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 A

Explanation

When encountering a client who is sexually aggressive, it is important for the nurse to establish firm limits and boundaries to ensure the safety and well-being of both the client and the healthcare team. This response promotes the maintenance of a therapeutic environment and helps prevent potential harm to the client, staff, and other patients.

the other choices are incorrect:

1. "Tell the client that you are going to report to the director of the unit." While it is important to report any concerning behaviors or incidents to the appropriate personnel, simply informing the client about reporting to the director may not be the most effective initial response. Prioritizing immediate actions to ensure safety and setting boundaries is crucial before involving higher-level staff.

2. "Walk away and have someone else take care of the client." Leaving the situation and passing the responsibility to someone else without addressing the issue directly is not an appropriate response. It is the nurse's responsibility to provide care and manage challenging situations within their scope of practice and training. Collaboration and support from the healthcare team may be sought, but abandoning the client is not an acceptable approach.

3. "It happens frequently, so just ignore it; they will stop." Ignoring sexually aggressive behavior is not an appropriate response. Such behavior should be taken seriously and addressed promptly to ensure the safety and well-being of everyone involved. Ignoring the behavior may enable its continuation and potentially lead to further harm or escalation of the situation.

A. The client will have stabilization and management of symptoms. B. The client will have an improvement in the quality of life. C. The client will return to prior level of functioning D. The client will be adherent to the medication regimen.

Correct Answer is B

Explanation

a.Stabilization and management of symptoms are critical goals for any client with schizophrenia. However, in psychiatric rehabilitation, the focus goes beyond merely stabilizing symptoms. The goal is often to enhance the client’s ability to function in daily life and improve their overall well-being, not just manage symptoms.

b.The primary outcome of a psychiatric rehabilitation program is to help clients improve their overall quality of life. This includes helping them develop skills for independent living, managing their symptoms effectively, enhancing social interactions, and improving their sense of purpose and well-being.

c.In cases of chronic mental health conditions like schizophrenia, it may not always be realistic or possible for clients to return to their prior level of functioning before the onset of the illness. The focus is more on helping the client achieve the best possible level of functioning within the limits of their condition, rather than returning to a specific previous state.

d.While medication adherence is crucial in the treatment of schizophrenia, it is just one component of managing the condition. Psychiatric rehabilitation is a holistic process that includes psychosocial interventions, skills training, and social support. Medication adherence supports symptom management, but it is not the primary outcome.

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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

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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