A nurse is assessing cognitive functioning of a patient. Which action will the nurse take?
a. Administer a Mini-Mental State Examination (MMSE).
b. Ask the patient to state name, location, and what month it is.
c. Ask the patient's family if the patient is behaving normally.
d. Administer the hearing handicap inventory for the elderly (HHIE-S).
ANS: A
The MMSE is a formal diagnostic tool that is used to assess a patient's level of cognitive functioning. The Mini-Mental State Examination (MMSE) is a tool you can use to measure disorientation, change in problem-solving abilities, and altered conceptualization and abstract thinking. Asking the patient orientation questions evaluates only the patient's orientation to self and surroundings, not abstract reasoning or critical thinking ability. Family members are not the most reliable source of information about the patient, although information received from the family should be considered. The HHIE-S is a 5-minute, 10-item questionnaire that assesses how the individual perceives the social and emotional effects of hearing loss. The higher the HHIE-S score, the greater the handicapping effect of a hearing impairment.
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