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Health Assessment > Mental Status, Ch. 5 > Flashcards

Mental Status, Ch. 5 Flashcards

1
Q

What is Mental Status?

A

A person’s emotional and cognitive functioning

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2
Q

What triggers Stress?

A

It is triggered by traumatic life events and transient dysfunction

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3
Q

Mental Disorder

A

A much greater response to a traumatic life event is characterized by a significant behavioral or psychological pattern, that is associated with distress

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4
Q

Organic Disorder

A

Caused by brain disease of known specific organic cause (e.g. anxiety disorder, dementia, alcohol and drug intoxication, and withdrawl)

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5
Q

Psychiatric Mental Illness

A

Organic Etiology hasn’t been established (anxiety disorder, or schizophrenia)

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6
Q

When do we need to do a mental status exam?

A
  • Evaluating recent trauma
    -Report of decline cognitive ability
    -When patient requires thorough exam of emotional and cognitive functioning
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7
Q

What are factors affecting Mental Status?

A

-Developmental Competence
-Genetics and Environment
-Sexual and Gender Minority

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8
Q

What are the 4 components of a mental status exam? (ABCT)

A

ABCT
-Appearance
-Behavior
-Cognition
-Thought Process and Perceptions

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9
Q

What are some components of Mental Status Exam?

A

Consciousness
Language
Mood and Affect
Orientation
attention
Memory
Abstract reasoning
Thought Process
Thought Content
Perceptions

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10
Q

What are components of Appearance (General Survey)?

A

-Posture
-Body Movements
-Dress
-Grooming and hygiene
-Pupils

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11
Q

What are components of Behavior (General Survey)?

A

-Level of Consciousness (LOC)
-Facial Expression
-Speech
-Mood and affect

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12
Q

What are components of Cognitive Functioning (general Survey)?

A

-Orientation
-Attention Span
-Recent Memory
-Remote Memory
-New Learning (4 unrelated words)

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13
Q

What are components of Thought Process (General Survery)?

A

-Thought process: thinking is logical, goal directed, coherent, relevant
-Thought Content: what they say is consistent and logical
-Perceptions: Person should be consistently aware of reality
Suicidal thoughts

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14
Q

What’s the scale used for Anxiety Disorders?

A

Generalized Anxiety disorder Scale (GAD-7) 7=7items

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15
Q

What is the scale used for Depression Disorders?

A

Patient Health Questionaire-2(PHQ-2) or PHQ-9

2 and 9 are questions

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16
Q

What does Cognitive Impairment look like?

A

-Clouding Consciousness
-Impaired Alertness
-Impaired Memory
-Disoriented, Language Impairment
-Hallucinations
-Increased Confusion at night
-Agitation

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17
Q

What are some components of Delirium?

A

-Acute disturbance of consciousness and cognition(Short period of time)
-No History of Dementia
-May develop in addition to dementia during period of hospitalization
-Medical conditions preclude (prevent from happening)this condition

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18
Q

What are some components of Dementia?

A

-Multiple Cognitive deficits
-Chronic disturbance of consciousness and cognition
-Long and Short-Term memory loss, with short term more pronounced.
-Disturbances in executive function
-Speech and Language disturbances

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19
Q

Level of Consciousness

A

A term used to describe a person’s awareness and understanding of what is happenings in his or her surroundings

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20
Q

Cognitive Impairment

A

When a person has trouble remembering, learning new things concentrating, or making decisions that affect their everyday life.

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21
Q

What is the Sedation Scale?

A

A scale used to Assess level of consciousness

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22
Q

What is the Gaslow Coma Scale?

A

Measures best motor, verbal and eye response, determinate of LOC, a score < 8 denotes Coma.

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23
Q

What is Global Aphasia?

A

Most common and severe. Spontaneous speech is absent or reduced to few stereotyped words or sounds. Comprehension is absent or reduced, repetition, reading, and writing are severely impaired. Language recovery is poor.

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24
Q

Broca’s(Expressive) Aphasia

A

The person can understand language but cannot use language effectively. Usually uses Short sentences w/ no connecting words. Can’t repeat, or read aloud, auditory and reading comprehension are intact.

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25
Q

Wernicke(Receptive) Aphasia

A

Can hear sounds and words, but cannot relate them to previous experiences. Speech is Fluent, effortless and well articulated has many word substitutions and made-up words. Speech can be incomprehensible. Impaired repetition, reading and writing.

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26
Q

What should you do to communicate with Broca affected patient?

A

-Speak Clearly
-Books on Tape
-Picture board
-written words, can read and understand
-Yes/No questions
-Email

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27
Q

What should you do to communicate with Wernicke affected patient?

A

-Picture Board
-Don’t keep talking and repeating
-Don’t write, Can’t read
-Use gestures to help with understanding

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28
Q

What are mental disorders etiology

A

Organic, Psychiatric

29
Q

dementia is ______________ disturbance of consciousness and cognition

A

chronic

30
Q

delirium is _____________ disturbance of consciousness and cognition

A

acute

31
Q

dementia has ___________ cognitive deficits

A

multiple

32
Q

dementia has what kind of memory loss

A

long term and short term

33
Q

what is special about dementia short term memory loss

A

more pronounced

34
Q

what may preclude delirium

A

medical conditions

35
Q

Is dementia reversible or irreversible?

A

Irreversible

36
Q

Is delirium reversible or irreversible?

A

Reversable

37
Q

What do you check for before starting a mental status assessment?

A

Always check sensory status, Vision and Hearing impairment

38
Q

Sedation Scale S-4
S

A

Asleep easy to arouse

39
Q

Sedation Scale S-4
1

A

Awake and Alert

40
Q

Sedation Scale S-4
2

A

Slightly drowsy, arousable, drifts off to sleep during conversation

41
Q

Sedation Scale S-4
3

A

Frequently drowsy arousable, drifts off to sleep during conversations

42
Q

Sedation Scale S-4
4

A

Somnolent, minimal or no response to physical stimulation

43
Q

Levels of Consciousness Include

A

Awake-interactive
Lethargic-sleepy, drowsy
Stuporous-resist waking up
Obtunded-cannot maintain arousal
Comatose-non-interactive

44
Q

what is the most common type of aphasia

A

Global Aphasia

45
Q

What type of aphasia is most severe?

A

Global Aphasia

46
Q

What are the 3 types of Aphasia?

A

Global.
Broca’s (Expressive)
Wernicke’s (Receptive)

47
Q

Global Aphasia is caused by:

A

A large lesion that affects anterior and posterior Language areas

48
Q

How would a patient w/ global aphasia present?

A

Speech is absent or only a few words
No comprehension
Can’t repeat, write or read.

49
Q

Are people with Broca/Expressive Aphasia able to understand?

A

Yes

50
Q

Are people with Broca/Expressive Aphasia able to express self using language?

A

No

51
Q

Are people with Broca/Expressive Aphasia able to repeat or read aloud?

A

No

52
Q

Where is the Lesion Broca’s/Expressive Aphasia?

A

In the Motor Cortex of the Anterior portion of the Brain (Broca’s Area)

53
Q

Are people with Broca’s/Expressive aphasia auditory and reading comprehension intact?

A

Yes

54
Q

What is the opposite of Broca Aphasia?

A

Wernicke’s/Receptive.

55
Q

Where is the Lesion for Wernicke/Receptive Aphasia?

A

Posterior Area of language Center

56
Q

Are people with Wernicke/Receptive Aphasia able to hear sounds?

A
57
Q

How would someone with Wernicke/Receptive Aphasia talk ?

A

Speech is fluent, patient has urge to speak, but words are made-up and frequented w/ word substitutions, result is incomprehensible speech.

58
Q

People with Wernicke/Receptive Aphasia have impaired:

A

Repetition, Reading and Writing

59
Q

In the Older Adult what is slower?

A

Response time (allow patient time to respond)

60
Q

We need to plan teaching at what pace for the older adult?

A

Slower pace

61
Q

For the aging adult we need to consider if the person has had multiple losses why?

A

To adjust learning techniques.

62
Q

A major characteristic of dementia is:
A. Impairment of short and long term memory
B. Hallucinations
C. Sudden onset of symptoms
D. Substance-induced

A

A. Impairment of short and long term memory

62
Q

During an examination, the nurse can assess mental status by which activity?

A. Examining the patient electroencephalogram (EEG)
B. Observing the patient as he or she performs an IQ test
C. Observing the patient and evaluating during the examination
D. Examining the patients response to a specific set of questions

A

C. Mental Status can be something you assess and evaluate during your assessment

63
Q

Which of the following basic functions should the nurse test first in assessment of the mental status?

A. Behavior
B. Consciousness
C. Judgement
D. Language

A

B. Consciousness

64
Q

Optimal Functioning of Mental health aims towards simultaneous

A

life Satisfaction in work, caring relationships, and within self

65
Q

Usually mental health strike balance, allowing a person to function

A

socially and occupationally

66
Q

What suicidal individual is at high risk?

A

Patients who have a plan

67
Q

Difference between Cognitive Function and Consciousness

A

Cognition involves mental processes and propositional attitudes, such as knowledge, belief, and desire;

Consciousness is awareness of oneself and one’s surroundings.

68
Q

We want to avoid

A

Stereotyping

Health Assessment (7 decks)

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