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 C
Explanation
Choice A Reason:
A patient who states "I have no one who cares about me. "This statement relates more to the need for belonging and love, which is a lower level on Maslow's hierarchy.
Choice B Reason:
A patient who states "I have never met my career goals." This statement relates to self-esteem and self-actualization needs, which are higher-level needs in Maslow's hierarchy.
Choice C Reason:
A patient who exhibits hostile and angry behaviors is correct. Maslow's hierarchy of needs places safety and security needs above other needs. The patient exhibiting hostile and angry behaviors may pose a threat to their own safety, the safety of others, or the overall therapeutic environment. Addressing safety concerns and de-escalating aggressive behaviors takes precedence in this situation.
Choice D Reason:
A patient upset that his family can only visit during visiting hours. This situation is related to social needs and may not be as immediate a concern as the hostile and angry behaviors described in option C.
Correct Answer is D
Explanation
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.
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