A nurse is assessing cognitive functioning of a patient. Which ...

[ts19998]

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).

Question 2

The nurse is creating a plan of care for a patient with glaucoma. Which nursing diagnosis will the nurse include in the care plan to address a safety complication of the sensory deficit?
 
  a. Body image disturbance
  b. Social isolation
  c. Risk for falls
  d. Fear

[blakcmamba]

Answer to Question 1

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.

Answer to Question 2

ANS: C
A visual disturbance poses great risk for injury due to falling from impaired depth perception and inability to see obstacles. Body image disturbance, social isolation, and fear are all valid nursing diagnoses that apply to a patient with vision deficit; however, they do not address the greatest risk for injury.

[ts19998]

Excellent

[ttt030911]

TYSM