A nurse is admitting an older adult client 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)
Abnormal Involuntary Movements Scale (AIMS)
Mental status examination (MSE)
Scale for Assessment of Negative Symptoms (SANS)
The Correct Answer is C
A. Brief Patient Health Questionnaire (Brief PHQ):
The Brief PHQ is a screening tool used to assess symptoms of depression. While it may be relevant to assess mood and emotional well-being, it is not specific to evaluating cognitive functioning or cognitive disorders.
B. Abnormal Involuntary Movements Scale (AIMS):
The AIMS is used to assess involuntary movements, particularly in individuals taking antipsychotic medications. It is not directly related to assessing cognitive disorders.
C,. Mental status examination (MSE)
Explanation:
When admitting an older adult client with a suspected cognitive disorder, including a mental status examination (MSE) as part of the assessment is crucial. The MSE is a structured assessment of a client's current cognitive functioning, emotional state, and thought processes. It helps to evaluate memory, attention, language, perception, orientation, mood, and other cognitive and emotional domains.
D. Scale for Assessment of Negative Symptoms (SANS):
The SANS is used to assess negative symptoms in individuals with schizophrenia. It focuses on features such as affective blunting, alogia, anhedonia, and other negative symptoms. While it may provide important information about a client's mental state, it is not primarily used to assess cognitive disorders.
Assessing cognitive function is a key component when evaluating older adult clients for cognitive disorders such as dementia or other cognitive impairments. The MSE provides valuable information to guide diagnosis and treatment planning for these conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "It doesn't really matter what time you take your medications as long as you don't skip any doses."
While it's important not to skip doses, taking medications at specific intervals is often necessary for maintaining therapeutic blood levels and optimal treatment outcomes. Disregarding specific timing can affect the effectiveness of the medications.
B. "We'll have to talk to your provider about switching to an alternative schedule."
This response may not consider the client's preferences and might not be necessary if the client's current schedule can be adjusted to suit their routine. Collaboration between the nurse and the client is essential.
C. "You really shouldn't change the schedule we established here in the facility."
While continuity in medication schedules is important, if the established schedule doesn't align with the client's daily life, there should be flexibility to adjust it in a way that still maintains the effectiveness of the medications.
D. "Let's work together to devise a time schedule that is convenient for you on a daily basis."
Explanation: It's important to consider the client's lifestyle and routines when developing a medication schedule to ensure optimal adherence. Collaboratively working with the client to create a schedule that fits their daily activities increases the likelihood that they will consistently take their medications as prescribed.
Correct Answer is C
Explanation
A. Regression: Incorrect
Regression is a defense mechanism in which a person reverts to an earlier stage of development in response to stress or anxiety. For example, an adult might start behaving like a child when faced with a difficult situation. In this case, the student berating the teacher doesn't demonstrate a return to an earlier developmental stage, so regression is not the correct choice.
B. Conversion: Incorrect
Conversion refers to the conversion of emotional distress into physical symptoms, such as experiencing physical pain without any apparent physical cause. This mechanism is often seen in conditions like conversion disorder. The student berating the teacher is not exhibiting physical symptoms as a response to emotional distress, so conversion is not the correct choice.
C. Projection: Correct
Projection is the act of attributing one's own unacceptable feelings or thoughts to another person. In this scenario, the student is projecting their own failure onto the teacher and the course by blaming them for the failure. They are unable to accept their own role in the failure and are instead placing the blame on external factors. This aligns with the behavior described in the scenario.
D. Undoing: Incorrect
Undoing involves trying to compensate for or negate an unacceptable action or thought with a contrary action. For instance, someone who had angry thoughts might engage in excessive acts of kindness to "undo" those thoughts. The student berating the teacher is not engaging in actions to negate their negative feelings or thoughts; they are expressing their frustration directly.

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