Chapter 19: Mental Status Flashcards
(41 cards)
a nurse is providing care for a pt who has hepatic encephalopathy secondary to chronic alcohol abuse. The nurse’s assessment reveals that the pt often provides incorrect answers to the questions. As well as the pt makes statements that are not grounded in reality. what nursing diagnosis is suggested by the assessment date?
acute confusion
What is hepatic encephalopathy
decline in brain function that happens when the liver fails to properly remove toxins, especially ammonia, from the blood.
The nurse is admitting a client to the unit for surgery the next morning. The nurse notes that the client speaks at an accelerated pace and jumps from topic to topic, none of which progresses to sensible conversation. What would the nurse document about this client
pt demonstrates flight of ideas
the nurse asks a pt to draw the face of a clock with numbers and hands to make it read 3 o’clock. what is tested by the completion of this task?
constructional ability
the nurse begins the health history with a focus on the client’s mental status. why does the nurse ask for the client’s age?
provides a reference point for psychosocial developmental level
The nurse is performing a comprehensive health assessment on a client. The nurse would use the SBIRT tool when the client makes what statement
I drink most days of the week
during the health history interview, what component of cognitive function can the nurse quickly assess
memory and attention
during a comprehensive assessment, the nurse identifies signs of possible dementia. what is the best action of the nurse?
perform the SLUMS examination to assess cognitive function
a client opens the eyes and answers questions however falls back asleep within seconds. How should the nurse document this assessment finding?
lethargy
a client states reports feeling like a burden to the family and totally worthless. what response would be appropriate for the nurse to make to this client?
Have you thought of killing yourself?
during the assessment the nurse asks a client to explain what the following means: “a penny saved is a penny earned” the nurse is assessing what?
abstract reasoning
The nurse is assessing a client diagnosed with a posterior superior temporal lobe lesion who is exhibiting Wernicke aphasia. What finding should the nurse anticipate in the client
rapid speech that lacks meaning
The nurse documents findings from the client’s Everyday Cognition (ECog) questionnaire. Which information will the nurse document regarding the results of the test
cognitive and functional decline
The nurse notes that an older adult client is wearing layers of clothing on a warm, fall day. What would be the priority assessment at this time
asking whether the client often feels cold
A nurse asks a client the following question: “What do you do if you have pain?” The nurse is assessing which of the following aspects of cognitive function
judgment
A nurse has been asked to complete a mental status examination of a psychiatric-mental health client. Which of the following is included in this assessment
evaluation of insight and judgement
As part of assessing the client’s level of consciousness, the nurse asks questions related to person, place, and time. Which of these statements is true
orientation to time is usually lost first and orientation to person is usually lost last
Which of the following statements by a client would the nurse recognize as evidence of an absence of insight
sometimes i feel like the world would be better off if i were dead but who doesn’t feel like that from time to time
While conducting an assessment the nurse suspects that a client is making up things in response to specific questions. What behavior is this client demonstrating
confabulation
The nurse utilizes the Depression Questionnaire on a client who has recently moved to a long-term care facility. The total score is 22. What would the nurse to do next
refer for further evaluation
The nurse is performing a mental health assessment on an older adult client. The nurse suspects Alzheimer disease when which of the following is observed
decreased poor judgment, difficulty completing familiar tasks, challenges in planning or solving problems
The nurse is performing an initial assessment of a client with suicidal ideation. What would the nurse consider “lethal” examples of suicidal ideations
history of suicide attempts, access to the means, specific plan
A new nurse asks the charge nurse what the Mini-Mental Status Examination tests. What is the appropriate response by the charge nurse
a quick took that is useful to examine the orientation, memory, speech and cognitive functions
When assessing the mental status of a 67-year-old client, the nurse detects some difficulty with free-flow of thought and following directions. Which of the following would the nurse do first
assess the client’s vision and hearing