A nurse is performing a mental status examination on an older adult client who has delirium.

Which of the following tools can the nurse use to assess the client’s attention span and concentration?

Mini-Mental State Examination (MMSE).

Confusion Assessment Method (CAM).

Clock Drawing Test (CDT).

Digit Span Test (DST).

Answer and Explanation

The Correct Answer is D

The correct answer is D.

Digit Span Test (DST).

The DST is a tool that can be used to assess the client’s attention span and concentration by asking them to repeat a series of digits forward and backward (Martin, 1990).

The DST is part of the Mini-Mental State Examination (MMSE), which is a broader tool that covers other domains of cognitive functioning, such as orientation, memory, language, and visuospatial skills (Folstein et al., 1975).

Choice A is wrong because the MMSE is not a specific tool for attention span and concentration, but rather a general screening tool for cognitive impairment.

Choice B is wrong because the Confusion Assessment Method (CAM) is a tool that can be used to diagnose delirium, but not to assess attention span and concentration.

The CAM focuses on four features of delirium: acute onset and fluctuating course, inattention, disorganized thinking, and altered level of consciousness (Inouye et al., 1990).

Choice C is wrong because the Clock Drawing Test (CDT) is a tool that can be used to assess visuospatial skills and executive function, but not attention span and concentration.

The CDT requires the client to draw a clock face with numbers and hands indicating a specific time (Shulman et al., 1986).

Normal ranges for the DST vary depending on the age and education level of the client, but generally a score of 5 or more digits forward and 4 or more digits backward is considered normal (Martin, 1990).

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Correct Answer is B

Explanation

Intention tremors and nystagmus.These are some of the common symptoms of multiple sclerosis (MS), a condition that affects the central nervous system and causes communication problems between the brain and the rest of the body.Intention tremors are involuntary shaking movements that occur when a person tries to perform a precise action, such as reaching for an object or writing.Nystagmus is a condition where the eyes make repetitive, uncontrolled movements, often resulting in reduced vision and depth perception.

Choice A is wrong because muscle atrophy and fasciculations are more typical of motor neuron diseases, such as amyotrophic lateral sclerosis (ALS), which affect the nerve cells that control voluntary muscle movements.

Choice C is wrong because flaccid paralysis and areflexia are signs of lower motor neuron lesions, which can be caused by spinal cord injuries, peripheral nerve disorders, or Guillain-Barré syndrome.

Choice D is wrong because hyperactive reflexes and spasticity are signs of upper motor neuron lesions, which can be caused by stroke, traumatic brain injury, or cerebral palsy.

Normal ranges for some of the symptoms mentioned are:.

• Intention tremors: none or minimal.

• Nystagmus: none or minimal.

• Muscle atrophy: none or minimal.

• Fasciculations: none or minimal.

• Flaccid paralysis: none or minimal.

• Areflexia: absent or reduced reflexes.

• Hyperactive reflexes: normal or slightly increased reflexes.

• Spasticity: normal or slightly increased muscle tone.

A. Muscle atrophy and fasciculations B.

Intention tremors and nystagmus C.

Flaccid paralysis and areflexia D.

Hyperactive reflexes and spasticity

A. Providing opportunities for group activities such as games, music, art or exercise B. Encouraging family members or volunteers to visit or call the clients regularly. C. Creating a homelike environment that promotes comfort, safety and privacy. D. Assigning consistent staff members who are familiar with the clients’ needs and preferences. E. Providing feedback or recognition for the clients’ achievements or contributions.

Correct Answer is ["A","B","C","D"]

Explanation

These interventions are appropriate for reducing social isolation in older adult clients who live in a long-term care facility because they provide opportunities for social interaction, support, comfort and familiarity.

Choice A is correct because group activities such as games, music, art or exercise can foster a sense of belonging, enjoyment and engagement among older adults.Group activities can also improve physical and mental health, cognitive function and well-being.

Choice B is correct because encouraging family members or volunteers to visit or call the clients regularly can enhance the quality and quantity of social relationships, which can reduce loneliness and isolation.Family members or volunteers can also provide emotional support, companionship and practical assistance to the clients.

Choice C is correct because creating a homelike environment that promotes comfort, safety and privacy can increase the clients’ satisfaction, autonomy and dignity.A homelike environment can also facilitate social interactions among the clients and the staff by providing common areas, personal belongings and familiar objects.

Choice D is correct because assigning consistent staff members who are familiar with the clients’ needs and preferences can improve the continuity and quality of care, as well as the trust and rapport between the clients and the staff.Consistent staff members can also recognize and respond to the clients’ social needs and preferences, and provide personalized interventions.

Choice E is incorrect because providing feedback or recognition for the clients’ achievements or contributions may not be effective in reducing social isolation, unless it is combined with other interventions that promote social interaction and support.Feedback or recognition alone may not address the underlying causes of social isolation, such as lack of meaningful relationships, low self-esteem or poor health.

Normal ranges for social isolation and loneliness are difficult to define, as they depend on various factors such as individual characteristics, cultural norms and measurement tools.However, some indicators of social isolation include having few or no social contacts, participating in few or no social activities, feeling disconnected from others or society, and having low levels of perceived social support.Some indicators of loneliness include feeling unhappy about one’s social situation, feeling left out or unwanted, lacking companionship or intimacy, and having low levels of perceived belongingness or connectedness.

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A nurse is performing a mental status examination on an older adult client who has delirium. Which of the following tools can the nurse use to assess the client’s attention span and concentration?

Nursing Test Bank

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The nurse is assessing a patient who has been diagnosed with multiple sclerosis (MS). Which of the following findings is most consistent with this condition?

Correct Answer is B

Explanation

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Correct Answer is ["A","B","C","D"]

Explanation

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A nurse is performing a mental status examination on an older adult client who has delirium.

Which of the following tools can the nurse use to assess the client’s attention span and concentration?