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.
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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Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Countertransference is incorrect. Countertransference involves the therapist's emotional reactions to the client based on the therapist's unresolved issues or feelings. It is not about viewing the client positively.
Choice B Reason:
Genuineness is incorrect. Genuineness, also known as congruence, is the therapist's ability to be authentic and transparent in the therapeutic relationship. While it contributes to a positive therapeutic environment, it is not specifically about viewing the client's worth and strengths.
Choice C Reason:
Positive Regard is correct. Positive regard, as proposed by Carl Rogers in person-centered therapy, refers to the therapist's genuine acceptance and caring for the client. It involves recognizing the client's worth, strengths, and potential for growth. Providing positive regard creates a supportive and nonjudgmental environment that facilitates the client's self-exploration and personal development.
Choice D Reason:
Empathy is incorrect. Empathy involves understanding and sharing the feelings of the client. While it contributes to a positive therapeutic relationship, it does not necessarily focus on viewing the client as having strengths and achievement potential.
Correct Answer is B
Explanation
A. Building a trusting relationship:Establishing trust is essential in therapeutic relationships, especially with clients at risk for self-harm. However, ensuring the client’s immediate safety by searching belongings takes precedence to protect the client from further harm.
B. Searching her belongings:This is the first priority to ensure Patty’s immediate safety and prevent access to any objects she could use to harm herself. This action addresses the immediate risk and creates a safer environment for her.
C. Orienting her to the unit. Orientation to the unit helps the client feel more comfortable and understand the rules and layout of the facility, but it is not as urgent as ensuring her safety upon admission.
D. Helping her settle into her room:Assisting Patty in getting comfortable is important for her overall well-being but is secondary to securing her environment by removing any potentially harmful items.
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