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).
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Related Questions
Correct Answer is C
Explanation
The correct answer is C.
Ego integrity vs despair.
According to Erikson’s psychosocial theory, older adults face the challenge of looking back on their lives and evaluating their accomplishments and failures.
If they feel satisfied with their life course, they achieve a sense of ego integrity, which is a feeling of wholeness and coherence.
If they feel regretful or dissatisfied, they experience despair, which is a sense of hopelessness and bitterness.
Choice A is wrong because trust vs mistrust is the first stage of Erikson’s theory, which occurs in infancy.
It involves developing a basic sense of trust in oneself and others based on the quality of caregiving.
Choice B is wrong because generativity vs stagnation is the seventh stage of Erikson’s theory, which occurs in middle adulthood.
It involves contributing to society and the next generation through work, parenting, or other activities.
Choice D is wrong because identity vs role confusion is the fifth stage of Erikson’s theory, which occurs in adolescence.
It involves developing a stable and coherent sense of self and one’s role in society.
Normal ranges for Erikson’s stages are:.
• Trust vs mistrust: birth to 18 months.
• Autonomy vs shame and doubt: 18 months to 3 years.
• Initiative vs guilt: 3 to 6 years.
• Industry vs inferiority: 6 to 12 years.
• Identity vs role confusion: 12 to 18 years.
• Intimacy vs isolation: 18 to 40 years.
• Generativity vs stagnation: 40 to 65 years.
• Ego integrity vs despair: 65 years and older.
Correct Answer is ["A","B","C"]
Explanation
The correct answer is A, B and C.
These are the factors that increase the risk of respiratory infections in elderly patients:.
• Decreased immune response: Elderly patients have a weaker immune system that makes them more susceptible to viral and bacterial infections.They also have a poor response to respiratory vaccines.
• Decreased chest wall compliance: Elderly patients have reduced elasticity of the lungs and chest wall, which makes it harder for them to breathe and expel mucus.
• Decreased alveolar surface area: Elderly patients have fewer and larger alveoli, which reduces the gas exchange area and oxygen diffusion capacity.
Choice D is wrong because decreased oxygen saturation is not a risk factor, but a consequence of respiratory infections.
Choice E is wrong because decreased bronchial dilation is not a specific factor for elderly patients, but a common feature of obstructive lung diseases.
Normal ranges for oxygen saturation are 95-100% and for bronchial dilation are variable depending on the type and severity of the disease.
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