The nurse is to perform a complete assessment of a client in her ...

[joe]

The nurse is to perform a complete assessment of a client in her home, using the Mini-Mental State Examination as one component.
 
  When the nurse arrives, the client is seated at the table with her husband, the TV is on, and sev-eral grandchildren are visiting. The client's husband says, Let's get on with this business. The client is quiet, but her hands are gripped tightly, and she is staring at the ceiling. The best action for the nurse to take would be to:
  1. Explain to the husband that accurate data will be sought, and ask him to stay with the grandchildren in another room
  2. Explain the importance of the testing process and make an appointment for an-other day when the environment can be better controlled
  3. Not perform the test during the assessment (because it will not be valid) and rely on observations and reports from the family
  4. Ask the husband to make an appointment to bring his wife to the clinic for testing

Question 2

In teaching a patient about treatment of alcoholism, the nurse needs to include that which herbal preparations increase CNS depression? (Select all that apply.)
 
  1. Kava kava
  2. Ginkgo
  3. Valerian
  4. Black cohosh
  5. Cowslip

[kingdude89]

Answer to Question 1

ANS: 2
Testing the client in her home under quieter, less distracting circumstances is the best solution. 1. Asking the husband to leave is likely to increase the client's anxiety and alter test results. 3. Use of the MMSE is an integral component of the assessment and must not be deleted. 4. Testing in the more familiar, comfortable surroundings of the home will yield more reliable results.

Answer to Question 2

ANS: 1, 3, 5
Ginkgo (option 2) and black cohosh (option 4) are not reported to cause CNS depression.