Exam 3 - Cognitive functioning scale

Question 1

phases of scale

Answer 1

stimulation phase (1, 2, 3) pt has altered LOC
structured phase (4, 5, 6) 
reintegration phase (7, 8) minimal confusion

Question 2

level I

no response

Answer 2

• deep sleep

Question 3

level II

generalized response

Answer 3

• response maybe be nonspecific, inconsistent, delayed, moaning, or moving
• some reaction when pt exposed

Question 4

level III
localized response

nursing intervention

Answer 4

• may blink
• respond to pain by moving
• vague awareness (will put at tube/catheter)
• begins to recognize family/friends

• explain what doing, reorient pt, simple short lang, allow extra time for pt to respond, rest periods, limit visitors

Question 5

level IV
confused-agitated

nursing intervention

Answer 5

• pt do not understand emotion or environment
• overreact, aggressive
• decreased ability to process info

• reorient, pt safety bc of increased agitation, do not force pt, find familiar calming activities for pt, room calm and quiet, rest periods, limit visitors

Question 6

level V
confused-inappropriate

nursing intervention

Answer 6

• attention for few mins
• difficulty making sense of things outside self
• lacks focus on specific tasks
• unable to start ADLs without direction
• may become overstimulated
• poor memory, making things up to fill memory gaps
• pt may wander off

•reorientation, repeat as needed, short simple lang, help organize start activities, encourage fam to bring person photos or items from home, rest periods, limit visitors

Question 7

level VI
confused-appropriate

nursing intervention

Answer 7

• occasionally oriented
• can remember day
• forgets details
• attention for 30 mins
• difficulty concentrating when noise or too many steps
• ADLs with assistance
• pt no longer wanders

• reorient if needed, encourage pt to participate in all therapies, assist with starting/continuing activities, use memory book to recall day’s events

Question 8

level VII

automatic-appropriate

Answer 8

• ADLs without assistance
• automatic robot like manner, slower rate of carrying out
• difficulty paying attention in distracting and stressful situations
• lacks insight into condition
• thinking is inflexible, rigid, stubborn

Question 9

level VIII
purposeful-appropriate

nursing intervention

Answer 9

• alert and oriented
• recall past and recent events
• independent ADLs
• acknowledges condition (thinking and memory)
• learn but at slower rate
• may still become overstimulated

•provide assistance in decision making, use adult simple short lang, encourage participation in therapies, encourage to use memory aids learned

Question 10

cognitive functioning scale

phases and 1-8

Answer 10

• stimulation phase
level I no response
level II generalized response
level III localized response
• structured phase
level IV confused-agitated
level V confused-inappropriate
level VI confused-appropriate
•reintegration phase
level VII automatic-appropriate
level VIII purposeful-appropriate