A nurse is performing a mental status examination on an older adult client who has delirium.
Which of the following tools can the nurse use to assess the client’s attention span and concentration?
Mini-Mental State Examination (MMSE).
Confusion Assessment Method (CAM).
Clock Drawing Test (CDT).
Digit Span Test (DST).
The Correct Answer is D
The correct answer is D.
Digit Span Test (DST).
The DST is a tool that can be used to assess the client’s attention span and concentration by asking them to repeat a series of digits forward and backward (Martin, 1990).
The DST is part of the Mini-Mental State Examination (MMSE), which is a broader tool that covers other domains of cognitive functioning, such as orientation, memory, language, and visuospatial skills (Folstein et al., 1975).
Choice A is wrong because the MMSE is not a specific tool for attention span and concentration, but rather a general screening tool for cognitive impairment.
Choice B is wrong because the Confusion Assessment Method (CAM) is a tool that can be used to diagnose delirium, but not to assess attention span and concentration.
The CAM focuses on four features of delirium: acute onset and fluctuating course, inattention, disorganized thinking, and altered level of consciousness (Inouye et al., 1990).
Choice C is wrong because the Clock Drawing Test (CDT) is a tool that can be used to assess visuospatial skills and executive function, but not attention span and concentration.
The CDT requires the client to draw a clock face with numbers and hands indicating a specific time (Shulman et al., 1986).
Normal ranges for the DST vary depending on the age and education level of the client, but generally a score of 5 or more digits forward and 4 or more digits backward is considered normal (Martin, 1990).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B.
Diphenhydramine.Diphenhydramine is an antihistamine and sedative medication that can causedeliriumin older adults, especially when used in high doses or for a long time.Delirium is a serious change in mental abilities that results in confused thinking and reduced awareness of the surroundings.It can be caused by various factors, such as infections, medications, surgery, or alcohol or drug use or withdrawal.Delirium can have serious consequences, such as increased risk of falls, complications, and death.
Choice A is wrong because acetaminophen is a pain reliever and fever reducer that does not usually cause delirium in older adults.
However, acetaminophen overdose can cause liver damage and altered mental status.
Choice C is wrong because metformin is an oral medication that lowers blood sugar levels in people with type 2 diabetes.
Metformin does not typically cause delirium in older adults.
However, metformin can cause a rare but serious condition called lactic acidosis, which can cause confusion and other symptoms.
Choice D is wrong because lisinopril is an angiotensin-converting enzyme (ACE) inhibitor that lowers blood pressure and prevents heart failure.
Lisinopril does not usually cause delirium in older adults.
However, lisinopril can cause a rare but serious condition called angioedema, which can cause swelling of the face, tongue, or throat and difficulty breathing.
Normal ranges for some relevant laboratory tests are:.
• Albumin: 3.5-5.0 g/dL.
• Potassium: 3.5-5.0 mEq/L.
• Total cholesterol: <200 mg/dL.
• Hemoglobin: 13.5-17.5 g/dL for men; 12.0-15.5 g/dL for women.
Correct Answer is B
Explanation
The correct answer is B.
Older adults may experience changes in sexual response or function due to physiological factors.This is because aging can affect the sex organs, hormones, blood flow, and nerve signals that are involved in sexual arousal and performance.These changes do not mean that older adults cannot enjoy a satisfying sex life, but they may require some adjustments or treatments to overcome any difficulties.
Choice A is wrong because older adults have the same need for intimacy and affection as younger adults, and sexuality is an important component of emotional and physical intimacy that can enhance well-being and quality of life.
Choice C is wrong because older adults with chronic diseases or disabilities can still have sexual activity, as long as they are comfortable and safe.They may need to consult with their health care providers about any precautions or modifications they should make to accommodate their conditions.
Choice D is wrong because older adults are not at lower risk for sexually transmitted infections (STIs) than younger adults.In fact, older adults may be more vulnerable to STIs due to lower immune function, thinner vaginal tissues, lack of condom use, and other factors.
Therefore, older adults should practice safe sex and get tested regularly for STIs.
Normal ranges for sexual response or function vary widely depending on the individual, the partner, the situation, and other factors.
There is no one standard or ideal way to experience sexuality and intimacy in older adulthood.The most important thing is to communicate openly with one’s partner and health care provider about any concerns or preferences, and to seek help if needed.
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