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 isB.
Loss of muscle mass and strength.Sarcopenia is a condition that affects older adults and causes a progressive decline in skeletal muscle mass, strength, and function.This can lead to an increased risk of falls, fractures, disability, and mortality.
Choice A is wrong because the loss of bone mass and strength is calledosteoporosis, not sarcopenia.Osteoporosis is a condition that affects the density and quality of bones, making them more prone to fracture.
Choice C is wrong because loss of joint flexibility and range of motion is calledarthritis, not sarcopenia.
Arthritis is a term that refers to inflammation of the joints, which can cause pain, stiffness, swelling, and reduced mobility.
Choice D is wrong because loss of skin elasticity and moisture is calledskin aging, not sarcopenia.
Skin aging is a process that involves changes in the structure and function of the skin, such as wrinkles, sagging, dryness, and decreased wound healing.
Normal ranges for muscle mass and strength vary depending on age, sex, body size, and physical activity level.However, some general indicators of sarcopenia include:.
• A muscle mass index (muscle mass divided by height squared) below 7.26 kg/m2 for men and 5.45 kg/m2 for women.
• A handgrip strength below 30 kg for men and 20 kg for women.
• A gait speed below 0.8 m/s for both sexes.
Correct Answer is A
Explanation
The correct answer is A.“Do you drive your own car or use public transportation?.” This question is appropriate for the domain ofmode of transportation, which is one of the eight areas of occupational performance assessed by the Lawton Instrumental Activities of Daily Living (IADLs) Scale.The scale evaluates a person’s ability to engage in more complex activities thought necessary for functioning in community settings.
Choice B is wrong because it is not related to the domain of mode of transportation, but rather to the domain ofability to use a telephone.The scale asks about the person’s ability to operate a telephone, dial numbers, and answer calls.
Choice C is wrong because it is not related to the domain of mode of transportation, but rather to the domain ofshopping.The scale asks about the person’s ability to take care of all shopping needs independently, shop for small purchases, or need assistance with shopping.
Choice D is wrong because it is not related to the domain of mode of transportation, but rather to the domain ofmobility.The scale does not assess mobility directly, but it may be inferred from the person’s ability to travel by public transportation or car.
The Lawton IADLs Scale has a summary score that ranges from 0 (low function, dependent) to 8 (high function, independent) for women, and 0 to 5 for men.The score identifies areas of need in regard to care and support.
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