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NSG 316 > Topic 14 > Flashcards

Topic 14 Flashcards

1
Q

mental status

A

a person’s emotional and cognitive functioning
strikes a balance between good and bad days, allowing person to function socially and occupationally

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2
Q

mental disorder

A

an illness that affects a person’s thoughts, emotions, and behaviors

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3
Q

organic disorders

A

Due to brain disease of known specific organic cause (e.g., delirium, dementia, alcohol and drug intoxication and withdrawal)

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4
Q

psychiatric mental illness

A

organic etiology has not yet been established (e.g., anxiety disorder or schizophrenia)

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5
Q

when do you perform a full mental status examination

A

when any abnormality in affect or behavior is discovered and in certain situations

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6
Q

mental status: aging adult

A

o Older adulthood contains more potential for losses
o Grief and despair surrounding theses losses can affect mental status and can result in disability, disorientation, or depression
o Chronic diseases such as heart failure, cancer, diabetes, and osteoporosis include fear of loss of life

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7
Q

the four main headings of mental status assessment:

A

A-B-C-T
-Appearance
-Behavior
-Cognition
-Thought processes

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8
Q

aphasia

A

impairment of language ability secondary to brain damage

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9
Q

brain lesions

A

trauma, tumor, cerebrovascular accident or stroke

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10
Q

when is a full mental status examination necessary

A

-Patients whose initial screening suggests an anxiety disorder or depression
-Behavioral changes, such as memory loss, inappropriate social interaction
-Brain lesions
-Aphasia
-Symptoms of psychiatric mental illness, especially with acute onset

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11
Q

what things does the nurse ask about when determining the orientation of a client?

A

-time(day of the week, date, year, season)
-place(where person lives, address, phone number, present location, type of building, name of city and state)
-person(own name, age, who examiner is, type of worker)

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12
Q

attention span

A

ability to concentrate-noting completes a thought without wandering

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13
Q

assessing recent memory

A

Assess in context of interview by 24-hour diet recall or by asking time person arrived at agency

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14
Q

confabulates

A

makes up plausible explanation for his actions without intention to deceive, to fill in gaps of memory loss

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15
Q

assessing remote memory

A

In the context of the interview, ask verifiable past events;
describe past health, the first job, birthday and anniversary dates, and historical events that are relevant for that person

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16
Q

Remote memory is lost when

A

cortical storage area for that memory is damaged, such as in Alzheimer disease, dementia, or any disease that damages cerebral cortex

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17
Q

the four unrelated words test

A

Pick four words with semantic and phonetic diversity; ask person to remember the four words
have him or her repeat the words
Ask for the recall of four words at 5, 10, and 30 minutes

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18
Q

what is a normal response of the four unrelated words test for a person younger than 60

A

an accurate 3- or 4-word recall after 5, 10, and 30 minutes

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19
Q

assessing word comprehension

A

ask person to name object in room

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20
Q

assessing reading

A

ask person to read available print; be aware that reading is related to educational level

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21
Q

assessing writing

A

ask person to make up and write a sentence; note coherence, spelling, and parts of speech

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22
Q

thought processes

A

Way person thinks should be logical, goal directed, coherent, and relevant; should complete thoughts

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23
Q

thought content

A

what person says should be consistent and logical

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24
Q

perceptions

A

an awareness of objects through the five senses

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25
Q

When the person expresses feelings of sadness, hopelessness, despair, or grief, it is important to assess…

A

any possible risk of physical harm to himself or herself

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26
Q

when screening for suicidal thoughts, begin with..

A

more general questions; if you hear affirmative answers, continue with more specific probing questions

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27
Q

Mini-Mental State Exam (MMSE)

A

o Concentrates only on cognitive functioning, not on mood or thought processes
o 11 questions, 5 to 10 minutes to administer

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28
Q

the Mini-Mental State Exam (MMSE) can detect

A

dementia and delirium and differentiate from psychiatric mental illness

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29
Q

normal for the Mini-Mental State Exam (MMSE) is…

A

average 27;

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30
Q

scores between what numbers on the Mini-Mental State Exam (MMSE) indicare no cognitive impairment

A

scores between 24 and 30 indicate no cognitive impairment

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31
Q

what should be assessed before any aspect of mental status?

A

sensory status (vision and hearing changes)

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32
Q

Glasgow Coma Scale is useful in..

A

testing consciousness in aging persons in whom confusion is common

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33
Q

Mini-Cog

A

a reliable, quick, and easily available instrument to screen for cognitive impairment in healthy adults
-o Tests person’s executive function, including ability to plan, manage time, and organize activities, and working memory

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34
Q

what does a Mini-Cog consist of

A

o Consists of three-item recall test and clock-drawing test

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35
Q

what id normal for the mini-cog test

A

no cognitive impairment or dementia can recall the three words and draw a complete, round, closed clock circle with all face numbers in correct position and sequence and hour and minute hands indicating time you requested

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36
Q

alert

A

awake or readily aroused; oriented, fully aware of external and internal stimuli and responds appropriately; conducts meaningful interpersonal interactions.

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37
Q

Lethargic or Somnolent

A

Not fully alert; drifts off to sleep when not stimulated; can be aroused to name when called in normal voice but looks drowsy; responds appropriately to questions or commands but thinking seems slow and fuzzy; inattentive; loses train of thought; spontaneous movements are decreased.

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38
Q

obtunded

A

(Transitional state between lethargy and stupor; some sources omit this level.) Sleeps most of time; difficult to arouse—needs loud shout or vigorous shake; acts confused when is aroused; converses in monosyllables; speech may be mumbled and incoherent; requires constant stimulation for even marginal cooperation.

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39
Q

Stupor or Semi-coma

A

Spontaneously unconscious; responds only to persistent and vigorous shake or pain; has appropriate motor response (i.e., withdraws hand to avoid pain); otherwise can only groan, mumble, or move restlessly; reflex activity persists

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40
Q

coma

A

completely unconscious, no response to pain or to any external or internal stimuli

41
Q

dysphonia

A

impairment or change in voice quality that affects the ability to speak or sing

42
Q

Dysarthria

A

slow, slurred speech

43
Q

global aphasia

A

affects receptive and expressive language skills (written and verbal) as well as auditory and visual comprehension

44
Q

Broca’s aphasia

A

expressive language impairment - speaking and writing

45
Q

Wernicke’s aphasia

A

receptive aphasia - difficult time understanding written and spoken language - speech lacks content or meaning

46
Q

Delerium

A

confused thinking and reduced awareness of surroundings

47
Q

Dementia

A

group of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person’s ability to perform ADL’s

48
Q

depression

A

persistently depressed mood or loss of interest in activities that affects daily life

49
Q

panic attack

A

a defined period of intense fear, anxiety, and dread accompanied by signs of dyspnea, choking, chest pain, increased heart rate, palpitations, nausea, and sweating.

50
Q

agoraphobia

A

An irrational fear of being in places or situations where escape might be difficult.

51
Q

specific phobia

A

a pattern of debilitating fear when faced with a particular object or situation.

52
Q

social anxiety disorder

A

A persistent and irrational fear of being in social situations.

53
Q

Generalized Anxiety Disorder (GAD):

A

A pattern of excessive worrying and morbid fear about anticipated “disasters” in the job, personal relationships, health, or finances.

54
Q

Obessive-Compulsive Disorder (OCD)

A

A pattern of recurrent obsessions (intrusive, uncontrollable thoughts) and compulsions (repetitive ritualistic actions) done to decrease anxiety and prevent a catastrophe.

55
Q

PTSD (Post Traumatic Stress Disorder)

A

This follows a traumatic event outside the range of usual human experience involving actual or threatened death.

56
Q

Three most frequently abused prescription opioid pain relievers were products using the following:

A

-Oxycodone
-Hydrocodone
-Methadone

57
Q

Prescription Drug Abuse occurs when.

A

an individual takes medication that was prescribed for someone else or takes medication in a manner that is different from that prescribed

58
Q

Older adults have numerous characteristics that increase risk of alcohol use including:

A

o Liver metabolism and kidney functioning decrease,
(increases availability of alcohol in blood for longer periods)
o Less tissue mass means increased alcohol concentration in blood
o multiple medications that can interact adversely with alcohol
o Drinking alcohol increases risk of falls, depression, and gastrointestinal problems

59
Q

If patient is currently intoxicated or going through substance withdrawal, collecting any history data is..

A

difficult and unreliable

60
Q

R-R-R-R

A

o Risk of bodily harm: drinking and driving, operating machinery, swimming?
o Relationship trouble: family or friends?
o Role failure: interference with home, work, or school obligations?
o Run-ins with law: arrests or other legal problems?”

61
Q

AUDIT tool will help

A

detect less severe alcohol problems (hazardous and harmful drinking) as well as alcohol abuse and dependence disorders

62
Q

AUDIT covers three domains:

A

o Alcohol consumption
o Drinking behavior or dependence
o Adverse consequences from alcohol

63
Q

AUDIT-C

A

Shorter version of AUDIT for acute and critical care units
- screening test for heavy drinking and/or active abuse
Score: 3 or above = heavy or at-risk drinking

64
Q

CAGE questionnaire

A

cut down, annoyed, guilty, eye opener

65
Q

Screening women for alcohol problems

A

TWEAK questions help identify at-risk drinking in women, especially pregnant women

66
Q

TWEAK

A

-Tolerance: how many drinks can you hold? Or how many drinks does it take to make you feel high?
-Worry: have close friends or relatives complained about your drinking?
-Eye-opener: do you sometimes take a drink in morning when you first get up?
-Amnesia: has a friend or family member told you about things you said but could not remember?
-Kut down: do you sometimes feel the need to cut down?

67
Q

SMAST-G questionnaire

A

for older adults who report social or regular drinking of any amount of alcohol. low risk response is 0 or 1 point. (10 questions)

68
Q

what is the most commonly used biochemical marker of alcohol drinking

A

Serum protein, gamma glutamyl transferase (GGT)

69
Q

Breath alcohol analysis (Breathalizer)

A

detects any amount of alcohol in end of exhaled air following a deep inhalation until all ingested alcohol is metabolized

70
Q

blood alcohol concentration (BAC)

A

the basis for a legal interpretation of drinking

71
Q

CIWA-Ar Tool for assessment of withdrawal

A

o Nausea vomiting
o Tremor
o Paroxysmal sweats
o Anxiety
o Agitation
o Tactile disturbances
o Auditory disturbances
o Visual disturbances
o Headache
o Orientation and clouding of sensorium

72
Q

Intoxication

A

Ingestion of substance produces maladaptive behavioral changes because of effects on the central nervous system

73
Q

abuse

A

Daily use needed to function, inability to stop, impaired social and occupational functioning, recurrent use when it is physically hazardous, substance-related legal problems

74
Q

dependence

A

Physiologic dependence on substance

75
Q

tolerance

A

Requires increased amount of substance to produce same effect

76
Q

withdrawal

A

Cessation of substance produces syndrome of physiologic symptoms

77
Q

Intimate partner violence defined by the Centers for Disease Control and Prevention

A

-Physical or sexual violence, use of physical force, or threat of such violence
-Psychological or emotional abuse or coercive tactics after/prior physical violence between persons: Spouses, nonmarital partners, former spouses

78
Q

as mandatory reporters of abuse you need only have

A

Suspicion that elder abuse and/or neglect may have occurred in order to generate a call to the authorities

79
Q

Physical abuse

A

violent acts that result or could result in injury, pain, impairment, or disease

80
Q

Physical neglect

A

failure of family or caregiver to provide basic goods and services such as food, shelter, health care, and medications

81
Q

Psychological abuse

A

behaviors that result in mental anguish

82
Q

Psychological neglect

A

failure to provide basic social stimulation

83
Q

Financial abuse

A

intentional misuse of elderly person’s financial and material resources

84
Q

Financial neglect

A

failure to use elderly person’s assets to provide needed services

85
Q

Complications from injuries or bleeding from trauma

A

changes in circulatory homeostasis and fluctuations in blood pressure and pulse, shock, and death

86
Q

Infections can progress to

A

generalized sepsis, then death in immunocompromised aging patients

87
Q

Assault, or stress leading up to or following assault, can contribute to

A

cardiac complications

88
Q

STIs and related complications for younger women are present in

A

older sexually assaulted women

89
Q

Abuse of the elderly often is coupled with

A

neglect

90
Q

Caregivers caring for elderly persons may struggle with their own severe physical and cognitive health challenges leading to

A

caregiver role strain

91
Q

Routine, universal screening for IPV means the following

A

Asking every woman at every health care encounter if she has been abused by a husband, boyfriend, or other intimate partner or ex-partner

92
Q

Alerts women that questions about domestic violence are coming and makes sure they

A

know they are not being singled out for these questions

93
Q

If a woman answers yes to any of the Abuse Assessment Screen (AAS) questions, then ask questions to

A

assess how recent and how serious the abuse was

94
Q

Important components of physical examination of known survivor of IPV or elder abuse include the following:

A

Complete head-to-toe visual examination, especially if patient is receiving health services for reported abuse

95
Q

Health evaluations for known or suspected elder abuse and neglect should include baseline laboratory tests, including:

A

-complete blood count with platelet level,
-basic blood chemistries,
-serum liver function tests,
-coagulation panel,
-urinalysis

96
Q

Danger Assessment (DA)

A

The more yes answers, the more serious the danger of the woman’s situation

97
Q

IPV Factors among Ethnic and Racial Minorities: Legal Regulations

A

-societal stressors
-Legal regulations
-Lack of access
-Cultural values and gender roles

98
Q

Documentation of IPV, child abuse, and elder abuse must include the following:

A

o Detailed, nonbiased progress notes
o Use of injury maps
o Photographic documentation in health record
o Other aspects of abuse history, including reports of past abusive incidents, can be paraphrased with use of partial direct quotations
o Written documentation of histories of IPV and elder abuse needs to be verbatim but within reason
o Critical to document exceptionally poignant statements made by victim that identify perpetrator and severe threats of harm made by perpetrator

NSG 316 (9 decks)

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