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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
The statements by the client that would require the nurse to notify the health care provider to cancel the MRI procedure are:
● “I had a pacemaker inserted a few years ago because my heart was not beating fast enough.”
● "I fell down my basement steps last year and broke my hip and had to have a hip replacement.”
● “When I was diagnosed with mitral valve prolapse, they had to replace the valve with a prosthetic valve."
These statements indicate that the client has metallic implants or devices in their body, which can be affected by the strong magnetic field of an MRI machine. This can pose a risk to the client’s safety and may interfere with the accuracy of the MRI results.
The other statements do not necessarily require the cancellation of the MRI procedure, but the nurse may need to take additional precautions or provide additional support to ensure the client’s comfort and safety during the procedure.
Here is a detailed explanation of why the other choices do not necessarily require the cancellation of the MRI procedure:
● “I have such terrible anxiety, I don’t know if I can remain still throughout the procedure.”: While anxiety can make it difficult for a client to remain still during an MRI procedure, it does not necessarily require the cancellation of the procedure. The nurse may provide additional support or medication to help the client manage their anxiety and remain still during the procedure.
● “I have diabetes mellitus type and have been taking insulin for many years.”: Having diabetes and taking insulin does not necessarily require the cancellation of an MRI procedure. The nurse may need to take additional precautions to ensure that the client’s blood sugar levels are stable during the procedure, but it does not pose a direct risk to the client’s safety or interfere with the accuracy of the MRI results.
Correct Answer is C
Explanation
Culturally competent care involves understanding and respecting the diverse cultural backgrounds of clients. It requires the nurse to acquire knowledge about the client's specific culture and how it influences their healthcare preferences and practices. By taking the time to learn about the client's cultural background, the nurse can better understand their unique needs, beliefs, and values related to health and healthcare.
While continuing education and gaining knowledge about different cultures are important aspects of providing culturally competent care, it is essential to go beyond generalized expectations about cultural groups. Each individual within a culture can have unique beliefs and preferences, so it is crucial to approach each client as an individual rather than relying solely on broad cultural stereotypes.
Behaving as appropriate for the nurse's own culture may lead to misunderstandings or misinterpretations of the client's needs and preferences. It is important for the nurse to be aware of their own cultural biases and to approach care in a culturally sensitive and respectful manner.
Therefore, the best approach for the nurse to provide culturally competent care is to find out as much as possible about the client's specific cultural values, beliefs, and health practices. This
knowledge can guide the nurse in tailoring care that is respectful, responsive, and appropriate for the client's cultural background.
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