GENERAL SURVEY

Question 1

a nurse is assessing a client who is admitted with abdominal pain. the client reports that the pain is “in the stomach and is a crampy, dull ache.” which type of pain should the nurse identify this client is experiencing?

Answer 1

visceral

Question 2

a nurse is reviewing the vital signs for a client who was admitted with shortness of breath. the nurse notes the client’s respiratory rate is 24/min. the nurse should use which of the following terms when documenting this finding?

Answer 2

tachypnea

Question 3

A nurse is measuring the respiratory rate of a client who has an irregular breathing pattern. For how many seconds should the nurse count the client’s respiration?

Answer 3

1 full minute

Question 4

A nurse is measuring the oxygen saturation of a client who has cyanosis of the extremities. using a pulse oximeter, where does the nurse place the sensor probe?

Answer 4

> forehead
forefinger
bridge of nose
earlobe

Question 5

which of the following is considered an unexpected finding for a 40-year-old client’s pulse?

Answer 5

stronger radial pulse on left compared to right

Question 6

a nurse is taking a rectal temperature on a client. which of the following actions does the nurse perform?

Answer 6

> lubricates the probe cover

>inserts the probe into rectum 1 to 1.5 in

Question 7

A nurse is performing an initial survey on a client and calculates a BMI of 31 kg/m^2. The nurse classifies this client in which of the following wight ranges

Answer 7

obese

Question 8

A nurse is calculating the BMI for a client who weighs 150 lb and is 5ft 4 in… what is the BMI

Answer 8

25.7

Question 9

A nurse is assessing a client’s behavior during the initial survey. Which of the following does the nurse include in this assessment.

Answer 9

> client’s clothing

>client’s speech

Question 10

A nurse is performing an initial assessment on a client’s skin. Which of the following observations will require further assessment of the client’s circulation?

Answer 10

Cyanosis is noted on fingers

Question 11

you are documenting the client’s pain in a narrative note. which of the following statements would be most appropriate to include in the medical record?

Answer 11

“my pain is a 7”

Question 12

You are documenting the client’s level of orientation in a narrative note. Which of the following statements would be most appropriate to include in the medical record?

Answer 12

The client is oriented to person and situation but unable to correctly identify the time

Question 13

which sample charting would be most appropriate to include in the medical record?

Answer 13

Mr. Dobbs is cooperative and follows commands. He is oriented to person, and situation but is unable to correctly identify the current year. The client states “My pain is a 7” and identifies his stomach as the site of his pain. Client is observed grimacing and holding his hand over his stomach. His skin is intact with exception of noticeable dry patches on scalp and a scar on the right knee. He is able to walk without assistance

Question 14

A nurse is performing an initial assessment on a client’s skin. Which of the following observations will require further assessment of the client’s circulation?

A: Skin is warm to touch
B: Skin is dry
C: Freckles are noted on face
D: Cyanosis is noted on fingers

Answer 14

D: Cyanosis is noted on fingers

Rationale: Cyanosis, or bluish skin color, indicates poor blood flow. The nurse will need to check capillary refill and radial pulses.

Question 15

A nurse is assessing a client’s behavior during the initial survey. Which of the following does the nurse include in this assessment? Select all that apply.

A: Client's level of education
B: Client's clothing
C: Client's speech
D: Client's occupation
E: Client's hobbies

Answer 15

B: Client’s clothing

Rationale: The type of clothing a client is wearing can offer information to the nurse about client behavior. For example, a client wearing dirty, unkempt clothing may have a lack of desire to look neat due to depression, or an inability to care for self due to financial or physical concerns

C: Client’s speech

Rationale: The client’s speech is included in the assessment of client behavior. For example, a client who has difficulty expressing an idea could have aphasia

Question 16

A nurse is performing an initial survey on a client and calculates a BMI of 31 kg/m^2. The nurse classifies this client in which of the following weight ranges?

A: Underweight
B: Normal weight
C: Overweight
D: Obese

Answer 16

D: Obese

Rationale: A client with a BMI greater than 30 kg/m^2 is considered obese

Question 17

A nurse is taking a rectal temperature on a client. Which of the following actions does the nurse perform? Select all that apply.

A: Selects the blue probe.
B: Lubricates the probe cover
C: Asks the client to lie in a prone position
D: Inserts the probe into the rectum 1 to 1.5in
E: Cleans probe with warm soapy water after use

Answer 17

B: Lubricates the probe cover

Rationale: The cover is lubricated for comfort and prevention of injury

D: Inserts the probe into the rectum 1 to 1.5in

Rationale: The nurse does not want to insert further than 1.5in due to risk of injury

Question 18

Which of the following is considered an unexpected finding for a 40-year-old client’s pulse?

A: Brisk pulse strength of +2
B: Equal time space between each pulsation
C: Pulse rate of 95/min
D: Stronger radial pulse on left compared to right

Answer 18

D: Stronger radial pulse on left compared to right

Rationale: An equal bilateral pulse is considered an expected finding. This assessment may indicate blood flow or malposition of the right radial artery

Question 19

A nurse is measuring the oxygen saturation of a client who has cyanosis of the extremities. Using a pulse oximeter, where does the nurse place the sensor probe? Select all that apply.

A: Forefinger
B: Thumb
C: Forehead
D: Bridge of nose
E: Earlobe
F: Great toe

Answer 19

C: Forehead
D: Bridge of nose
E: Earlobe

Rationale: When a client has cyanosis of the extremities, it is best to select an area with good circulation.

Question 20

A nurse is measuring the respiratory rate of a client who has an irregular breathing pattern. For how many seconds should the nurse count the client’s respirations?

Answer 20

1 min (or 60 seconds)

Rationale:
The nurse should count respirations of a client who has an irregular breathing pattern for 1 full minute. This ensures that the calculated rate is accurate.

Question 21

A nurse is reviewing the vital signs for a client who was admitted with shortness of breath. The nurse notes the client’s respiratory rate is 24/min. The nurse should use which of the following terms when documenting this finding?

A: Hypoventilation
B: Apnea
C: Tachypnea
D: Cheyne-stokes respirations
E: Labored

Answer 21

C: Tachypnea

Rationale: Tachypnea is the term for a respiratory rate which is above the expected range of 12 to 20 breaths per minute for an adult

Question 22

A nurse is assessing a client who is admitted with abdominal pain. The client reports that the pain is "in the stomach and is a crampy, dull ache." Which type of pain should the nurse identify this client is experiencing?
A: Neuropathic
B: Somatic
C: Visceral
D: Referred

Answer 22

C: Visceral

Rationale: Visceral is pain related to large internal organs

Question 23

A nurse is admitting a client who is 162.6 cm (64 in) tall and weighs 68.2 kg (150 lb). Using the BMI table shown below, what should the nurse record as the client’s BMI? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Answer 23

B is correct. The nurse should identify that 25 is the BMI of the client.

Question 24

A nurse is conducting a general survey on a client and notes a continuous twitching movement of a muscle in the client's left arm. Which of the following terms should the nurse use to describe this involuntary movement?
Fasciculation
Spasticity
Tic
Myoclonus

Answer 24

Fasciculation

A client who has fasciculation will exhibit a continuous twitching motion of a muscle when the muscle is at rest.

Question 25

``` A nurse is documenting information in a client's medical record during an initial assessment. Which of the following information should the nurse include in the documentation? (Select all that apply.) Current medication list Past medical history Use of assistive devices Height and weight Behavior and mood ```

Answer 25

Use of assistive devices is correct. The client's use of assistive devices is part of the initial assessment and should be documented at this time. Height and weight is correct. Measuring the client's height and weight is part of the initial assessment and should be documented at this time. Behavior and mood is correct. Observing the client's behavior and mood is part of the initial assessment and should be documented at this time.

Question 26

A nurse is preparing to obtain a client's height during a general survey. Which of the following actions should the nurse take? Measure the client's shoe heel height with a tape measure and deduct this amount. Have the client gently lift their chin and look toward the ceiling. Ensure the client's feet are in contact with the wall or measuring pole. Skip the height measurement if the client cannot stand.

Answer 26

Ensure the client's feet are in contact with the wall or measuring pole. The nurse should ensure that the client's feet, shoulders, and buttocks are in direct contact with the measuring pole or against the wall if the stadiometer is a wall-mounted device.

Question 27

``` A nurse is caring for a middle adult client who has stomatitis and is unable to hold an oral probe in their mouth. Which of the following alternative routes should the nurse use to obtain the most accurate core temperature of the client? Axillary Temporal Tympanic Rectal ```

Answer 27

Rectal Although rectal temperatures are usually higher than oral temperatures, it is the most accurate method for obtaining a client's core temperature. Because obtaining a rectal temperature is invasive, it is not used often, but it is typically the route selected for a client who is not able to hold an oral probe in their mouth.

Question 28

``` A nurse is having difficulty obtaining a pulse oximetry reading from a client. The nurse should identify that which of the following factors can interfere with obtaining a pulse oximetry reading? Hypertension Fever Recent scan with contrast dye Thin, brittle nails ```

Answer 28

Recent scan with contrast dye A nurse might have difficulty obtaining a pulse oximetry reading from a client who has recently undergone testing that involved the injection of a contrast dye into the circulatory system. The dyes can alter the transmission of the LED light used by the pulse oximetry sensor.

Question 29

A nurse is caring for a client who is reporting pain as 4 on a scale of 0 to 10. Upon further assessment, which of the following findings should the nurse identify as manifestations of chronic pain? (Select all that apply.) The client reports that the pain has been present for approximately 4 years. The client reports never feeling total relief from pain. The client's pain can be attributed to an acute injury or illness. The client reports that the pain is recurring and does not always originate in the same location. The client describes the pain as transient.

Answer 29

The client reports that the pain has been present for approximately 4 years is correct. Pain is diagnosed as chronic once it has been present for 6 months or longer. The client reports never feeling total relief from pain is correct. Persistent pain is defined as pain that lasts longer than 6 months and can reach a severe level. The pain continues to persist after the predicted trajectory of healing, and the level of pain does not correspond to physical findings. The client reports that the pain is recurring and does not always originate in the same location is correct. Recurrent pain that does not always originate in the same location can indicate abnormal processing of stimuli from pain receptors. As a result, chronic pain can originate from peripheral sites to the source of the pain.

Question 30

A nurse is planning on obtaining an orthostatic blood pressure from a client who has syncope. In what order should the nurse take the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 4. Take the client's blood pressure in a seated position. 2. Take the client's blood pressure in the supine position. 3. Keep the cuff in place and assist the client to a seated position. 1. Place the client in a supine position and allow them to rest. 5. Assist the client to stand and obtain their blood pressure.

Answer 30

Place the client in a supine position and allow them to rest is the first step. The nurse should place the client in the supine position and have them rest for at least 3 min. Take the client's blood pressure in the supine position is the second step. The nurse should take the client's baseline BP and pulse reading while the client is supine. Keep the cuff in place and assist the client to a seated position is the third step. The nurse should keep the cuff in place and assist the client to a seated position. Take the client's blood pressure in a seated position is the fourth step. The nurse should take the client's blood pressure and pulse while they are in a seated position. Assist the client to stand and obtain their blood pressure is the fifth step. The nurse should assist the client to stand and take a standing blood pressure and pulse reading. Orthostatic hypotension is indicated by a drop in systolic pressure of greater than 20 mm Hg or in diastolic pressure of greater than 10 mm Hg after the client stands.

Question 31

A nurse is conducting a general survey on a client who is being admitted to a long-term care facility. The nurse is assessing the client's emotional state. Which of the following findings should the nurse record as a subjective, unexpected finding? The client is sitting in a relaxed posture. The client asks for a tissue and uses it to wipe away an occasional tear. The client tells the nurse that visits from their friends and family make them smile. The client reports they feel sad and lonely most of the time.

Answer 31

The client reports they feel sad and lonely most of the time. The nurse should record this statement as a subjective, unexpected finding. It is subjective because it is something the client reported, and it is unexpected because a client who reports feeling sad and lonely most of the time should be evaluated for depression.

Question 32

A nurse is documenting a client's vital signs in the medical record following a general survey. Which of the following entries should the nurse place in the record? Temperature 95° F, client is hypothermic Pulse rate indicates tachycardia Oxygen saturation 96% on oxygen 2 L/min via nasal cannula Blood pressure 108/65 mm Hg in left arm

Answer 32

Oxygen saturation 96% on oxygen 2 L/min via nasal cannula The nurse should record the percentage of the client's oxygen saturation and indicate whether the client is on room air or is receiving oxygen. If the client is on oxygen, the nurse should record the type of the device and the rate at which oxygen is being delivered.

Question 33

``` A nurse is completing an initial assessment checklist on an older adult client. The client is accompanied by their caregiver. For which of the following indicators should the nurse observe when assessing for potential maltreatment of the client? (Select all that apply.) Dirty clothing Unexplained physical injuries Oriented to person, place, and time Able to express coherent thoughts Malnourished appearance ```

Answer 33

Dirty clothing is correct. Dirty clothing on a client can be an indicator of neglect. Unexplained physical injuries is correct. Unexplained physical injuries can be an indication of physical abuse and require further assessment. Malnourished appearance is correct. A malnourished appearance might indicate that the client's caregiver is failing to provide basic necessities, such as food or water, and can be an indicator of neglect.

Question 34

A nurse assesses a client's respiratory rate and notes that it is below the expected reference range. The nurse should identify that which of the following findings can cause a decreased respiratory rate? The client has been a chronic smoker for 10 years. The client takes a narcotic pain medication for chronic pain. The client reports anxiety due to being in the hospital. The client has a history of anemia.

Answer 34

The client takes a narcotic pain medication for chronic pain. Some medications for pain, such as narcotics and opioid analgesics, can depress the rate as well as the depth of respirations due to depressing the central nervous system.

Question 35

``` A nurse is providing teaching to a client who asks, "What are things that can affect my blood pressure?" Which of the following information should the nurse include as factors that affect blood pressure? (Select all that apply.) Time of day Obesity Diuretic medication Height Smoking ```

Answer 35

Time of day is correct. The nurse should explain to the client that blood pressure will increase during the day and begin to decrease in the late afternoon. Obesity is correct. Clients who are obese are at an increased risk for developing hypertension. Diuretic medication is correct. A client who takes diuretic medication will have a decreased blood pressure due to the reduction of resorption of sodium and water by the kidneys. Smoking is correct. Vasoconstriction of blood vessels occurs when a person smokes, causing an increase in blood pressure.

Question 36

``` A nurse is obtaining a client's pulse and notes a regular rhythm with a rate of 110/min. The nurse should identify this as which of the following unexpected findings? Bradycardia Tachycardia Atrial fibrillation Pulse deficit ```

Answer 36

Tachycardia A heart rate of greater than 100/min is considered tachycardia. The nurse should further assess the client for a potential cause, such as anxiety, fever, or pain.

Question 37

``` A nurse is assessing a client's respirations and notes they are shallow and at a rate of 24/min. The nurse should identify this as which of the following unexpected findings? Tachypnea Bradypnea Apnea Hyperventilation ```

Answer 37

Tachypnea A client who has rapid, shallow breathing at a rate greater than 20 to 24/min is experiencing tachypnea. Tachypnea can be caused by fever, fear, or exercise, as well as client conditions like alkalosis or pneumonia.

Question 38

Assessment

Answer 38

gather data from the client through interview, PE, and observation to make judgements

Question 39

Planning

Answer 39

use problem-solving and decision making skills to prioritize outcomes and goals, and develop interventions to meet those goals

Question 40

Implentation

Answer 40

carry out the interventions that have been established, use clinical judgement to monitor the client's progress towards achieving their goals

Question 41

Analysis

Answer 41

use clinical judgement to evaluate data collected to formulate the client's problems, including actual and potential problems

Question 42

evaluation

Answer 42

assess the effectiveness and achievability of the goals and the need for interventions to be adjusted

Question 43

What are some parts of critical thinking? (5)

Answer 43

contextual awareness, analyzing assumptions, exploring alternatives, using credible sources, reflecting and deciding

Question 44

what is contextual awareness?

Answer 44

understanding the status of the client and the events that have led to their interaction with the healthcare team

Question 45

what does analyzing assumptions involve?

Answer 45

involves the nurse evaluating the client's clinical situation and the use or modification of standard approaches to meet the health needs and concerns of the client

Question 46

Example of analyzing assumption w someone who has an open fraction to a lower extremity. what would be more beneficial?

Answer 46

nurse should evaluate whether it would be more beneficial to perform a focused assessment of the injured area or to engage in a standard head to toe approach when performing the health assessment

Question 47

how would you explore alternatives in nursing?

Answer 47

this includes the use of holistic approaches for treating the whole person

Question 48

what factors should be considered when providing care for a patient?

Answer 48

a culmination of the individual's physical health, lifestyle choices, culture, living environments, and life experiences

Question 49

what is considered using credible sources when providing care?

Answer 49

using institution standards, state standards, and multiply scholarly sources to determine best practices

Question 50

how does reflecting and deciding the best care for the patient essential?

Answer 50

nurses should do self reflecting, then reflect on the client goals and decide on interventions with client input

Question 51

what should the nurse be aware of?

Answer 51

appropriate methods of communication among team members

Question 52

what kind of care is a priority?

Answer 52

evidence based

Question 53

what is not part of critical thinking for PNs

Answer 53

analyzing assumptions

Question 54

what are the ethical practices? 5

Answer 54

nonmaleficence, beneficence, autonomy, justice, confidentiality

Question 55

what is first and foremost in healthcare?

Answer 55

nonmaleficence

Question 56

what does nonmaleficence mean?

Answer 56

to do no harm

Question 57

what does beneficence mean?

Answer 57

to act to promote the good of the client

Question 58

what is the ultimate goal for the client

Answer 58

a return to health and homeostasis

Question 59

what does autonomy mean?

Answer 59

the client's right to make decisions. they may also refuse treatment if they desire

Question 60

what is important to note for autonomy?

Answer 60

the client needs to have the mental capacity to act and desire on their own behalf

Question 61

what does justice mean?

Answer 61

treat everyone fairly regardless of their ability to pay for treatment, their social status, or cultural or religious background

Question 62

what should nurses be when providing care?

Answer 62

fair and impartial

Question 63

what does confidentiality mean?

Answer 63

respecting the rights of the client to maintain privacy

Question 64

what is HIPPA?

Answer 64

the health insurance portability and accountability act of 1996

Question 65

what does HIPPA do?

Answer 65

is a law that establishes public standards regarding, how, with whom, and when health information can be shared

Question 66

what does HIPPA ensure?

Answer 66

ensures protection and security of personal health information electronically, verbally, and written

Question 67

what is infection control?

Answer 67

consists of using standard precautions during a physical assessment and should be implemented with all clients

Question 68

what is not appropriate to think in regards to infection control?

Answer 68

cannot think "the client looks clean" and not wear gloves with contact

Question 69

what is hand hygiene

Answer 69

first line of defense must wash for at least 15 seconds and use friction should be done before and after or whenever

Question 70

how long should you rub when using an alcohol based rub

Answer 70

20s to 30s

Question 71

what does PPE stand for?

Answer 71

personal protective equipment

Question 72

what is part of PPE?

Answer 72

googles or face shields, gowns, masks, and gloves

Question 73

what is physical privacy?

Answer 73

needed to make client feel secure. curtain should be pulled, doors closed, draping can be used with blankets

Question 74

what should be taken into consideration with physical privacy?

Answer 74

religious, cultural, and personal preferences

Question 75

what should a room have for physical privacy?

Answer 75

an exam table or client bed that can be raised or lowered during the exam, a pillow, blanket or sheet, and a bedside table

Question 76

what is personal privacy?

Answer 76

maintain the cient's personal privacy throughout the assessment as well.

Question 77

what does personal privacy entail?

Answer 77

maintaining confidentiality and ensuring that the client has been identified properly

Question 78

what is client identification?

Answer 78

an institution policy that involves an identification bracelet scanner in some facilities or ask name and date of birth and compare to their bracelet

Question 79

what is mandated reporting?

Answer 79

if a nurse suspects abuse, by law they are required by law to report it. It can involve a child, adult, dependent adult, or older adult

Question 80

what are the categories for mandated reporting?

Answer 80

physical neglect or abuse, psychological or emotional abuse, and sexual abuse

Question 81

What is ISBARR

Answer 81

Identify, situation, background, assessment, recommendation, read back orders

Question 82

spasticity

Answer 82

alteration in muscle tone manifested as increased tonicity

Question 83

rigidity

Answer 83

alteration in muscle tone manifested as resistance to any manipulation of the joint

Question 84

fasciculation

Answer 84

alteration in muscle movement seen as continuous, rapid twitching of a muscle at rest

Question 85

myoclonus

Answer 85

alteration in muscle movement that is seen as a sudden jerking of muscle

Question 86

example of myoclonus

Answer 86

hiccups, seizure activity, and a single myoclonic jerk of the arm or leg

Question 87

tic

Answer 87

alteration in muscle movement characterized by involuntary, repetitive movement of a muscle group related to a neurologic or psychogenic nause

Question 88

tremors

Answer 88

alteration in muscle movement by opposing muscle groups that results in a rhythmic movement of one or more joints

Question 89

what do you use to measure height

Answer 89

stadiometer

Question 90

what do you use to weigh adolescent and adults

Answer 90

standing balance or an electronic scale

Question 91

BMI formula lbs

Answer 91

lb/height in x 703

Question 92

BMI formula kg

Answer 92

kg/height m

Question 93

BMI #s for adults underweight, healthy wt, overwt, obese

Answer 93

<18.5 kg/m, 18.5-24.9 kg/m, 25-29.9 kg/m, 30+

Question 94

Oral expected temp, avg temp, and older adult

Answer 94

36-38 37 (98.6) 35-36.1 C due to less body fat

Question 95

Rectal temp how much higher than oral

Answer 95

0.5 C and 0.9 F higher

Question 96

temporal temp how much higher than oral

Answer 96

nearly 0.5 C and 1 F higher

Question 97

axillary temp how much higher than oral

Answer 97

usually 0.5 C and 0.9 F higher

Question 98

tympanic temp how much higher than oral

Answer 98

consistent w oral

Question 99

most accurate temp readin

Answer 99

rectal

Question 100

least accurate temp

Answer 100

axillary

Question 101

visceral pain and how is it described

Answer 101

begins in the larger internal organs | described as deep cramping, squeezing, dull pain

Question 102

example of visceral pain

Answer 102

appendicitis

Question 103

somatic pain

Answer 103

associated with the musculoskeletal system

Question 104

deep somatic pain originates from where?

Answer 104

in muscles, bones, tendons, ligaments, and blood vessels

Question 105

describe somatic pain

Answer 105

throbbing pain or deep achy feeling

Question 106

what is ANS response

Answer 106

sweating, nausea, and tachycardia

Question 107

acute pain is also known as

Answer 107

transient pain

Question 108

how long is acute pain

Answer 108

has a short duration and is related to an injury or illness, pain does not last for more than 6 months

Question 109

chronic pain is also known as

Answer 109

persistent pain

Question 110

chronic pain

Answer 110

last longer than 6 months, pain is recurring and can reach a severe level

Question 111

2 types of chronic pain

Answer 111

malignant or nonmalignant

Question 112

malignant pain is caused by

Answer 112

tissue death (necrosis) or organ distention caused by a growing tumor

Question 113

nonmalignant pain is caused by

Answer 113

wide variety of causes including musculoskeletal conditions and nerve disorders

Question 114

what are the four main components of the general survey?

Answer 114

physical appearance, body structure, mobility, and behavior

Question 115

age goes under which category of the general survey?

Answer 115

physical appearance (do they look how old they say to be)

Question 116

sex goes under which category of the general survey?

Answer 116

physical appearance (is their sexual growth and development appropriate for their age)

Question 117

level of consciousness goes under which category of the general survey?

Answer 117

physical appearance (are they alert and oriented and respond appropriately to your questions) A & O x 3 they know the person, place, and time

Question 118

skin color goes under which category of the general survey?

Answer 118

physical appearance (is their tone even and is their skin intact)

Question 119

facial features goes under which category of the general survey?

Answer 119

physical appearance (does their fair make symmetric movements)

Question 120

stature goes under which category of the general survey?

Answer 120

body structure (does their height appear normal for their age)

Question 121

nutrition goes under which category of the general survey?

Answer 121

body structure (does their weight appear evenly distributed)

Question 122

position and posture goes under which category of the general survey?

Answer 122

body structure (do they stand and sit comfortably)

Question 123

body build and contour goes under which category of the general survey?

Answer 123

body structure (is their arm span equal to their height and are the halves of their body equal in length)

Question 124

gait and range of motion goes under which category of the general survey?

Answer 124

mobility gait= they walk smooth and shoulder match to foot width range of motion= full mobility of each joint

Question 125

facial expression, mood, speech, dress, and hygiene goes under which category of the general survey?

Answer 125

behavior

Question 126

term for a person's emotional and cognitive functioning

Answer 126

mental status

Question 127

this assessment focuses on the effect that illness has on the patient and family.

Answer 127

mental status assessment

Question 128

term for a significant behavioral or psychological pattern that is associated with distress and the person's response is much greater than what is expected

Answer 128

mental disorder

Question 129

mental status functioning is inferred through what?

Answer 129

individual behaviors

Question 130

what are the four main parts of the mental status examination? (ABCT)

Answer 130

appearance behavior cognition thought processes

Question 131

when do you perform a mental status examination?

Answer 131

when you discover any abnormality

Question 132

what should you look for when noting appearance in the mental status examination?

Answer 132

posture and position, body movement, dress, grooming, and hygiene

Question 133

what should you look for when noting behavior in the mental status examination?

Answer 133

level of consciousness, facial expression, speech, and mood and affect

Question 134

when dealing with cognitive functions in the mental status examination, what does orientation deal with?

Answer 134

the date, season, and the year

Question 135

orientation, attention span, recent and remote memory, and new learning (4 unrelated words test) all deal with which part of the mental status examination?

Answer 135

cognition

Question 136

term for the absence of speech

Answer 136

aphasia

Question 137

term for being able to compare and evaluate alternatives in a situation and reach an appropriate course of action

Answer 137

judgement

Question 138

this is a simplified scored form of the cognitive functions of the mental status examination that has a maximum score of 30

Answer 138

mini mental exam (27 is a normal mental status)

Question 139

this testing for kids is designed to detect developmental delays

Answer 139

denver II screening

Question 140

what is the additional mental testing for older adults called?

Answer 140

the mini-cog (screens for cognitive impairment) clock drawing test and 3-item recall test

Question 141

what are the two types of intimate partner violences?

Answer 141

1. physical and/or sexual violence 2. psychological and emotional or coercive tactics when there has been prior physical and/or sexual violence between persons who are spouses, nonmarital partners, or former spouses or partners

Question 142

what must the actions be in elder abuse and neglect?

Answer 142

intentional actions

Question 143

assessing for intimate partner violence is ________.

Answer 143

universal (asking every women at every health care encounter if they have been abused)

Question 144

what is the test used to asses for IPV/domestic violence in older women?

Answer 144

abuse assessment screen

Question 145

who does the AMA Elder Abuse Screening test?

Answer 145

older adults who are cognitively intact

Question 146

when screening for child abuse and neglect, where should the caregiver be?

Answer 146

away from the child so they don't change their answers. its important to get the childs age and developmental level

Question 147

term for any injury beyond temporary redness of the skin

Answer 147

trauma

Question 148

this test assess for the risk of homicide

Answer 148

DA danger assessment (yes/no assessment)