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 ["2"]
Explanation
To determine the number of capsules the nurse will administer, we need to consider the dosage prescribed and the available strength of the capsules.
The prescription states: cephalexin (Keflex) 0.5 g p.o. qid (four times a day).
Given that the available strength of cephalexin capsules is 250 mg, we need to convert the prescribed dosage from grams (g) to milligrams (mg) to match the capsule strength.
1 g = 1000 mg
0.5 g = 0.5 * 1000 mg = 500 mg
Now we know that the prescribed dosage is 500 mg, and each capsule contains 250 mg.
To calculate the number of capsules needed, we divide the prescribed dosage by the strength of each capsule:
Number of capsules = Prescribed dosage / Capsule strength
Number of capsules = 500 mg / 250 mg
Number of capsules = 2
Therefore, the nurse will administer 2 capsules of cephalexin (Keflex) for each dose.
Correct Answer is C
Explanation
Boarding refers to the practice of holding patients, including those with mental health disorders, in the emergency department (ED) for extended periods due to the unavailability of appropriate psychiatric or mental health treatment facilities. This situation often occurs when there is a lack of inpatient psychiatric beds or insufficient community-based mental health resources.
When the nurse notifies the manager about clients with mental health disorders still present in the ED for over 48 hours, they are likely raising concerns about the practice of boarding. The nurse is highlighting the issue of keeping individuals with mental health disorders in an inappropriate setting for an extended duration, which can have negative implications for both the clients and the ED.
The other options are not directly related to the phenomenon of clients with mental health disorders staying in the ED for an extended period:
1. Temporary detaining orders for clients: Temporary detaining orders refer to legal provisions that allow for the involuntary detention of individuals who are at risk to themselves or others due to mental health concerns. While this may be relevant in certain situations, it does not address the broader issue of clients staying in the ED beyond 48 hours.
2. The revolving door for clients: The revolving door phenomenon refers to individuals repeatedly seeking care in the ED due to ongoing or recurrent health issues. While this may be a concern in the context of mental health, it does not specifically address the issue of clients with mental health disorders staying in the ED for over 48 hours.
3. The cost of holding clients in the ED for over 48 hours: While the cost of providing care and resources to clients staying in the ED for an extended period is a valid consideration, it does not encompass the broader issue of the appropriateness of this practice for clients with mental health disorders.
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