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:

Encourages staff to provide frequent negative feedback to patient is incorrect. A therapeutic milieu typically focuses on positive reinforcement and constructive feedback to support patients' growth and development.

Choice B Reason:

Enforces rules and behavioral limits flexibly is incorrect. While establishing rules and limits is important for maintaining safety, flexibility in enforcing them allows for individualized care and consideration of the patient's unique needs.

Choice C Reason:

Permits additional privileges for voluntary admitted patients is incorrect. Additional privileges may be granted based on the patient's progress and participation in their treatment. However, it should be done thoughtfully and as part of a therapeutic plan rather than as a blanket permission for all voluntary admitted patients.

Choice D Reason:

Provides patients a sense of security and comfort is correct. A therapeutic milieu refers to the therapeutic environment or surroundings in a psychiatric setting that promotes the patient's well-being, safety, and recovery. This environment should be supportive, safe, and conducive to healing. Providing patients with a sense of security and comfort is essential for their overall well-being and progress in treatment.

A. "Now that we've discussed your reasons for being here and how often we will meet. I'd like to talk about what we will do at the time of your discharge." B. "You are being discharged today, so I’d like to bring up the subject of termination which includes discussing your time here and summarizing what coping skills you have attained. C. "Now that we are working on your problem-solving skills and the behaviors you'd like to change like to bring up the issue of termination D. Haven’t met my new patient yes, but am working through my findings of anxiety in dealing with patient who wanted to kill herself

Correct Answer is C

Explanation

Choice A Reason:

"Now that we've discussed your reasons for being here and how often we will meet, I'd like to talk about what we will do at the time of your discharge." This option seems to introduce the topic of termination prematurely, especially if the client's issues and goals haven't been adequately addressed yet.

Choice B Reason:

"You are being discharged today, so I'd like to bring up the subject of termination, which includes discussing your time here and summarizing what coping skills you have attained."This option presents termination at the time of discharge without prior discussion or collaboration with the client.

Choice C Reason:

"Now that we are working on your problem-solving skills and the behaviors you'd like to change, I'd like to bring up the issue of termination." In therapeutic relationships, termination is an essential phase that involves discussing the ending of the relationship and summarizing the progress made. Bringing up the topic of termination when actively working on the client's goals and issues is appropriate. It allows for a collaborative discussion about the achievements, future plans, and coping strategies that the client has developed during the therapeutic process.

Choice D Reason:

"I haven't met my new patient yet, but am working through my feelings of anxiety in dealing with a parent who wanted to kill herself." This statement is not related to the discussion of termination in the ongoing nurse-patient relationship.

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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

Which is a characteristic of therapeutic milieu when caring for a patient in the psychiatric healthcare setting?

Correct Answer is D

Explanation

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

Correct Answer is C

Explanation

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The nurse can best communicate to a patient that she has been listening by:

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

Which goal represents Beck's cognitive-behavioral model?

The nurse states to the patient "You say that you are sad, but you are smiling..." Which option describes the purpose of this therapeutic communication technique?