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Health Assessment > Mental Status/Nutrition/BMI > Flashcards

Mental Status/Nutrition/BMI Flashcards

1
Q

2 things you look for when assessing mental health

A

Level of Consciousness

Orientation – time,
place and person and
remote memory

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2
Q

• Normal voice – patient looks at you and responds fully and appropriately

A

Alert

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3
Q

• Speak to patient in loud voice; appears drowsy, opens eyes and looks at you, responds to questions and falls asleep

A

Lethargic

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4
Q

• Shake patient and speak in loud voice; opens eyes and looks at you but responds slowly and confused

A

Obtunded

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5
Q

Apply painful stimuli or shake vigorously; arouses from sleep only after painful stimuli

A

Stupor

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6
Q

Apply repeated painful stimuli; unarousable, no evident response

A

Coma

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7
Q

Coma Type-Arms flexed, plantar flexed, arms move towards core

A

Decorticate

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8
Q

Coma Type-One sided paralysis

A

Hemiplegia

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9
Q

Coma Type- Extended limbs

A

Decerebrate

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10
Q

Coma Type-No movement, completely flaccid

A

Vegetative

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11
Q

usually caused by acute illness or drug toxicity and is a temporary state

A

Delirium

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12
Q

Acute
Somnolent
Fully reversible when caught early
Fluctuates between lucidity and confusion

A

Delirium

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13
Q
  • Measures eye, verbal and motor response in patients with traumatic brain injuries
  • Lower scores indicate a higher impairment
A

Glasgow Coma Scale

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14
Q

Lowest-Highest score on Glasgow Coma Scale

A

3 (deep coma) to 15 (normal)

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15
Q

loss of voice; affects larynx or nerve supply

A

Aphonia

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16
Q

impairment in the voice, quality or pitch of the voice; hoarse or only able to whisper

A

Dysphonia

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17
Q

lack of muscle control; affects the lips and tongue

A

Dysarthria

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18
Q

can’t produce or understand language

A

Aphasia

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19
Q
  • Receptive
  • Fluent
  • Rapid Speech
  • Sentences lack meaning
  • Speech totally incomprehensible
A

Wernicke’s aphasia

20
Q

Wernicke’s aphasia originates in

A

• Posterior superior temporal lobe

21
Q

• Can speak and enunciate clearly but the sentences make no sense. “Word salad”

A

Wernicke’s aphasia

22
Q
  • Expressive
  • Nonfluent
  • Slowed Speech
  • Understands what is being said
  • Struggles to speak
A

Broca’s aphasia

23
Q

Broca’s aphasia originates in

A

• Posterior inferior frontal lobe

24
Q

• Can understand speech but have a really hard time expressing the words

A

Broca’s aphasia

25
Q
  • Orientation and short-term memory
  • 30 points; 24 is cutoff
  • Screens for dementia
  • Best for screening more severe cases of dementia
A

MMSE

26
Q
  • Most popular-easier to use
  • Orientation, short term memory and executive decision making
  • COGNITIVE CHANGE OVER TIME
  • Screen for mild or early dementia
  • 30 points; dementia 21-26
A

SLUMS

27
Q
  • Orientation, short term memory and executive decision making
  • Visual/Spatial awareness
  • 30 point scale; cutoff is 26
A

Montreal Cognitive Assessment

28
Q
  • Best for mild impairment; SPECIFICALLY distinguishes between dementia and Alzheimer’s
  • Also has clock drawing test-critical thinking
A

Montreal Cognitive Assessment

29
Q
  • Short term memory and executive decision making

* Brief screening tool to differentiate patients with dementia from those without it

A

Mini Cog

30
Q
  • 3 minutes

* Includes a 3 item recall test and clock drawing test

A

Mini Cog

31
Q
  • Acute onset, disorganized thinking

* Delirium screening tool

A

CAM

32
Q

Repeatedly asks the same questions
Becomes lost or disoriented in familiar places
Cannot follow directions
Is disoriented as to the date or time of day

A

Alzheimer’s

33
Q

Doesn’t recognize and is confused about familiar people
Has difficulty with routine tasks such as paying bills
Neglects personal safety, hygiene, and nutrition

A

Alzheimer’s

34
Q 
Falling asleep
Sleep during the night
Waking up too early
Sleeping too much
Feeling sad
Decreased or increased appetite
Decreased or increased weight
A

Depression

35
Q 
Apparent State of Health
Level of Consciousness
Facial Expression
Odors of the Body and Breath
Dress, Grooming, and Personal Hygiene
Posture, Gait, Motor Activity
Speech
Mood and Affect
A

General Survey

36
Q

Name the vital signs (excluding pain) and normal ranges

A
  • Temperature – oral 96.4 – 99.5°F
  • Pulse – 60 – 100 beats/minute
  • Respirations 12 – 20 breaths/minute
  • Blood Pressure – 120/80
37
Q

What’s the formula for waist to hip ratio, and what is normal for men and women?

A

Waist circumference
Hip circumference = waist to hip ratio
Females: less than or equal to 0.80
Males: less than or equal to 0.90

38
Q

Normal waist circumference for men and women?

A

Female: less than or equal to 35 inches (88cm)
Male: less than or equal to 40 inches (102cm)

39
Q

IBW % formula

A

Actual Weight x 100 = % IBW

IBW

40
Q

Explain what each IBW % means

A
  • Severe malnutrition: less then 70%
  • Moderate malnutrition: 70 – 80%
  • Possible malnutrition/Lean: 80 – 90%
  • Overweight: 10% above IBW
  • Obese: 20% above IBW
41
Q

Body Frame formula

A

Height in cm
___________
Wrist circumference in cm

42
Q

What are the small/medium/large body frame ranges for men and women

A

Body Frame Ranges
Large Medium Small
Men >10.4 10.4 – 9.6 <9.6
Women >10.9 10.9 – 9.9 <9.9

43
Q

IBW formula for women?

A

o 100lbs for the first 5 feet + 5lbs for every inch
o -10% for small frame
o +10 for large frame
o Example: 5’ 6” = 100 + (56=30) = 130lbs for normal frame
o Small frame 1300.10 = 13 130 - 13 = 117lbs
o Large frame 130 + 13 = 143lbs

44
Q

IBW formula for men?

A

o 106lbs for the first 5 feet + 6lbs for every inch
o -10% for small frame
o +10 for large frame
o Example: 5’ 9” = 106 + (69=54) = 160lbs for normal frame
o Small frame 1600.10 = 16 160 - 16 = 144lbs
o Large frame 160 + 16 = 176lbs

45
Q

For Glasgow Coma Scale, what is range for vegetative state?

A

<3

46
Q

Useful screening tool to facilitate assessment of depression in older adults

A

Geriatric Depression Scale

47
Q

Tool used to measure the impact headaches have on your ability to function on the job.

A

Headache Impact Test

Health Assessment (6 decks)

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