Which of the following should the nurse use to assess a nonverbal older adult for delirium?
A) Cranial nerves XI and XII
B) Confusion Assessment Method
C) MMSE-2
D) Controlled Word Association Test

Question

Quizplus · Accepted Answer

The Confusion Assessment Method is a tool for measuring delirium in patients who are intubated or nonverbal.Assessing the accessory (CN XI)and hypoglossal (CN XII)cranial nerves provides clues about the patient's ability to swallow.The nurse uses the Controlled Word Association Test to assess for a neurologic cause of an older adult's cognitive dysfunction.This tool is an index of frontal lobe functioning and provides an assessment of executive function,including the patient's frontal lobe functioning and his or her ability to refrain from distraction and perseveration.The MMSE-2 is a valid and reliable tool to assess cognitive function; however,it is unable to pinpoint discrete areas of neurologic dysfunction.

Which of the Following Should the Nurse Use to Assess