The nurse is performing an admission assessment for a client admitted to the behavioral health unit. Which social/cultural category will the nurse document that may be contributing to the client's degree of mental illness? Select all that apply. (Select All that Apply.)

The nurse should include the following components when performing a mental status examination (MSE) on a client with a new diagnosis of dementia:

● Grooming: Assessing the client's grooming and personal hygiene can provide insights into their ability to care for themselves and maintain basic activities of daily living.

● Long-term memory: Evaluating the client's long-term memory can help identify any deficits or impairments in their ability to recall past events, experiences, or personal information. This is particularly relevant in dementia, as it often affects memory function.

● Support systems: Assessing the client's support systems, such as family members, friends, or caregivers, is essential in understanding the resources available to the client and the level of assistance they may require in managing their dementia. However, this does not occur within the mental status exam.

● Affect: Evaluating the client's affect refers to observing their emotional expression and responsiveness during the assessment. In dementia, changes in affect can occur, such as a flat affect or inappropriate emotional responses.

The component that should not be included in the MSE for a client with dementia is:

● Presence of pain: While pain assessment is an important aspect of caring for individuals with various health conditions, including dementia, it is not a specific component of the mental status examination. Pain assessment is typically addressed separately and should be conducted when necessary or based on the client's specific complaints or indications of pain.

Nurses should focus on clients' cultures, rather than their ethnicity, when providing care: Cultural competence involves understanding and respecting the beliefs, values, practices, and customs of different cultures. It is important for nurses to recognize that culture extends beyond ethnicity and encompasses various aspects such as religion, language, socioeconomic status, and more. By focusing on clients' cultures, nurses can provide care that is sensitive and tailored to their unique needs and preferences.

The following are incorrect:

Nonverbal communication is important in many cultures: Nonverbal communication, including body language, facial expressions, and gestures, plays a significant role in communication across cultures. Different cultures may have specific nonverbal cues and interpretations. Nurses

should be aware of these variations and understand how nonverbal communication impacts their interactions with clients. By being attentive to nonverbal cues, nurses can enhance communication, build trust, and promote effective care.

Nurses should not expect clients to adapt to the care provided regardless of culture: Culturally competent care acknowledges and respects the diversity of clients' cultural backgrounds. It is important for nurses to recognize that clients' cultural beliefs, values, and practices may influence their healthcare preferences and decisions. Nurses should strive to provide care that is congruent with clients' cultural values and preferences, rather than expecting them to adapt entirely to a standardized approach. This promotes patient-centered care and enhances client satisfaction and outcomes.

"Culture plays no role in determining when a client will seek medical care" is incorrect. Culture significantly influences an individual's healthcare-seeking behaviors, including beliefs about illness, preventive care practices, and help-seeking patterns. Understanding these cultural factors is essential for nurses to provide appropriate and effective care.