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 ["B","C","D"]
Explanation
Choice A rationale
While monitoring abdominal girth can be important in patients with cirrhosis, especially those with ascites, it is not typically an assessment finding that requires immediate follow-up.
Choice B rationale
A blood pressure of 82/58 mm Hg is low and could indicate hypotension, which requires immediate follow-up.
Choice C rationale
A heart rate of 101/min is elevated and could indicate tachycardia, which requires immediate follow-up.
Choice D rationale
An oxygen saturation of 92% is lower than the normal range of 95% to 100%, indicating potential hypoxia, which requires immediate follow-up.
Correct Answer is D
Explanation
Choice A rationale
While gloves are part of the standard personal protective equipment (PPE) for healthcare workers, they are not specifically required for droplet precautions when preparing a patient’s meal tray.
Choice B rationale
Goggles are not specifically required for droplet precautions when preparing a patient’s meal tray. They are typically used to protect the eyes during procedures that may generate splashes of blood, body fluids, secretions, or excretions.
Choice C rationale
A gown is not specifically required for droplet precautions when preparing a patient’s meal tray. Gowns are typically used during procedures that may generate splashes of blood, body fluids, secretions, or excretions.
Choice D rationale
A mask is required for droplet precautions. Droplets that are generated by the patient can be inhaled by individuals who are within close proximity. Wearing a mask can help to prevent the inhalation of these droplets.
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