A nurse is admitting an older adult client to the unit who has a suspected cognitive disorder. Which of the following inventories should be included as part of the admission assessment?
Brief Patient Health Questionnaire (Brief PHQ).
Scale for Assessment of Negative Symptoms (SANS).
Mental status examination (MSE).
Abnormal Involuntary Movements Scale (AIMS).
The Correct Answer is C
Choice A rationale:
The Brief Patient Health naire (Brief PHQ) is primarily used for assessing the presence and severity of depressive symptoms and not specifically for cognitive disorders. It consists of nine items that assess the frequency of specific symptoms over the past two weeks.
Choice B rationale:
The Scale for Assessment of Negative Symptoms (SANS) is a tool used to assess negative symptoms in schizophrenia and other related psychotic disorders. It includes items related to affective blunting, alogia, anhedonia, and avolition, which are not directly relevant to the assessment of cognitive disorders.
Choice C rationale:
The Mental Status Examination (MSE) is a comprehensive assessment of cognitive function, including orientation, memory, attention, language, and executive function. It provides valuable information about the client's cognitive abilities and can aid in diagnosing cognitive disorders such as dementia or delirium.
Choice D rationale:
The Abnormal Involuntary Movements Scale (AIMS) is used to assess the presence and severity of tardive dyskinesia, a movement disorder commonly associated with the use of antipsychotic medications. It is not relevant to the assessment of cognitive disorders.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Joining a bowling league 2 months ago indicates that the client is actively seeking social interactions and engaging in activities. While grief can manifest in various ways, joining a social activity does not necessarily indicate maladaptive grief. It's important for individuals to find ways to connect with others and continue living their lives after the loss of a loved one.
Choice B rationale:
Meeting his daughter for dinner every week demonstrates ongoing communication and emotional connection with family. This behavior suggests a healthy attempt at maintaining relationships and coping with the loss. Regular interactions with family members can be supportive during the grieving process.
Choice C rationale:
Keeping his partner's closet untouched since her death is a sign of maladaptive grief. This behavior suggests an inability to let go of personal belongings and move forward after a significant period of time. In healthy grieving, individuals usually work through their emotions and gradually start reorganizing their living spaces and personal items.
Choice D rationale:
Exercising at a local health facility 3 days each week indicates that the client is engaging in self-care and maintaining physical health. While exercise can be a coping mechanism, this behavior alone does not provide enough evidence to determine whether the client is experiencing maladaptive grief.
Correct Answer is D
Explanation
The correct answer is choiced. "So, it seems that you feel responsible for what happened to your mother.”
Choice A rationale:This response attempts to reassure the son but may come off as dismissive of his feelings. It does not encourage further discussion or exploration of his emotions.
Choice B rationale:This response is overly reassuring and dismisses the son’s feelings of guilt. It does not address his emotional state or encourage him to express his concerns.
Choice C rationale:This response questions the son’s feelings directly, which might make him defensive. It does not validate his emotions or encourage him to talk more about his feelings.
Choice D rationale:This response acknowledges the son’s feelings and encourages him to express his emotions. It is a therapeutic communication technique that helps the son feel heard and understood, which is crucial in providing emotional support.
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