A nurse is assessing cognitive functioning of a patient. Which action will the nurse take?
Ask the patient’s family if the patient is behaving normally.
Ask the patient to state name, location, and what month it is.
Administer the Hearing Handicap Inventory for the Elderly (HHIE-S).
Administer a Mini-Mental State Examination (MMSE).
The Correct Answer is D
Choice A reason: Asking the family about normal behavior provides subjective context but lacks standardized cognitive assessment. Cognitive function requires objective tools like the MMSE to evaluate memory, orientation, and attention. Relying solely on family input risks missing subtle deficits, delaying diagnosis of conditions like dementia or delirium critical for patient management.
Choice B reason: Asking for name, location, and month tests orientation, a component of cognitive assessment, but is too limited. The MMSE offers a comprehensive evaluation of memory, language, and visuospatial skills. This narrow approach risks overlooking broader cognitive impairments, potentially missing early dementia or other neurological conditions requiring targeted interventions.
Choice C reason: The HHIE-S assesses hearing impairment, not cognitive function. Hearing loss may affect communication but isn’t a direct cognitive measure. Using this tool for cognition misdirects assessment, risking failure to identify cognitive deficits like memory loss, delaying diagnosis and management of conditions such as Alzheimer’s disease or acute confusional states.
Choice D reason: Administering the MMSE is a standardized, comprehensive tool to assess cognitive function, evaluating orientation, memory, attention, language, and visuospatial skills. It detects impairments in conditions like dementia or delirium, guiding diagnosis and treatment. Its structured approach ensures reliable identification of cognitive deficits, critical for planning care and interventions in clinical settings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Intersectionality examines how overlapping identities (e.g., race, gender, socioeconomic status) shape unique experiences of health and care. Focusing on experiences allows nurses to address disparities and tailor interventions, ensuring equitable care. This approach recognizes systemic factors, critical for understanding patients’ barriers and needs in diverse healthcare contexts.
Choice B reason: Focusing on illness alone overlooks intersectionality’s emphasis on how social identities shape health experiences. Illness is a clinical factor, not a social construct like race or class. This narrow focus risks missing systemic inequities, reducing care effectiveness for patients with complex social determinants influencing their health outcomes.
Choice C reason: Values are personal beliefs, not the primary focus of intersectionality, which examines social identities and systemic inequities shaping experiences. Prioritizing values risks ignoring structural factors like discrimination, limiting the nurse’s ability to address disparities and provide culturally sensitive care critical for patients from marginalized backgrounds.
Choice D reason: Health is an outcome, not the focus of intersectionality, which explores how identities like ethnicity or gender create unique experiences of care access and treatment. Focusing on health alone misses social determinants, risking generic care that fails to address inequities, critical for equitable nursing practice in diverse populations.
Correct Answer is C
Explanation
Choice A reason: Health promotion involves teaching lifestyle changes, not physical touch or emotional support, as seen here. Presence focuses on being with the patient empathetically. Assuming health promotion misaligns with the action, risking neglect of the patient’s emotional and spiritual needs, critical for comfort in terminal illness care settings.
Choice B reason: Offering transcendence involves fostering spiritual meaning, not physical touch or presence. The nurse’s hand-touching establishes emotional connection, not existential exploration. Assuming transcendence overlooks the relational aspect of presence, potentially missing the patient’s immediate need for comfort and connection in the context of terminal illness care.
Choice C reason: Establishing presence involves being physically and emotionally available, as shown by sitting and touching the patient’s hand. This empathetic connection, rooted in Watson’s caring theory, fosters comfort and trust, critical for terminally ill patients. Presence supports emotional well-being, ensuring holistic care and dignity in end-of-life situations.
Choice D reason: Doing for involves performing tasks like bathing, not emotional support through touch. The nurse’s action establishes presence, not task-oriented care. Assuming doing for risks misinterpreting the action, potentially neglecting the patient’s need for empathetic connection, essential for psychological comfort in terminal illness care.
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