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A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE), the nurse should include which of the following data? (Select all that apply.)
- A. Ability to perform calculations
- B. Coping skills
- C. Recall ability
- D. Long-term memory
- E. Level of orientation
Correct Answer: A, C, D, E
Rationale: The correct answers are A, C, D, and E. In a Mental Status Examination for a client with dementia, assessing the ability to perform calculations (A) is important to evaluate cognitive function. Recall ability (C) is crucial as memory impairment is a common feature of dementia. Long-term memory (D) is essential to assess for signs of cognitive decline. The level of orientation (E) is vital to determine the client's awareness of time, place, and person, which can be impaired in dementia. Coping skills (B) are important but not typically assessed in an MSE for dementia. The other choices (F, G) do not directly relate to the cognitive impairment typically seen in dementia.
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A nurse is teaching about electroconvulsive therapy (ECT) with a newly licensed nurse. The nurse should identify that the newly licensed nurse understands the teaching when she states that ECT treats which of the following disorders?
- A. Narcotic addiction
- B. Major depressive disorder
- C. Personality disorder
- D. Eating disorder
Correct Answer: B
Rationale: ECT is most commonly used for treatment-resistant major depressive disorder.
A nurse is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?
- A. Identify the client's nutritional status.
- B. Request a mental health consult.
- C. Plan a therapeutic diet for the client.
- D. Provide a structured environment for the client.
Correct Answer: A
Rationale: The correct answer is A: Identify the client's nutritional status. The priority is to assess the client's nutritional status due to the significant weight loss. This will help determine if the client is at risk of malnutrition or other health issues. B, requesting a mental health consult, is not the first priority as addressing the client's physical health is crucial before addressing mental health concerns. Planning a therapeutic diet (C) can come after assessing the nutritional status. Providing a structured environment (D) may be important but not as critical as determining the client's nutritional status first.
A nurse is caring for a client who has schizophrenia who consistently does the opposite of what the nurse asks of him. The nurse recognizes this as which of the following alterations in behavior?
- A. Automatic obedience
- B. Waxy flexibility
- C. Negativism
- D. Impaired impulse control
Correct Answer: C
Rationale: The correct answer is C: Negativism. Negativism is a behavior where the client does the opposite of what is asked or expected. In this case, the client with schizophrenia consistently does the opposite of what the nurse asks, which aligns with negativism. Automatic obedience (A) is when a client complies without question, waxy flexibility (B) is characterized by maintaining limbs in the position they are placed in, and impaired impulse control (D) involves difficulty controlling impulses, none of which fit the scenario described.
A nurse is caring for several clients who have mental health disorders at an assisted-living facility. Which of the following clients should the nurse determine needs to be seen by a provider immediately?
- A. A client who is taking olanzapine and experiences dizziness when first standing up
- B. A client who is taking chlorpromazine and reports vomiting twice
- C. A client who is taking thioridazine and has daytime drowsiness
- D. A client who is taking clozapine and has flu-like manifestations
Correct Answer: D
Rationale: The correct answer is D. Clozapine is associated with a serious side effect called agranulocytosis, which can manifest as flu-like symptoms such as fever, sore throat, and malaise. Agranulocytosis is a potentially life-threatening condition that requires immediate medical attention to prevent complications. Clients taking clozapine should be monitored closely for signs of infection. Choices A, B, and C describe common side effects of antipsychotic medications that are not typically considered emergencies. For example, dizziness upon standing (A), vomiting (B), and daytime drowsiness (C) are known side effects that may not require immediate medical attention unless severe or persistent. Therefore, the client taking clozapine with flu-like manifestations (D) should be seen by a provider immediately due to the potential seriousness of agranulocytosis.
A nurse is caring for a client who has major depressive disorder. Which of the following findings should the nurse expect?
- A. Dismissal of past failures
- B. Psychomotor agitation
- C. An increase in energy
Correct Answer: B
Rationale: The correct answer is B: Psychomotor agitation. In major depressive disorder, psychomotor agitation is a common symptom characterized by restlessness, pacing, fidgeting, or hand-wringing. This is due to the increased inner tension and anxiety experienced by the individual. Dismissal of past failures (A) is not a typical finding in major depressive disorder, as individuals often dwell on negative thoughts. An increase in energy (C) is unlikely, as fatigue and low energy levels are more common in depression. The other choices are not provided, but it's important to remember that psychomotor agitation can be a key indicator in identifying major depressive disorder.