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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A Reason:
Grooming is correct. Grooming assesses the client's personal care and hygiene, providing insight into their ability to perform self-care activities.
Choice B Reason:
Long-term memory is correct. Evaluating long-term memory helps assess the client's ability to recall past events and information, which can be affected in individuals with dementia.
Choice C Reason:
Support systems is incorrect. While support systems are crucial in the overall care of individuals with dementia, they are not typically assessed in a traditional MSE.
Choice D Reason:
Affecting is correct. Affect refers to the client's emotional expression. Assessing affect helps in understanding the client's emotional state, which can be important in diagnosing and managing dementia.
Choice E Reason:
Presence of pain is incorrect. While assessing pain is essential in clinical care, it may be more pertinent to a physical assessment than a mental status examination specifically focused on cognitive functioning.
Correct Answer is B
Explanation
Choice A Reason:
"It might help you feel better if you talk about it." While encouraging communication is generally good, the client has clearly expressed a desire not to talk at the moment. Pressuring them to talk may not be beneficial.
Choice B Reason:
"I'll just sit here with you for a few minutes then." This response acknowledges the client's need for solitude while showing a willingness to provide presence and support. It respects the client's autonomy and allows them to lead the interaction.
Choice C Reason:
"I understand; I've felt like that before, too." While expressing empathy can be helpful, it's important not to overshadow the client's experience by sharing personal feelings at this moment.
Choice D Reason:
"Why are you feeling so down?" This question may feel intrusive and may not be well-received by the client, especially when they've indicated a preference not to talk. It's important to approach the conversation with sensitivity and respect for the client's boundaries.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.