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).

Answer and Explanation

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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Correct Answer is D

Explanation

The correct answer is D.

Delirium.

The nurse should monitor the client for delirium, which is a state of acute mental confusion that can be caused by fever, infection, dehydration, or medications.

Delirium can affect the client’s cognition, attention, orientation, memory, and behavior.It can also increase the risk of falls, complications, and mortality.

Choice A is wrong because dehydration is not a complication of fever, but rather a possible cause of fever.

Dehydration occurs when the body loses more fluid than it takes in, and it can impair the body’s ability to regulate its temperature.Dehydration is more common and dangerous in older adults because they have a lower volume of water in their bodies, a weaker thirst response, and may have conditions or medications that increase fluid loss.

Choice B is wrong because hypothermia is not a complication of fever, but rather a condition of abnormally low body temperature.

Hypothermia can occur when the body loses heat faster than it can produce it, such as in cold weather or water exposure.Hypothermia can affect the brain, heart, and other organs, and can lead to death if not treated promptly.

Choice C is wrong because seizures are not a common complication of fever in older adults.

Seizures are sudden episodes of abnormal electrical activity in the brain that can cause changes in movement, sensation, behavior, or consciousness.

Seizures can have various causes, such as head injury, stroke, infection, or epilepsy.

Fever-induced seizures are more likely to occur in young children than in older adults.

A. Follow up with the primary care provider regularly. B. Avoid alcohol and tobacco use C. Take over-the-counter sleeping pills as needed. D. Engage in physical and mental activities daily. E. Wear glasses and hearing aids if prescribed.

Correct Answer is ["A","B","D"]

Explanation

The correct answer isA, B and D.

Here is why:.

• Following up with the primary care provider regularly can help detect and treat any medical conditions that may cause or contribute to delirium, such as infections, electrolyte imbalances, or medication side effects.

• Avoiding alcohol and tobacco use can prevent delirium caused by intoxication or withdrawal, as well as improve overall health and cognitive function.

• Engaging in physical and mental activities daily can help maintain brain health, prevent cognitive decline, and reduce stress and boredom that may trigger delirium.

Choice C is wrong because taking over-the-counter sleeping pills as needed can increase the risk of delirium, especially in older adults.Sleeping pills can cause confusion, drowsiness, memory impairment, and falls that may lead to delirium.Instead of sleeping pills, it is better to have good sleep habits such as uninterrupted sleep, avoiding caffeine and naps, and having a regular bedtime routine.

Choice E is wrong because wearing glasses and hearing aids if prescribed can help prevent delirium, not cause it.Sensory impairment such as poor vision and hearing can make a person more prone to delirium, as they may feel disoriented, isolated, or misunderstood.Wearing glasses and hearing aids can help improve communication, orientation, and awareness of surroundings.

Delirium is a serious change in mental abilities that results in confused thinking and a lack of awareness of one’s surroundings.It usually comes on fast and can be caused by various factors such as fever, infection, surgery, medication, or emotional distress.

Delirium can often be prevented.

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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?

Nursing Test Bank

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Correct Answer is D

Explanation

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Correct Answer is ["A","B","D"]

Explanation

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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?