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 B
Explanation
The transition from a group home to an evolving consumer household typically involves promoting independence and empowering the client to become more self-sufficient. The ultimate goal is to enable the client to fulfill their daily responsibilities without the need for constant supervision or assistance.
The others are incorrect:
While meeting with a therapist on a weekly basis may be part of the client's overall mental health support, it is not the specific goal of transitioning to an evolving consumer household.
Using the increased emotional support of paid staff may be a temporary measure during the transition period, but the long-term goal is for the client to become self-reliant and less dependent on constant emotional support.
Resolving crises within a shorter time period is a desirable outcome for any mental health support system, but it does not directly relate to the specific goal of fulfilling daily responsibilities without supervision.
Correct Answer is C
Explanation
When creating a plan of care for a client experiencing a situational crisis, it is important to set measurable and obtainable goals that can guide the client's progress and provide clear indicators of achievement.
Considering the options provided, the most measurable and obtainable goal for the client experiencing a situational crisis would be:
The client will resume the pre-crisis level of functioning.
This goal is measurable as it involves assessing the client's functioning before the crisis and monitoring their progress in returning to that level. It is also obtainable as it focuses on restoring the client's previous abilities and skills, rather than relying on subjective or introspective factors. By setting specific criteria to determine the pre-crisis level of functioning and regularly evaluating the client's progress, the nurse can measure the client's achievement of this goal and adjust the plan of care accordingly.
The client will resume the pre-crisis level of functioning: Resuming the pre-crisis level of functioning is a measurable and obtainable goal. It involves identifying the client's previous level of functioning and working towards returning to that state. By assessing the client's functional abilities before the crisis and monitoring progress over time, it is possible to measure and track the extent to which they have regained their previous level of functioning.
The client will discover a new sense of self-sufficiency in coping: While this goal is important for the client's long-term growth and development, it is not easily measurable or obtainable in a specific timeframe. "Discovering a new sense of self-sufficiency" is a subjective and introspective process that may require extensive self-reflection and personal growth, making it difficult to measure and set a concrete timeline for achievement.
The client will express anger regarding the crisis event: Expressing anger can be a normal and healthy part of the healing process during a crisis. However, it is not necessarily the most
measurable or obtainable goal. The expression of anger can vary greatly among individuals, and it may not be an appropriate or necessary response for everyone. Additionally, the focus of the plan of care should extend beyond anger expression and encompass a broader range of emotions and coping strategies.
The client will identify possible causes for the crisis: While understanding the possible causes of the crisis can be an important part of the recovery process, it may not be the most measurable or obtainable goal on its own. Identifying the causes of a crisis can involve complex factors that may require professional assessment and a deeper exploration of the client's history and circumstances. It is more appropriate as an ongoing process within therapy rather than a specific goal with a clear endpoint.
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