The nurse is caring for a client who, though depressed, has been oriented to time, place, and person
For the last 24 hours, however, the client has repeatedly asked the staff, "Where am I?" The nurse anticipates that the most appropriate tool to assess this client's cognitive status is the: 1. Cognitive Capacity Screening Examination (CCSE).
2. Mini-Mental Status Examination (MMSE).
3. Beck Depression Inventory (BDI).
4. Duke Anxiety-Depression Scale (DUKE-AD).
Cognitive Capacity Screening Examination (CCSE).
Rationale: The Cognitive Capacity Screening Examination (CCSE) is most reliable for distinguishing between acute and chronic cognitive disorders. While an excellent screening tool, the Mini-Mental Status Examination (MMSE) is not the tool of choice for this client due to the acute nature of the onset of symptomology. The Beck Depression Inventory (BDI) and the Duke Anxiety-Depression Scale (DUKE-AD) evaluate depression, but have no focus on cognitive dysfunction.
You might also like to view...
Calculate the alveolar ventilation of a patient in the postanesthesia care unit, following general anesthesia, if the patient inhales 400 mL of air in each breath 10 times per minute.
A) 1.5 L/min B) 2.0 L/min C) 2.5 L/min D) 3.0 L/min
The nurse is assisting a newly delivered mother ambulate to the nursery to see the baby. The client complains of light-headedness and begins to faint. What is the nurse's most important action?
1. Ensure the client's modesty as she falls. 2. Be certain the client does not hit the head on anything. 3. Call for immediate assistance. 4. Check the vital signs and for excessive vaginal bleeding.
The spouse of a client with bipolar disorder asks the nurse, "Is this cycling of moods from de-pressed to manic going to continue the rest of his life?" What information should serve as the ba-sis for the nurse's reply?
1. Clinical observation tells us that mood disorders tend to remit and recur. 2. Most significant others of clients with mood disorders seek divorces. 3. Most mood disorders are cured within 5 years of onset. 4. Persons from higher socioeconomic groups will respond better to medication.
Postoperative wound infection is a concern for S.P. Describe what you would do to monitor
her for a wound infection. What will be an ideal response?