A nurse is admitting an elderly patient suspected of having a cognitive disorder.
What inventories should be included as part of the admission assessment?
Scale for Assessment of Negative Symptoms (SANS)
Mental status examination (MSE)
Abnormal Involuntary Movements Scale (AIMS)
Mini-Mental State Examination (MMSE) .
The Correct Answer is B
Choice A rationale
The Scale for Assessment of Negative Symptoms (SANS) is a tool used to assess negative symptoms in schizophrenia and is not typically used in the assessment of cognitive disorders.
Choice B rationale
The Mental Status Examination (MSE) is a key part of the clinical assessment process in psychiatric practice. It is a structured way of observing and describing a patient’s current state of mind, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight, and judgement.
Choice C rationale
The Abnormal Involuntary Movements Scale (AIMS) is a rating scale that measures involuntary movements known as tardive dyskinesia (a side effect of long-term use of antipsychotic drugs). It is not typically used in the assessment of cognitive disorders.
Choice D rationale
The Mini-Mental State Examination (MMSE) is a commonly used test for complaints of memory problems or when a diagnosis of dementia is being considered. However, in this case, the MSE would be a more comprehensive tool.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Celery sticks are safe to consume while on a monoamine oxidase inhibitor (MAOI) medication. They do not contain tyramine, which can cause a hypertensive crisis if consumed while taking an MAOI8.
Choice B rationale
Sliced apples are also safe to consume while on an MAOI medication. They do not contain tyramine.
Choice C rationale
Bologna sandwiches should be avoided while on an MAOI medication. Bologna is a type of processed meat that can be high in tyramine.
Choice D rationale
A glass of whole milk is safe to consume while on an MAOI medication. It does not contain high levels of tyramine.
Correct Answer is A
Explanation
Choice A rationale
The patient’s blood pressure is significantly low, which could indicate hypotension, a serious side effect of epidural analgesia. This should be the nurse’s priority as it can lead to complications such as decreased perfusion to vital organs.
Choice B rationale
Lower extremity weakness can be a side effect of epidural analgesia, but it is not as immediately life-threatening as hypotension.
Choice C rationale
A slight increase in temperature may not be an immediate concern unless it continues to rise or is accompanied by other signs of infection.
Choice D rationale
Severe itching can be a side effect of epidural analgesia, but it is not as immediately life- threatening as hypotension.
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