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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Free Nursing Study Resources

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

Explanation

The correct answer isA, B, and E.

The nurse should instruct the patient to do the following:.

• Trim nails straight across and file edges smoothly.

• Soak nails in warm water before trimming to soften them.

• Report any signs of infection or inflammation around nails.

These are good practices for nail hygiene and health, especially for the elderly who may have dry, brittle or thickened nails.Trimming nails straight across and filing them prevents ingrown nails and reduces the risk of injury or infection.Soaking nails in warm water makes them easier to cut and less likely to crack or split.Reporting any signs of infection or inflammation around nails is important to prevent complications and get appropriate treatment.

Choice C is wrong because using a metal nail file or scissors to cut nails can damage the nail plate and cause splitting or tearing.Choice D is wrong because applying a clear nail polish to protect nails from cracking is unnecessary and may worsen nail health by trapping moisture and bacteria under the polish.

To maintain healthy nails, the elderly should also scrub the underside of their nails with soap and water, moisturize their nails and cuticles, avoid biting or chewing their nails, eat nutritious foods rich in calcium and vitamins B and C, and use sterilized nail grooming tools.

:Fingernail Care for the Elderly - assisting hands-il-wi.com:Fingernails: Do’s and don’ts for healthy nails - Mayo Clinic:Nail Hygiene | CDC - Centers for Disease Control and Prevention.

A. Elevated white blood cell count. B. Decreased serum creatinine level. C. Increased urine specific gravity. D. Altered mental status. E. Positive urine culture.

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

Explanation

The correct answer isA, D, and E.

Here is why:.

A. Elevated white blood cell count.

This is a sign of infection and inflammation in the body, which can be caused by a UTI.An elevated white blood cell count can also indicate a complication of UTI such as pyelonephritis (kidney infection) or sepsis (blood infection).

D. Altered mental status.

This is a common symptom of UTI in older adults, especially those with dementia or other cognitive impairments.UTIs can cause confusion, agitation, delirium, or behavioral changes in the elderly due to the effects of infection and inflammation on the brain.

E. Positive urine culture.

This is the definitive test to diagnose a UTI, as it identifies the type and number of bacteria present in the urine.A positive urine culture confirms the presence of a UTI and guides the appropriate antimicrobial treatment.

The other choices are wrong because:.

•.

B. Decreased serum creatinine level.

This is not a sign of UTI or its complications.

Serum creatinine is a measure of kidney function, and it usually increases when the kidneys are damaged or impaired.A decreased serum creatinine level may indicate other conditions such as liver disease, muscle wasting, or malnutrition.

•.

C. Increased urine specific gravity.

This is not a sign of UTI or its complications.

Urine specific gravity is a measure of urine concentration, and it usually increases when the body is dehydrated or has high levels of solutes in the urine.An increased urine specific gravity may indicate other conditions such as diabetes mellitus, heart failure, or dehydration.

Normal ranges for some of these tests are:.

• White blood cell count: 4,000 to 11,000 cells per microliter (mcL) of blood.

• Serum creatinine: 0.6 to 1.2 milligrams per deciliter (mg/dL) for men and 0.5 to 1.1 mg/dL for women.

• Urine specific gravity: 1.005 to 1.030.

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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

Naxlex Comprehensive Predictor Exams

The nurse is teaching an elderly patient about nail care and hygiene. The nurse should instruct the patient to do which of the following? (Select all that apply.).

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

Explanation

The nurse is reviewing the laboratory results of an older adult client who has a urinary tract infection (UTI). Which of the following findings should alert the nurse to a possible complication of UTI in older adults? (Select all that apply.).

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

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?