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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When discussing culturally competent care at a nursing staff inservice, the nurse should include information about the importance of focusing on clients’ cultures when providing care. Culture plays a significant role in determining when a client will seek medical care and how they will respond to treatment. Nonverbal communication is important in many cultures and can provide valuable information about a client’s needs and preferences. Nurses should strive to provide care that is respectful of and responsive to clients’ cultural beliefs and practices, rather than expecting clients to adapt to the care provided.
● “Culture plays no role in determining when a client will seek medical care.” This statement is incorrect because culture can play a significant role in determining when and how a client seeks medical care. Cultural beliefs and practices can influence a client’s understanding of health and illness, their attitudes towards healthcare providers, and their willingness to seek and adhere to treatment.
● “Nonverbal communication is important in few cultures.” This statement is incorrect because nonverbal communication is important in many cultures. Nonverbal cues such as body language, facial expressions, and gestures can convey important information about a client’s emotions, needs, and preferences. Understanding and responding to nonverbal communication can help nurses provide culturally competent care.
● “Nurses should expect clients to adapt to the care provided regardless of culture.” This statement is incorrect because it is not culturally competent to expect clients to adapt to the care provided without considering their cultural beliefs and practices. Nurses should strive to provide care that is respectful of and responsive to clients’ cultural beliefs and practices. This may involve adapting the care provided to meet the unique needs of each client.
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.
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