ROLE IN HEALTH ASSESSMENT: MENTAL HEALTH STATUS Flashcards
(132 cards)
1
Q
- What are the current roles of nurses in health assessment?
A
Acute Care Nurses
Critical Care Outreach Nurses
Ambulatory Care Nurses
Home Health Nurses
Public Health Nurses
School and Hospice Nurses
2
Q
- A nursing role focused on caring for short-term medical conditions.
A
Acute Care Nurse
3
Q
- A nursing role responsible for handling deteriorating patients (e.g., ventilator-dependent, comatose).
A
Critical Care Outreach Nurse
4
Q
- A nurse who provides care in outpatient settings like clinics.
A
Ambulatory Care Nurse
5
Q
- A nurse who visits patients in their homes to provide medical services.
A
Home Health Nurse
6
Q
- A nursing specialty focusing on promoting community health.
A
Public Health Nurse
7
Q
- A nurse caring for children in schools and terminally ill patients.
A
School and Hospice Nurse
8
Q
- What are the four basic techniques of physical examination?
A
Inspection
Palpation
Percussion
Auscultation
9
Q
- The examination technique that involves visually assessing a patient’s body for abnormalities.
A
Inspection
10
Q
- The technique that involves using hands to feel for texture, temperature, moisture, swelling, and tenderness.
A
Palpation
11
Q
- The technique that involves tapping the body to assess underlying structures.
A
Percussion
12
Q
- The technique that involves listening to body sounds, such as heart or lung sounds, using a stethoscope.
A
Auscultation
13
Q
- What are the types of palpation?
A
Light Palpation
Deep Palpation
14
Q
- The type of palpation used to assess surface characteristics like skin texture and moisture.
A
Light Palpation
15
Q
- The type of palpation used to feel internal organs and detect masses.
A
Deep Palpation
16
Q
- What are the core values of nursing in conducting health assessment?
A
Caring
Integrity
Diversity
Empathy
Communication
17
Q
- The ability to understand a patient’s experiences and feelings while maintaining professional distance.
A
Empathy
18
Q
- The value that fosters positive relationships and enhances patient well-being.
A
Caring
19
Q
- The recognition of the uniqueness of individuals, values, and backgrounds in healthcare.
A
Diversity
20
Q
- The ability to interact effectively to exchange information in clinical settings.
A
Communication
21
Q
- The ethical principle that respects dignity and moral wholeness of every person.
A
Integrity
22
Q
- What are the zones of interaction in health assessment?
A
Intimate Zone (0-1 ft)
Personal Zone (1-4 ft)
Social Zone (4-12 ft)
Public/Business Zone (12+ ft)
23
Q
- The interaction zone used for breath sound assessments.
A
Intimate Zone
24
Q
- The interaction zone used for physical exams and blood pressure checks.
A
Personal Zone
25
25. The interaction zone used for patient interviews.
Social Zone
26
26. The interaction zone used for public speaking or large groups.
Public/Business Zone
27
27. What are the techniques of communication in health assessment?
Facilitation (General Leads)
Silence
Reflection
Clarification
Confrontation
Interpretation
Explanation
Summary
28
28. A communication technique where the nurse remains quiet to allow the patient to speak.
Silence
29
29. A communication technique that repeats the patient’s words to encourage elaboration.
Reflection
30
30. A communication technique that helps verify understanding.
Clarification
31
31. A communication technique where the nurse provides honest feedback about inconsistencies.
Confrontation
32
32. What are the ethical and legal considerations in nursing?
Nursing care follows ethical and legal boundaries
The Code of Ethics for Nurses guides safe practice
33
33. The document that provides a framework for ethical nursing practice.
Code of Ethics for Nurses
34
34. What are the characteristics of professionalism in nursing?
Knowledge
Conscientious actions
Responsibility
Understanding history and research
Awareness of professional organizations and standards
35
35. A professional quality in nursing that involves acting with knowledge, responsibility, and awareness of standards.
Professionalism
36
36. What are the four phases of the interview process?
Pre-Introductory Phase
Introductory Phase
Working Phase
Summary and Closing Phase
37
37. The phase of the interview where data is gathered before meeting the patient.
Pre-Introductory Phase
38
38. The phase of the interview where rapport is built and expectations are explained.
Introductory Phase
39
39. The phase of the interview where most data collection occurs.
Working Phase
40
40. The phase of the interview where findings are summarized and future steps are discussed.
Summary and Closing Phase
41
41. What are common thought process disorders?
Blocking
Confabulation
Neologism
Circumlocution
Circumstantiality
Loosening association
Flight of ideas
Word salad
Echolalia
Clanging
42
42. A thought disorder characterized by sudden stops in speech.
Blocking
43
43. A thought disorder where a person fabricates stories to fill memory gaps.
Confabulation
44
44. A thought disorder involving the creation of new words.
Neologism
45
45. What are common thought content disorders?
Phobia
Hypochondriasis
Obsession
Compulsion
Delusion
46
46. An irrational, persistent fear of an object or situation.
Phobia
47
47. A disorder characterized by excessive worry about having a serious illness.
Hypochondriasis
48
48. A false, fixed belief resistant to reasoning or facts.
Delusion
49
49. What are the non-modifiable risk factors for mental health issues?
Increasing age
Genetic predisposition
Family history of mental illness
50
50. What are the modifiable risk factors for mental health issues?
Chronic diseases
Head trauma
Smoking
Late initiation of hormone therapy
51
1. What are the methods of examination (assessment techniques)?
Inspection
Palpation
Percussion
Auscultation
52
2. What are the types of palpation?
Light Palpation
Moderate Palpation
Deep Palpation
Deep Bimanual Palpation
53
3. What are the parts of the hand used for palpation?
Palmar Surface
Dorsal Surface
Ulnar Surface
54
4. What are the psychomotor skills in nursing?
Hands-on skills for providing comfort, assessing patients, and performing procedures.
55
5. What are the critical thinking skills required in nursing?
Accurate clinical decision-making
Questioning assumptions
Exploring perspectives
Applying knowledge ethically
56
6. What is the role of teaching in nursing?
Providing patients and families with accurate, complete, and relevant health information.
57
7. What biographical data is collected during health assessment?
Name
Address
Phone Number
Sex
Date & Place of Birth
Nationality
Marital Status
Religion
Education Level
Occupation
58
8. What are the methods for collecting history of present illness (HPI)?
COLDSPA
PQRSTU
59
9. What does COLDSPA stand for?
Character
Onset
Location
Duration
Severity
Pattern
Associated Factors
60
10. What does PQRSTU stand for?
Provocative/Palliative
Quality
Radiation/Region
Severity
Timely
Understanding of Patient's Perception
61
11. What are the components of past personal health history?
Childhood Illness
Adult Illnesses
Surgeries
Hospitalizations
Immunizations
Allergies
Diagnostic Tests
62
12. What does GPTPAL stand for in obstetric history?
Gravida
Parity
Term
Preterm
Abortion
Living Children
63
13. What is Naegele’s Rule used for?
Estimating the Expected Date of Delivery (EDD).
64
14. What is the purpose of family history in health assessment?
Identifies hereditary health conditions using a genogram.
65
15. What is the purpose of environmental history?
Assesses a patient’s surroundings for physical, psychological, and social risk factors.
66
16. What are the risk factors for mental health issues?
Non-Modifiable Risk Factors:
- Age
- Genetics
- Family history
Modifiable Risk Factors:
- Diabetes
- Hypertension
- Head trauma
- Smoking
- Late hormone therapy
67
17. What client education should be provided for mental health?
Engaging in mentally stimulating activities
Maintaining a healthy lifestyle
Avoiding head trauma risks
Following a heart-healthy diet
68
18. What are the positions for physical examination?
Dorsal Recumbent
Supine
Sitting
Lithotomy
Sims
Prone
Semi-Fowler’s
High-Fowler’s
69
19. What are the components of a mental status examination (ABCT)?
A – Appearance: Posture, grooming, hygiene
B – Behavior: Facial expressions, speech, mood
C – Cognition: Orientation, memory
T – Thought Process: Logical flow of ideas
70
20. What are common thought process disorders?
Blocking
Confabulation
Neologism
Circumlocution
Circumstantiality
Loosening Association
Flight of Ideas
Word Salad
Echolalia
Clanging
71
21. A thought disorder characterized by sudden stops in speech.
Blocking
72
22. A thought disorder where a person fabricates stories to fill memory gaps.
Confabulation
73
23. A thought disorder involving the creation of new words.
Neologism
74
24. What are common thought content disorders?
Phobia
Hypochondriasis
Obsession
Compulsion
Delusion
75
25. An irrational, persistent fear of an object or situation.
Phobia
76
26. A disorder characterized by excessive worry about having a serious illness.
Hypochondriasis
77
27. A false, fixed belief resistant to reasoning or facts.
Delusion
78
28. What are common perception disorders?
Hallucination
Illusion
79
29. A sensory perception disorder where a person sees, hears, or feels something that isn't real.
Hallucination
80
30. A misinterpretation of a real external stimulus.
Illusion
81
31. What are the key assessments for suicide risk?
ALWAYS SCREEN FOR SUICIDAL THOUGHTS in patients showing signs of severe distress.
82
1. What are the components of the Glasgow Coma Scale (GCS)?
Eye Opening Response
Verbal Response
Motor Response
83
2. How is eye opening response scored in GCS?
4 – Spontaneous
3 – To sound
2 – To pain
1 – No response
84
3. How is verbal response scored in GCS?
5 – Oriented
4 – Confused
3 – Inappropriate words
2 – Incomprehensible sounds
1 – No response
85
4. How is motor response scored in GCS?
6 – Obeys commands
5 – Localizes pain
4 – Withdraws from pain
3 – Abnormal flexion (Decorticate)
2 – Abnormal extension (Decerebrate)
1 – No response
86
5. What is the total score range for GCS?
15 – Best response (Fully alert)
9-12 – Moderate brain injury
3-8 – Severe brain injury (Coma)
87
6. What does a GCS score of 3 indicate?
Deep coma or brain death
88
7. What does a GCS score of 15 indicate?
Normal, fully conscious individual
89
8. What does a GCS score of ≤8 indicate?
The patient is in a coma and may require intubation
90
9. What does GPTQL stand for in obstetric history?
Gravida
Parity
Term
Preterm
Abortion
Living
91
10. What does Gravida (G) refer to in GPTQL?
The number of times a woman has been pregnant, regardless of the outcome
92
11. What does Parity (P) refer to in GPTQL?
The number of pregnancies carried to viable gestational age (≥20 weeks)
93
12. What does Term (T) refer to in GPTQL?
The number of pregnancies carried to full term (≥37 weeks)
94
13. What does Preterm (P) refer to in GPTQL?
The number of pregnancies delivered before 37 weeks but after 20 weeks
95
14. What does Abortion (A) refer to in GPTQL?
The number of pregnancies that ended before 20 weeks, either spontaneously (miscarriage) or induced
96
15. What does Living (L) refer to in GPTQL?
The number of children currently alive
97
16. What are the possible outcomes in a GPTQL score of G3P2T2P0A1L2?
- G3: The woman has been pregnant three times
- P2: Two pregnancies reached viability
- T2: Two were full-term
- P0: No preterm births
- A1: One miscarriage or abortion
- L2: Two children are currently alive
98
17. What are the three major assessment techniques in physical examination?
Inspection
Palpation
Percussion
Auscultation
99
18. What is the order of examination techniques?
Normal: Inspection → Palpation → Percussion → Auscultation
For Abdomen: Inspection → Auscultation → Percussion → Palpation
100
19. What are the types of palpation?
Light Palpation
Moderate Palpation
Deep Palpation
Bimanual Palpation
101
20. What are the parts of the hand used for palpation?
Palmar Surface: Detects vibration
Dorsal Surface: Assesses temperature
Ulnar Surface: Assesses fremitus (vibration from speech)
102
21. What are the components of the mental status examination (ABCT)?
A – Appearance: Posture, grooming, hygiene
B – Behavior: Facial expressions, speech, mood
C – Cognition: Orientation, memory
T – Thought Process: Logical flow of ideas
103
1. A nurse is assessing an elderly patient who appears disheveled, with poor hygiene and a flat affect. The patient is unable to recall events from earlier in the day and reports hearing voices. What is the most appropriate action?
a) Assume the patient is experiencing dementia
b) Ask the patient if the voices are telling them to harm themselves
c) Report the findings as normal for aging
d) Ignore the hallucinations since they are not distressing the patient
b) Ask the patient if the voices are telling them to harm themselves
104
2. During a health assessment, the patient states, "I feel worthless, and nothing matters anymore." What should the nurse do first?
a) Document the statement and continue the assessment
b) Ask the patient directly if they have thoughts of self-harm
c) Encourage the patient to focus on positive aspects of life
d) Tell the patient their feelings will improve over time
b) Ask the patient directly if they have thoughts of self-harm
105
3. A nurse is performing a mental status examination using the ABCT method. Which of the following is an example of assessing the "C" component?
a) Noting the patient’s facial expressions
b) Checking the patient’s ability to recall recent events
c) Observing the patient’s posture and grooming
d) Evaluating the patient’s speech for clarity
b) Checking the patient’s ability to recall recent events
106
4. A patient with a history of schizophrenia repeatedly makes up new words that have no meaning. What term best describes this speech pattern?
a) Echolalia
b) Neologism
c) Flight of ideas
d) Clang association
b) Neologism
107
5. A nurse is conducting an assessment using the COLDSPA method. The patient describes a dull, aching pain in their lower back that started two weeks ago and worsens when standing for long periods. Which letter of COLDSPA is addressed when the patient describes what makes the pain worse?
a) Character
b) Onset
c) Duration
d) Pattern
d) Pattern
108
6. A 28-year-old pregnant woman reports that her last menstrual period was on March 10. Using Naegele’s Rule, what is her estimated due date?
a) December 17
b) December 10
c) December 3
d) January 10
b) December 17
109
7. A nurse is palpating a patient’s abdomen and notices a rigid, board-like texture. What is the priority action?
a) Continue palpating to determine the cause
b) Stop the palpation and notify the provider immediately
c) Ask the patient if they recently ate a large meal
d) Document the findings and monitor for pain
b) Stop the palpation and notify the provider immediately
110
8. A patient with severe depression and suicidal thoughts is admitted for care. What is the highest priority in the nurse’s assessment?
a) Evaluating the patient's coping mechanisms
b) Checking for access to means of self-harm
c) Assessing the patient’s social support system
d) Asking about the patient’s past trauma
b) Checking for access to means of self-harm
111
9. A nurse is assessing a patient's cognitive function. Which of the following would indicate an abnormal finding?
a) The patient correctly identifies the season and location
b) The patient repeats a series of numbers backward
c) The patient is unable to recall three words after five minutes
d) The patient is aware of their birthday and family members
c) The patient is unable to recall three words after five minutes
112
10. A patient is unable to understand or express language but is alert and able to follow commands. Which condition does this describe?
a) Dysarthria
b) Aphasia
c) Agnosia
d) Ataxia
b) Aphasia
113
11. A patient who was recently diagnosed with diabetes appears withdrawn and repeatedly states, “I don’t know how to take care of myself.” What is the nurse’s best response?
a) "You need to focus on learning how to manage your condition."
b) "What part of your care feels overwhelming to you?"
c) "I will ask your doctor to refer you to a specialist."
d) "Many people feel this way at first, but you’ll adjust over time."
b) "What part of your care feels overwhelming to you?"
114
12. Which of the following statements by a nurse demonstrates professional integrity during an assessment?
a) "I cannot share that information because it is confidential."
b) "I will do my best to ensure your privacy is protected."
c) "I can tell you what another patient experienced in a similar case."
d) "It’s okay, you can tell me anything, and I will keep it a secret."
b) "I will do my best to ensure your privacy is protected."
115
13. A patient suddenly stops speaking mid-sentence and stares into space. After a few seconds, they resume talking as if nothing happened. Which disorder does this behavior suggest?
a) Clang association
b) Blocking
c) Loosening of associations
d) Flight of ideas
b) Blocking
116
14. A nurse is educating a patient on lifestyle changes to reduce their risk of stroke. Which modifiable risk factor should the nurse emphasize?
a) Family history
b) Genetics
c) Smoking
d) Gender
c) Smoking
117
15. A nurse is assessing a patient’s level of consciousness using the Glasgow Coma Scale (GCS). Which finding is most concerning?
a) A GCS score of 15
b) A GCS score of 9
c) A GCS score of 6
d) A GCS score of 12
c) A GCS score of 6
118
1. A pregnant woman visits the clinic for her prenatal checkup. Her obstetric history includes three previous pregnancies: one full-term birth, one preterm birth at 34 weeks, and one miscarriage at 12 weeks. All of her children are alive. What is her GPTAL documentation?
a) G3 P2 T1 P1 A1 L2
b) G3 P2 T2 P0 A1 L2
c) G3 P3 T1 P1 A1 L2
d) G3 P2 T1 P1 A0 L2
a) G3 P2 T1 P1 A1 L2
119
2. A patient has been pregnant five times. She delivered two full-term babies, one preterm baby at 32 weeks, and had two miscarriages before 20 weeks. Three of her children are alive. What is her GPTAL documentation?
a) G5 P3 T2 P1 A2 L3
b) G5 P4 T2 P1 A2 L3
c) G5 P3 T3 P0 A2 L3
d) G5 P3 T2 P1 A2 L2
a) G5 P3 T2 P1 A2 L3
120
3. A woman who is currently pregnant has had two previous pregnancies. One resulted in a miscarriage at 10 weeks, and the other was a full-term birth. Her child is alive. What is her GPTAL documentation?
a) G3 P1 T1 P0 A1 L1
b) G3 P2 T1 P1 A1 L1
c) G2 P1 T1 P0 A1 L1
d) G3 P1 T0 P1 A1 L1
a) G3 P1 T1 P0 A1 L1
121
4. A patient has had six pregnancies. She delivered four full-term infants, one preterm baby at 35 weeks, and had one miscarriage. Five of her children are still living. What is her GPTAL documentation?
a) G6 P5 T4 P1 A1 L5
b) G6 P4 T3 P1 A1 L5
c) G6 P5 T4 P1 A0 L5
d) G6 P5 T3 P2 A1 L5
a) G6 P5 T4 P1 A1 L5
122
5. A pregnant woman comes for her first prenatal visit. She has a history of three previous pregnancies: one full-term birth, one preterm birth at 30 weeks, and one stillbirth at 39 weeks. Two of her children are alive. What is her GPTAL documentation?
a) G4 P3 T2 P1 A0 L2
b) G4 P2 T1 P1 A1 L2
c) G4 P3 T2 P1 A0 L2
d) G4 P3 T1 P2 A0 L2
c) G4 P3 T2 P1 A0 L2
123
6. A patient arrives at the ER after a car accident. She opens her eyes when spoken to, is disoriented when answering questions, and withdraws her hand when painful stimuli is applied. What is her GCS score?
a) 9
b) 10
c) 12
d) 8
b) 10
124
7. A comatose patient is unresponsive to verbal commands, shows abnormal extension in response to pain, and does not open their eyes. What is their GCS score?
a) 6
b) 7
c) 8
d) 5
a) 6
125
8. A patient involved in a severe head injury is being assessed for their level of consciousness. They open their eyes in response to pain, produce incomprehensible sounds, and have abnormal flexion in response to pain. What is their GCS score?
a) 6
b) 7
c) 8
d) 9
b) 7
126
9. A nurse is assessing a patient with a suspected stroke. The patient obeys commands, speaks coherently, and opens their eyes spontaneously. What is their GCS score?
a) 13
b) 14
c) 15
d) 12
c) 15
127
10. A patient who was intubated due to head trauma is unresponsive to all stimuli, has no eye opening, and no motor response. What is their GCS score?
a) 4
b) 3
c) 5
d) 6
128
1. A pregnant woman reports that her last menstrual period (LMP) was on July 8. Using Naegele’s Rule, what is her expected due date?
a) April 8
b) April 15
c) April 1
d) March 15
b) April 15
129
2. A patient states that her last menstrual period started on November 25. Using Naegele’s Rule, what is her expected date of delivery?
a) September 1
b) August 18
c) September 2
d) August 25
d) August 25
130
3. A woman visits the clinic for prenatal care. She says her last menstrual period was on February 10. When is her estimated due date?
a) November 3
b) November 17
c) December 10
d) November 20
b) November 17
131
4. A nurse is assisting a newly pregnant woman in calculating her expected due date. The patient reports that her last period began on September 5. What is the estimated delivery date?
a) June 12
b) June 5
c) July 5
d) May 29
b) June 12
132
5. A woman with a positive pregnancy test wants to estimate her due date. She recalls that her last menstrual period was on May 22. What is her expected date of delivery?
a) February 29
b) March 1
c) February 15
d) February 22
d) February 29
