A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include? (Select all that apply.)
Grooming
Long-term memory
Support systems
Presence of pain
Affect
Correct Answer : A,B,E
The nurse should include the following components when performing a mental status examination (MSE) on a client with a new diagnosis of dementia:
● Grooming: Assessing the client's grooming and personal hygiene can provide insights into their ability to care for themselves and maintain basic activities of daily living.
● Long-term memory: Evaluating the client's long-term memory can help identify any deficits or impairments in their ability to recall past events, experiences, or personal information. This is particularly relevant in dementia, as it often affects memory function.
● Support systems: Assessing the client's support systems, such as family members, friends, or caregivers, is essential in understanding the resources available to the client and the level of assistance they may require in managing their dementia. However, this does not occur within the mental status exam.
● Affect: Evaluating the client's affect refers to observing their emotional expression and responsiveness during the assessment. In dementia, changes in affect can occur, such as a flat affect or inappropriate emotional responses.
The component that should not be included in the MSE for a client with dementia is:
● Presence of pain: While pain assessment is an important aspect of caring for individuals with various health conditions, including dementia, it is not a specific component of the mental status examination. Pain assessment is typically addressed separately and should be conducted when necessary or based on the client's specific complaints or indications of pain.
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Related Questions
Correct Answer is D
Explanation
The purpose of asking the client to describe their problems during the assessment is to obtain information about their perception of the problem. By asking the client to describe their problems
in their own words, the nurse gains insight into how the client perceives and understands their current situation. This information helps the nurse to understand the client's subjective experience, their concerns, and their specific needs related to the problem. It allows for a more accurate assessment of the client's situation and helps in developing an individualized plan of care tailored to their unique needs.
● Personal needs: While understanding a client’s personal needs is important in providing care, it is not the primary purpose of this specific question. The nurse may ask other questions to gather information about the client’s personal needs.
● Communication skills: Assessing a client’s communication skills may be important in some cases, but it is not the primary purpose of this specific question. The nurse may use other methods to assess the client’s communication skills.
● Admitting diagnosis: The admitting diagnosis is typically determined by a physician and is based on medical tests and examinations. While the nurse may gather information that can contribute to determining the admitting diagnosis, it is not the primary purpose of this specific question.
Correct Answer is C
Explanation
Systematic desensitization is a therapeutic technique used to help individuals gradually overcome their fears or phobias by exposing them to the feared stimulus in a controlled and systematic way. The goal is to reduce anxiety and increase relaxation through a step-by-step process.
The statement "What is the worst that will happen if you confront this fear?" aligns with the principle of systematic desensitization because it encourages the client to explore and challenge their negative beliefs or catastrophic thinking associated with their fear. By questioning the potential negative outcomes, the nurse is helping the client to reevaluate their fear response
and consider more realistic expectations. This process can contribute to the client's ability to confront their fear gradually and reduce anxiety over time.
The other statements are still helpful and supportive, but they do not specifically address the principles of systematic desensitization:
“I can see you are anxious. Let's stop for a minute." acknowledges the client's anxiety but does not actively engage in the technique of systematic desensitization.
"Use the deep breathing techniques we practiced yesterday." focuses on relaxation techniques, which can be helpful in managing anxiety but does not specifically address the principles of systematic desensitization.
“Tell me how you are feeling right now." encourages the client to express their feelings but does not directly engage in the technique of systematic desensitization.
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