with good mental health may experience stress at times. The mental health continuum recognizes that people can move along different points, experiencing fluctuations in mental health based on various factors.
Choice B Reason:
“People can shift along various points of the mental health continuum. “This statement acknowledges the dynamic nature of mental health, indicating that individuals can move between different points on the continuum based on their mental well-being.
Choice C Reason:
"Most people are on some point of the mental health continuum. “This statement recognizes that mental health is a spectrum, and most individuals fall somewhere along this continuum.
Choice D Reason:
"Mental health is an important point of the mental heat continuum. “This statement reinforces the significance of mental health as a key aspect of overall well-being, which aligns with the concept of the mental health continuum.
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