An older adult is admitted for altered cognition. The spouse indicates the client has become more forgetful over time. The nurse assesses the client's cognition using the Mini-Cog. The client is able to draw a clock correctly but is unable to recall the three words given at the beginning of the assessment. What do the results suggest to the nurse?
Dementia
Delusion
Depression
Delirium
The Correct Answer is A
A. In the Mini-Cog assessment, the inability to recall the three words (which tests short-term memory) while still being able to draw a clock (which tests visuospatial skills) could suggest early cognitive impairment or dementia. Dementia often presents with deficits in memory but may retain some other cognitive functions, like drawing. The result is consistent with a possible diagnosis of dementia, especially if memory issues are noted over time.
B. A delusion is a false belief held despite evidence to the contrary. Delusions are more related to psychiatric disorders and are not primarily assessed by the Mini-Cog. The Mini-Cog does not assess for delusions but rather focuses on cognitive function.
C. Depression can affect cognitive function, sometimes resulting in difficulties with concentration, memory, and other cognitive tasks. While depression can cause cognitive symptoms, it typically presents with other signs such as changes in mood, loss of interest in activities, and changes in sleep patterns.
D. Delirium is an acute, fluctuating change in cognition and attention, often caused by an underlying medical condition, medication, or intoxication. Delirium is characterized by rapid onset and fluctuating levels of consciousness and attention, which is not consistent with the Mini-Cog results showing stable performance on the clock drawing but poor recall.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The trigeminal nerve (CN V) is primarily responsible for sensation in the face and the motor control of the muscles used for chewing. It does not have a role in balance or equilibrium, so it would not be the focus when assessing balance issues.
B. The facial nerve (CN VII) controls the muscles of facial expression and provides taste sensation to the anterior two-thirds of the tongue. While it plays a significant role in facial movement and taste, it is not involved in balance or equilibrium.
C. The olfactory nerve (CN I) is responsible for the sense of smell. It does not have any role in balance or equilibrium. Balance issues are not related to the olfactory nerve, so this is not the appropriate focus for balance assessment.
D. The vestibulocochlear nerve (CN VIII) has two major components: the cochlear nerve, which is responsible for hearing, and the vestibular nerve, which is responsible for balance and equilibrium. The vestibular component of CN VIII is crucial for maintaining balance and spatial orientation. When a client reports spontaneous loss of balance, this nerve should be the focus of additional assessment.
Correct Answer is A
Explanation
A. 3- This is the lowest possible score on the GCS and reflects no eye opening, no verbal response, and no motor response to stimuli. Score of 4-6: The patient might exhibit some responses, but these responses are still severely impaired. For example, the patient might open their eyes to pain but not respond verbally or move purposefully.
B. A GCS score in the range of 13 to 15 reflects a higher level of consciousness.
C. A GCS score of 0 is not a valid score on the scale.
D. A GCS score in the range of 9 to 12 reflects moderate impairment of consciousness.
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