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)

Choice A Reason:

Triage and stabilization of the acute symptoms are a priority describes the focus of psychiatric emergency care. Psychiatric emergency care focuses on the rapid assessment, triage, and stabilization of individuals experiencing acute psychiatric symptoms or crises. The primary goal is to address immediate safety concerns, stabilize the individual's condition, and determine the appropriate level of care or intervention. This may involve crisis intervention, brief assessment, and referral to appropriate services.

Choice B Reason:

A nurse visits one to three times a week to assess for extreme agitation does not describe the focus of psychiatric emergency care. This describes a more routine or outpatient assessment schedule rather than the urgent and immediate focus of psychiatric emergency care.

Choice C Reason:

Overnight short-term observations are 1 to 3 days in duration does not describe the focus of psychiatric emergency care. This refers to a short-term observation period, which might occur in various psychiatric settings, but it does not specifically address the urgency of psychiatric emergencies.

Choice D Reason:

Antipsychotic medications are administered does not describe the focus of psychiatric emergency care. Administering antipsychotic medications is a treatment approach that may be part of the overall psychiatric care plan, but it does not specifically capture the immediate triage and stabilization focus of psychiatric emergency care.

Choice A Reason:

Wife/mother is incorrect. The wife/mother expresses that she is not skillful in conflict resolution, but her concerns are related to her own abilities rather than exhibiting specific problematic behaviors that are disruptive or distressing to the family system.

Choice B Reason:

Daughter is correct. The daughter, who is rebellious and in academic trouble, is most likely to be listed as the "identified patient" because her behavior is presenting visible challenges and concerns. In family systems therapy, addressing and understanding the dynamics surrounding the identified patient can provide insights into the broader family issues and interactions.

Choice C Reason:

Son is incorrect. The son is conflicted about where to attend college, which is a common developmental decision. While it may cause some family stress, it doesn't necessarily indicate the presence of disruptive or problematic behavior warranting the label of "identified patient."

Choice D Reason:

Husband/father is incorrect. The husband/father is skeptical of the idea that talking can be helpful, but skepticism or reluctance to engage in therapy does not necessarily make him the identified patient. His behavior doesn't present as a disruptive symptom within the family.