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. The client is sharing feelings and emotions with the nurse. B. The client is attending all therapy sessions and utilizing the services provided. C. The client states that they feel the issues have been resolved and no longer need to come. D. The client is answering questions related to the plan of care.

Correct Answer is A

Explanation

The identification phase of the nurse-client relationship is characterized by the client feeling comfortable and secure enough to open up and share their feelings, emotions, and personal experiences with the nurse. It involves establishing trust and rapport, which allows the client to feel supported and understood by the nurse. Sharing feelings and emotions indicates that the client has reached a level of comfort and trust in the therapeutic relationship, making it a key indicator of the identification phase.

The other behaviors mentioned in the options are not specifically related to the identification phase:

● The client attending therapy sessions and utilizing services provided is an important aspect of engagement and active participation in the therapeutic process. However, it does not specifically indicate the identification phase of the relationship.

● The client stating that they feel the issues have been resolved and no longer need to come suggests the termination phase of the nurse-client relationship rather than the identification phase. The termination phase occurs when the client feels they have achieved their goals and no longer require ongoing therapy.

● The client answering questions related to the plan of care is a general indicator of communication and collaboration in the therapeutic process. It does not specifically signify the identification phase but rather active involvement in the treatment plan.

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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

The nurse has established a therapeutic relationship with a client. Which behaviors identified will indicate that the client has entered into the identification phase of the nurse-client relationship?

Correct Answer is A

Explanation

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The nurse working in the ED of an urban hospital notifies the manager that there are several clients with mental health disorders still present in the ED that have been there over 48 hours. Which issue related to this phenomenon does the nurse discuss with the manager?

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.)