The nurse recognizes that a function of the Mental Status Exam is:

to obtain information about the client's medical history.

to establish limit setting.

to determine the client's IQ.

a method of organizing clinical observations.

Answer and Explanation

The Correct Answer is D

a. To obtain information about the client's medical history: While the MSE might reveal medical history clues, its primary focus is on mental status.
b. To establish limit setting: Limit setting is a separate therapeutic technique, not a function of the MSE.
c. To determine the client's IQ: IQ tests are separate assessments used to measure intelligence, not a function of the MSE.
d. a method of organizing clinical observations: A Mental Status Exam (MSE) is a structured way to assess a client's cognitive and emotional state. It focuses on areas like orientation, memory, attention, mood, and thought processes.

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Correct Answer is B

Explanation

a. Diphenhydramine: Diphenhydramine is an antihistamine that can also be used for its sedative properties to help calm an agitated client.
b. Ondansetron: Ondansetron is an antiemetic used to prevent nausea and vomiting, not for managing agitation or assaultive behavior. The nurse should question this order as it is not appropriate for the client's current symptoms.
c. Lorazepam: Lorazepam is a benzodiazepine used for its anxiolytic and sedative effects, making it appropriate for calming an agitated client.
d. Haloperidol: Haloperidol is an antipsychotic medication commonly used to manage severe agitation and aggressive behavior.

A. stop the client in the hall and tell them that they must pace in the day room instead. B. keep hands in pockets so as not to appear threatening. C. speak softly and calmly, D. offer the client a cup of coffee.

Correct Answer is C

Explanation

a. Stop the client in the hall and tell them that they must pace in the day room instead. This can be confrontational and might escalate the situation.
b. Keep hands in pockets so as not to appear threatening. While non-threatening body language is important, the focus should be on verbal communication.
c. Speak softly and calmly. De-escalation is key in such situations. A calm and non-threatening approach is essential to build rapport and assess the situation.
d. Offer the client a cup of coffee. Stimulants like caffeine might worsen anxiety.

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The nurse recognizes that a function of the Mental Status Exam is:

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Naxlex Comprehensive Predictor Exams

A client who is agitated and assaultive and unable to be verbally de-escalated is on the inpatient unit. The doctor ordered medications for the nurse to administer to the client. Which medication would the nurse question?

Correct Answer is B

Explanation

A client is noted to be pacing on the unit with their hands clenched and mumbling curses. The nurse knows that the initial approach to this client would be to:

Correct Answer is C

Explanation

The nurse recognizes that a function of the Mental Status Exam is:

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