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 ["A","B","D"]

Explanation

The correct answer isA, B and D.

Here is why:.

• Following up with the primary care provider regularly can help detect and treat any medical conditions that may cause or contribute to delirium, such as infections, electrolyte imbalances, or medication side effects.

• Avoiding alcohol and tobacco use can prevent delirium caused by intoxication or withdrawal, as well as improve overall health and cognitive function.

• Engaging in physical and mental activities daily can help maintain brain health, prevent cognitive decline, and reduce stress and boredom that may trigger delirium.

Choice C is wrong because taking over-the-counter sleeping pills as needed can increase the risk of delirium, especially in older adults.Sleeping pills can cause confusion, drowsiness, memory impairment, and falls that may lead to delirium.Instead of sleeping pills, it is better to have good sleep habits such as uninterrupted sleep, avoiding caffeine and naps, and having a regular bedtime routine.

Choice E is wrong because wearing glasses and hearing aids if prescribed can help prevent delirium, not cause it.Sensory impairment such as poor vision and hearing can make a person more prone to delirium, as they may feel disoriented, isolated, or misunderstood.Wearing glasses and hearing aids can help improve communication, orientation, and awareness of surroundings.

Delirium is a serious change in mental abilities that results in confused thinking and a lack of awareness of one’s surroundings.It usually comes on fast and can be caused by various factors such as fever, infection, surgery, medication, or emotional distress.

Delirium can often be prevented.

A. Monitor the client’s skin for signs of injury or infection. B. Teach the client to avoid exposure to extreme temperatures. C. Encourage the client to use assistive devices for mobility and balance. D. Provide the client with sensory stimulation such as massage or music. E. Advise the client to wear loose-fitting clothing and shoes.

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

Explanation

The correct answer isA, B, and C.

These interventions are appropriate for a client who has impaired tactile sensation due to aging.

• Ais correct because monitoring the client’s skin for signs of injury or infection can help prevent complications such as pressure ulcers, burns, or infections that might go unnoticed by the client due to reduced sensitivity.

• Bis correct because teaching the client to avoid exposure to extreme temperatures can protect the client from thermal injuries such as frostbite or heatstroke that might not be felt by the client due to diminished thermoreception.

• Cis correct because encouraging the client to use assistive devices for mobility and balance can enhance the client’s safety and independence by compensating for the loss of proprioception and kinesthesia that might impair the client’s coordination and stability.

• Dis wrong because providing the client with sensory stimulation such as massage or music is not directly related to impaired tactile sensation due to aging.While sensory stimulation might have other benefits for the client’s well-being, it does not address the specific problem of reduced touch perception.

• Eis wrong because advising the client to wear loose-fitting clothing and shoes is not helpful for a client who has impaired tactile sensation due to aging.In fact, loose-fitting clothing and shoes might increase the risk of falls or injuries by creating friction or slipping off the client’s body.

Normal ranges for tactile sensation vary depending on the type of stimulus, the location of the skin, and the method of testing.

However, some general guidelines are:.

• Vibration sense: normal threshold is less than 10 μm at 30 Hz on the fingertip.

• Temperature sense: normal threshold is less than 1°C difference between two stimuli on the forearm.

• Pressure sense: normal threshold is less than 10 g/mm2 on the fingertip.

• Pain sense: normal threshold is less than 0.5 g/mm2 on the fingertip.

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

Explanation

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

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?