A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE) the nurse should include which of the following data? (Select all that apply)

Coping skills

Ability to perform calculations

Recall ability

Long-term memory

Level of orientation.

Answer and Explanation

Correct Answer : B,C,D,E

Choice A Reason:

The coping skills (Choice A) may be observed and assessed as part of the broader clinical picture, but they are not typically specific components of a formal Mental Status Examination.

Choice B Reason:

Ability to perform calculations. This assesses the client's cognitive abilities, specifically related to mathematical reasoning and problem-solving.

Choice C Reason:

Recall ability. Assessing recall ability helps evaluate the client's short-term memory, which can be impaired in individuals with dementia.

Choice D Reason:

Long-term memory. Evaluating long-term memory provides insights into the client's ability to recall information from the distant past, which is another aspect of cognitive function.

Choice E Reason:

Level of orientation. Assessing orientation to time, place, and person is crucial in understanding the client's awareness of their surroundings and current circumstances, which can be affected in dementia.

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Correct Answer is D

Explanation

Choice A Reason:

In the orientation phase is false. The orientation phase is focused on establishing rapport, building trust, and identifying the patient's needs and goals. It is too early to discuss termination during this phase.

Choice B Reason:

On the working phase is false. The working phase involves active problem-solving, goal attainment, and skill development. While progress is being made, it is not the appropriate time to introduce the topic of termination.

Choice C Reason:

When the patient brings up the topic is false. While it's important to be responsive to the patient's concerns, addressing the issue of termination solely based on the patient's initiation may not provide a comprehensive and planned discussion. The nurse should guide the conversation about termination at the appropriate time, considering the progress made in therapy.

Choice D Reason:

The termination phase is the final phase of the therapeutic relationship, and it involves discussing and planning for the conclusion of the therapeutic alliance. It provides an opportunity for the nurse and patient to reflect on the progress made, revisit goals, and discuss strategies for maintaining gains after the conclusion of the formal therapeutic relationship.

A. Help the patient to identify personal strengths and limitations. B. Explore, in depth, the problems faced by the patient. C. Clarify how long the relationship will last. D. Review the terms of confidentiality. E. Help the patient prioritize and revise ineffective coping behaviors.

Correct Answer is ["A","D","E"]

Explanation

Choice A Reason:

Helping the patient to identify personal strengths and limitations is appropriate. This helps build a positive foundation for the therapeutic relationship by focusing on the patient's strengths and empowering them in the process.

Choice B Reason:

Explore, in depth, the problems faced by the patient is inappropriate. While understanding the patient's concerns is important, diving too deeply into problems at the beginning might be overwhelming. It's often more effective to gradually explore issues as trust is established.

Choice C Reason:

Clarifying how long the relationship will last is inappropriate. Specifying the duration of the therapeutic relationship may create anxiety for the patient. Therapeutic relationships are often open-ended, and discussing termination should occur at an appropriate time in the future.

Choice D Reason:

Reviewing the terms of confidentiality is appropriate. Clarifying the terms of confidentiality is important to establish trust and inform the patient about the boundaries of the therapeutic relationship.

Choice E Reason:

Helping the patient prioritize and revise ineffective coping behaviors is appropriate. Collaboratively working with the patient to identify and address ineffective coping behaviors is a therapeutic intervention that supports the patient in their journey toward improved mental health.

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A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE) the nurse should include which of the following data? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a therapeutic nurse-patient relationship, when would the nurse plan to first address the issue of termination?

Correct Answer is D

Explanation

Which action would the nurse include when beginning a relationship with a new patient? Select all that apply. (Select All that Apply.)

Correct Answer is ["A","D","E"]

Explanation

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Which statement reflects an accurate understanding of when termination would first be discussed as part of the nurse-patient relationship?

Which statement describes the focus of psychiatric emergency care?

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The nurse is educating a patient with depression about the mental health continuum. Which statement made by the patient indicates the need for additional teaching?