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 ["A","B","C","D"]
Explanation
The correct answer isA, B, C and D.
These are all factors that can increase the risk of sexually transmitted infections (STIs) in older adult clients.
A. Decreased immune system function with aging.This can make older adults more susceptible to infections and less able to fight them off.
B. Lack of knowledge or awareness about STIs.
Older adults may not have received adequate education or information about STIs, their symptoms, prevention and treatment.They may also have misconceptions or stigma about STIs that prevent them from seeking help or testing.
C. Reduced use of condoms or other barrier methods.
Older adults may not perceive themselves as at risk of STIs or may not know how to use condoms correctly or consistently.They may also face barriers such as cost, availability, embarrassment or partner resistance to using condoms.
D. Increased number of sexual partners or casual encounters.
Older adults may have more opportunities for sexual activity due to factors such as divorce, widowhood, online dating, travel or retirement.They may also engage in sexual behaviors that expose them to multiple or unknown partners, such as sex work, drug use or group sex.
Choice E is wrong becauseincreased vaginal dryness or atrophy with menopauseis not a risk factor for STIs in older adult clients.
While this condition can cause discomfort, pain or bleeding during sexual intercourse, it does not increase the likelihood of acquiring or transmitting an STI.However, it may affect the quality of life and sexual satisfaction of older women and their partners, and may require medical attention or lubrication products.
: Johnson BK.
Sexually transmitted infections and older adults.J Gerontol Nurs 2013;39(11):53-60.: World Health Organization (WHO).
Sexually transmitted infections (STIs).2022 Aug 22.: Journal of Gerontological Nursing (JGN).
Sexually Transmitted Infections and Older Adults.
2013 Sep 18.
Correct Answer is D
Explanation
The correct answer is D.
All of the above.
The nurse should ask all of these questions to assess the possible causes of the client’s condition.
Depression and social isolation in older adults can be triggered by various factors, such as:.
• Losses or changes in life, such as death of a spouse, retirement, relocation, or chronic illness.
• Lack of social support or contact with family, friends, or neighbors, which can lead to loneliness and reduced self-esteem.
• Decreased engagement or interest in activities or hobbies that provide meaning, pleasure, or stimulation, which can affect mood and cognitive function.
By asking these questions, the nurse can identify the specific factors that contribute to the client’s depression and social isolation, and provide appropriate interventions to address them.
For example, the nurse can:.
• Provide emotional support and empathy to the client and help them cope with their losses or changes.
• Encourage the client to maintain or increase their social interactions and connections with others who share similar interests or experiences.
• Assist the client to resume or find new activities or hobbies that suit their abilities and preferences, and provide positive feedback and reinforcement.
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