A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include? (Select all that apply.)
Grooming
Long-term memory
Support systems
Presence of pain
Affect
Correct Answer : A,B,E
The nurse should include the following components when performing a mental status examination (MSE) on a client with a new diagnosis of dementia:
● Grooming: Assessing the client's grooming and personal hygiene can provide insights into their ability to care for themselves and maintain basic activities of daily living.
● Long-term memory: Evaluating the client's long-term memory can help identify any deficits or impairments in their ability to recall past events, experiences, or personal information. This is particularly relevant in dementia, as it often affects memory function.
● Support systems: Assessing the client's support systems, such as family members, friends, or caregivers, is essential in understanding the resources available to the client and the level of assistance they may require in managing their dementia. However, this does not occur within the mental status exam.
● Affect: Evaluating the client's affect refers to observing their emotional expression and responsiveness during the assessment. In dementia, changes in affect can occur, such as a flat affect or inappropriate emotional responses.
The component that should not be included in the MSE for a client with dementia is:
● Presence of pain: While pain assessment is an important aspect of caring for individuals with various health conditions, including dementia, it is not a specific component of the mental status examination. Pain assessment is typically addressed separately and should be conducted when necessary or based on the client's specific complaints or indications of pain.
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Related Questions
Correct Answer is C
Explanation
Systematic desensitization is a therapeutic technique used to help individuals gradually overcome their fears or phobias by exposing them to the feared stimulus in a controlled and systematic way. The goal is to reduce anxiety and increase relaxation through a step-by-step process.
The statement "What is the worst that will happen if you confront this fear?" aligns with the principle of systematic desensitization because it encourages the client to explore and challenge their negative beliefs or catastrophic thinking associated with their fear. By questioning the potential negative outcomes, the nurse is helping the client to reevaluate their fear response
and consider more realistic expectations. This process can contribute to the client's ability to confront their fear gradually and reduce anxiety over time.
The other statements are still helpful and supportive, but they do not specifically address the principles of systematic desensitization:
“I can see you are anxious. Let's stop for a minute." acknowledges the client's anxiety but does not actively engage in the technique of systematic desensitization.
"Use the deep breathing techniques we practiced yesterday." focuses on relaxation techniques, which can be helpful in managing anxiety but does not specifically address the principles of systematic desensitization.
“Tell me how you are feeling right now." encourages the client to express their feelings but does not directly engage in the technique of systematic desensitization.
Correct Answer is C
Explanation
This definition highlights the importance of positive relationships, effective coping strategies, a positive self-concept, and emotional stability in determining mental health.
The others are incorrect:
1. It is not easy to determine if a person is mentally healthy or mentally ill: Assessing mental health and diagnosing mental illness requires a comprehensive evaluation by trained professionals. Mental health is a complex and multifaceted aspect of overall well-being that involves various factors, and determining someone's mental health status is not a simple or straightforward process.
2. Persons who engage in fantasies are mentally ill: Engaging in fantasies is not necessarily indicative of mental illness. Fantasies can be a normal part of human imagination and creativity. However, the context and intensity of fantasies, along with other psychological and behavioral indicators, would need to be considered in a comprehensive assessment to determine if there are any underlying mental health concerns.
3. Behavior that may be viewed as acceptable in one culture is always unacceptable in other cultures: Cultural norms and values vary across societies, and what may be deemed acceptable or unacceptable behavior can differ significantly. There is no
universal standard for judging the acceptability of behavior across all cultures. Cultural relativism recognizes that behaviors and norms should be understood within their cultural context.
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