A nurse assesses an older adult using a mini-mental status examination. The client is very slow to respond to the questions. Which of the following conditions may be present and will require follow-up by the nurse? (Select all that apply.)
A) Lack of education
B) Dementia
C) Depression
D) Confabulation
E) Concrete thinking
Ans: B, C
The nurse assesses the amount of time and effort expended in answering questions. This is particularly important when trying to differentiate between dementia and depression. Lack of education and concrete thinking would not slow the client in responding to assessment tools such as the mini-mental. Confabulation is when the client creates information.
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