Chapter 19: Mental Status Flashcards

(41 cards)

1
Q

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?

A

acute confusion

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2
Q

What is hepatic encephalopathy

A

decline in brain function that happens when the liver fails to properly remove toxins, especially ammonia, from the blood.

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3
Q

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

A

pt demonstrates flight of ideas

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4
Q

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?

A

constructional ability

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5
Q

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?

A

provides a reference point for psychosocial developmental level

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6
Q

The nurse is performing a comprehensive health assessment on a client. The nurse would use the SBIRT tool when the client makes what statement

A

I drink most days of the week

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7
Q

during the health history interview, what component of cognitive function can the nurse quickly assess

A

memory and attention

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8
Q

during a comprehensive assessment, the nurse identifies signs of possible dementia. what is the best action of the nurse?

A

perform the SLUMS examination to assess cognitive function

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9
Q

a client opens the eyes and answers questions however falls back asleep within seconds. How should the nurse document this assessment finding?

A

lethargy

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10
Q

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?

A

Have you thought of killing yourself?

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11
Q

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?

A

abstract reasoning

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12
Q

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

A

rapid speech that lacks meaning

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13
Q

The nurse documents findings from the client’s Everyday Cognition (ECog) questionnaire. Which information will the nurse document regarding the results of the test

A

cognitive and functional decline

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14
Q

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

A

asking whether the client often feels cold

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15
Q

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

A

judgment

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16
Q

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

A

evaluation of insight and judgement

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17
Q

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

A

orientation to time is usually lost first and orientation to person is usually lost last

18
Q

Which of the following statements by a client would the nurse recognize as evidence of an absence of insight

A

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

19
Q

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

A

confabulation

20
Q

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

A

refer for further evaluation

21
Q

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

A

decreased poor judgment, difficulty completing familiar tasks, challenges in planning or solving problems

22
Q

The nurse is performing an initial assessment of a client with suicidal ideation. What would the nurse consider “lethal” examples of suicidal ideations

A

history of suicide attempts, access to the means, specific plan

23
Q

A new nurse asks the charge nurse what the Mini-Mental Status Examination tests. What is the appropriate response by the charge nurse

A

a quick took that is useful to examine the orientation, memory, speech and cognitive functions

24
Q

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

A

assess the client’s vision and hearing

25
A nurse is caring for a group of clients on a mental health unit. The nurse notifies the health care provider when which of the following abnormal findings is observed
10 on the AUDIT
26
What is AUDIT
Alcohol Use Disorder Identification Test 10 question questionnaire; 0-7 low risk, 8-15 hazardous drinking, 16-19 harmful drinking, 20+ likely alcohol dependance
27
the client has been admitted for depression. what should the nurse include in the admission mental status assessment?
a recent loss, new physiological impairment, history of a stroke
28
what findings would indicate age-related change
forgetful at time (can be both)
29
what findings would indicate alzheimer's
forgetful at times (can be both), unable to manage a budget, constantly making poor decisions, unable to state where they are or why or the current date, difficulty carrying on the conversation
30
the outcome and costs of care of what diseases improve when depression is treated?
HIV/AIDS, dementia, diabetes
31
a nurse assesses an 80 year old client and documents the following findings. Based on these findings, what action should the nurse take? -making poor decisions -forgetting what day it is, but easily oriented -losing things from time to time -occasionally having difficulty finding the right word
record these as normal findings
32
the nurse learns during handoff communication during end-of-shift that a client has delirium. what should the nurse expect to assess in this client?
vacillates between lucidity and confusion; experiences visual and auditory hallucination; completely disoriented to time, place and person
33
a client's recent episode of becoming lost near home has prompted the nurse to use an assessmnet tool to help identify signs of dementia. which tool should the nurse use?
SLUMS tool
34
what is SLUMS
Saint Louis University Mental Status exam. -used to detect cognitive impairments & early signs of dementia -evaluates memory, attention, language & problem solving -high school edu: normal 27-30; mild cognitive impairment 21-26 -less than high school: normal 25-30; mild cog. impair 20-24
35
which clients are most at risk for depressive symptoms
females, divorced patients, chronically ill patients
36
a 27 year old patient who has had headaches, muscle aches, and fatigue for the last 2 months. The nurse has completed a thorough history, examination, and lab workups the result of which are normal. what would the next action be?
screening for depression
37
A nurse performs an admission assessment and notices that a client's speech is slow and the client has difficulty answering some of the questions. How can the nurse differentiate the cause of the client's slow speech
have the client read a few sentences out loud
38
The client has a Glasgow Coma Score of 7. The nurse understands this client is considered to be what
in coma
39
The nurse is precepting a new nurse to the mental health unit. The nurse intervenes when which of the following is observed during a focused mental health assessment in a locked unit
assessing the client's deep tendon reflexes with a reflex hammer
40
The nurse is preparing to assess clients scheduled for appointments in the community clinic. For which client risk factors will the nurse assess for substance use
poverty & history of substance abuse
41
The nurse needs to assess the visual, perceptual, and constructional ability of a client. Which of the following assessments should the nurse use
have the client draw the face of a clock