A nurse is providing presence to a patient and the family. Which nursing action does this involve?

Choice A reason: Acknowledging lost energy restates a symptom but does not address the patient’s emotional state. The patient’s statement, “What’s the use?” suggests despair beyond physical fatigue. This response misses the opportunity to explore psychological distress, limiting therapeutic communication and failing to support the patient’s emotional needs in a terminal illness.

Choice B reason: Stating “It sounds like you have lost hope” reflects the patient’s despair, as indicated by disinterest in work, care, and the phrase “What’s the use?” This empathetic response opens dialogue about emotional and spiritual needs, fostering trust. It aligns with holistic care, addressing the psychological impact of a terminal diagnosis effectively.

Choice C reason: Focusing on lost sleep restates a symptom without addressing the underlying hopelessness. Sleep issues are secondary to the patient’s emotional distress in a terminal illness. This response fails to engage with the patient’s despair, missing a chance to provide emotional support and explore deeper psychological or spiritual concerns.

Choice D reason: Noting lost appetite acknowledges a physical symptom but ignores the patient’s emotional withdrawal and hopelessness. The statement “What’s the use?” points to existential distress, not just eating issues. This response lacks depth, failing to address the psychological and spiritual dimensions critical in terminal illness care.

Choice A reason: Asking the family about normal behavior provides subjective context but lacks standardized cognitive assessment. Cognitive function requires objective tools like the MMSE to evaluate memory, orientation, and attention. Relying solely on family input risks missing subtle deficits, delaying diagnosis of conditions like dementia or delirium critical for patient management.

Choice B reason: Asking for name, location, and month tests orientation, a component of cognitive assessment, but is too limited. The MMSE offers a comprehensive evaluation of memory, language, and visuospatial skills. This narrow approach risks overlooking broader cognitive impairments, potentially missing early dementia or other neurological conditions requiring targeted interventions.

Choice C reason: The HHIE-S assesses hearing impairment, not cognitive function. Hearing loss may affect communication but isn’t a direct cognitive measure. Using this tool for cognition misdirects assessment, risking failure to identify cognitive deficits like memory loss, delaying diagnosis and management of conditions such as Alzheimer’s disease or acute confusional states.

Choice D reason: Administering the MMSE is a standardized, comprehensive tool to assess cognitive function, evaluating orientation, memory, attention, language, and visuospatial skills. It detects impairments in conditions like dementia or delirium, guiding diagnosis and treatment. Its structured approach ensures reliable identification of cognitive deficits, critical for planning care and interventions in clinical settings.