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

Answer and Explanation

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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Correct Answer is ["1"]

Explanation

To calculate the amount of mL the nurse should administer, we can use a proportion based on the available concentration of digoxin (Lanoxin) and the prescribed dose.

The available concentration is 0.5 mg/2 mL, which means there are 0.5 mg of digoxin in 2 mL of solution.

The prescribed dose is 0.25 mg.

Now we can set up the proportion:

0.5 mg / 2 mL = 0.25 mg / x mL

Cross-multiplying, we have:

0.5 mg * x mL = 2 mL * 0.25 mg

0.5x = 0.5

Dividing both sides by 0.5, we get:

x = 0.5 / 0.5

x = 1

Therefore, the nurse should administer 1 mL of digoxin (Lanoxin) to deliver a dose of 0.25 mg.

A. Meet with a therapist on a weekly basis. B. Fulfill daily responsibilities without supervision. C. Use the increased emotional support of paid staff. D. Resolve crises within a shorter time period. E. Resolve crises within a shorter time period.

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.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Order, digoxin (Lanoxin) 0.25 mg IM daily. Available digoxin (Lanoxin) 0.5 mg/2 mL How many mL will the nurse administer?

Correct Answer is ["1"]

Explanation

A client is being transferred from a group home to an evolving consumer household. The goal of this transition is for the client to eventually do what?

Correct Answer is B

Explanation

he nurse observes the client experiencing a panic attack in the day room in the behavioral health unit. Which is the priority action by the nurse?

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