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.
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.
Correct Answer is A
Explanation
The correct answer is A.
Adverse drug reactions.
Polypharmacy, which refers to the effects of taking multiple medications concurrently to manage coexisting health problems, is common among older adults.
It is defined as the regular use of at least five medications.
Polypharmacy can lead to an increase in geriatric syndromes, decrease in functional outcomes, and increased mortality.
One of the major risks of polypharmacy is adverse drug reactions, which are harmful or unintended effects of a medication that occur at normal doses.
Adverse drug reactions can result from drug-drug interactions, drug-disease interactions, drug-age interactions, or inappropriate prescribing.
Adverse drug reactions can cause symptoms such as confusion, dizziness, falls, bleeding, or organ damage.
They can also lead to hospitalizations, increased health care costs, and reduced quality of life.
Choice B is wrong because medication adherence, which is the extent to which patients take medications as prescribed by their health care providers, can actually decrease with polypharmacy.
This is because taking multiple medications can be complex, costly, and burdensome for older adults, especially if they have cognitive impairment or low health literacy.
Medication adherence can also be influenced by patients’ beliefs, preferences, and expectations about their medications.
Choice C is wrong because drug-drug interactions are not a risk of polypharmacy per se, but rather a cause of adverse drug reactions.
Drug-drug interactions occur when two or more drugs affect each other’s pharmacokinetics (absorption, distribution, metabolism, excretion) or pharmacodynamics (mechanism of action, efficacy, toxicity).
Drug-drug interactions can alter the therapeutic effects or safety of a medication.
Choice D is wrong because therapeutic effects are the intended or desired effects of a medication that benefit the patient’s health condition.
Therapeutic effects can decrease with polypharmacy due to drug-drug interactions that reduce the efficacy of a medication.
Therapeutic effects can also be diminished by prescribing cascade, which is a phenomenon where a new medication is prescribed to treat a symptom that is actually an adverse drug reaction of another medication.
Normal ranges for blood pressure are.
≤120/80.
mmHg for normal,.
120−129/80.
mmHg for elevated,.
130−139/80−89.
mmHg for stage 1 hypertension, and.
≥140/90.
mmHg for stage 2 hypertension.
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