ROLE IN HEALTH ASSESSMENT: MENTAL HEALTH STATUS Flashcards
- What are the current roles of nurses in health assessment?
Acute Care Nurses
Critical Care Outreach Nurses
Ambulatory Care Nurses
Home Health Nurses
Public Health Nurses
School and Hospice Nurses
- A nursing role focused on caring for short-term medical conditions.
Acute Care Nurse
- A nursing role responsible for handling deteriorating patients (e.g., ventilator-dependent, comatose).
Critical Care Outreach Nurse
- A nurse who provides care in outpatient settings like clinics.
Ambulatory Care Nurse
- A nurse who visits patients in their homes to provide medical services.
Home Health Nurse
- A nursing specialty focusing on promoting community health.
Public Health Nurse
- A nurse caring for children in schools and terminally ill patients.
School and Hospice Nurse
- What are the four basic techniques of physical examination?
Inspection
Palpation
Percussion
Auscultation
- The examination technique that involves visually assessing a patient’s body for abnormalities.
Inspection
- The technique that involves using hands to feel for texture, temperature, moisture, swelling, and tenderness.
Palpation
- The technique that involves tapping the body to assess underlying structures.
Percussion
- The technique that involves listening to body sounds, such as heart or lung sounds, using a stethoscope.
Auscultation
- What are the types of palpation?
Light Palpation
Deep Palpation
- The type of palpation used to assess surface characteristics like skin texture and moisture.
Light Palpation
- The type of palpation used to feel internal organs and detect masses.
Deep Palpation
- What are the core values of nursing in conducting health assessment?
Caring
Integrity
Diversity
Empathy
Communication
- The ability to understand a patient’s experiences and feelings while maintaining professional distance.
Empathy
- The value that fosters positive relationships and enhances patient well-being.
Caring
- The recognition of the uniqueness of individuals, values, and backgrounds in healthcare.
Diversity
- The ability to interact effectively to exchange information in clinical settings.
Communication
- The ethical principle that respects dignity and moral wholeness of every person.
Integrity
- What are the zones of interaction in health assessment?
Intimate Zone (0-1 ft)
Personal Zone (1-4 ft)
Social Zone (4-12 ft)
Public/Business Zone (12+ ft)
- The interaction zone used for breath sound assessments.
Intimate Zone
- The interaction zone used for physical exams and blood pressure checks.
Personal Zone
- The interaction zone used for patient interviews.
Social Zone
- The interaction zone used for public speaking or large groups.
Public/Business Zone
- What are the techniques of communication in health assessment?
Facilitation (General Leads)
Silence
Reflection
Clarification
Confrontation
Interpretation
Explanation
Summary
- A communication technique where the nurse remains quiet to allow the patient to speak.
Silence
- A communication technique that repeats the patient’s words to encourage elaboration.
Reflection
- A communication technique that helps verify understanding.
Clarification
- A communication technique where the nurse provides honest feedback about inconsistencies.
Confrontation
- What are the ethical and legal considerations in nursing?
Nursing care follows ethical and legal boundaries
The Code of Ethics for Nurses guides safe practice
- The document that provides a framework for ethical nursing practice.
Code of Ethics for Nurses
- What are the characteristics of professionalism in nursing?
Knowledge
Conscientious actions
Responsibility
Understanding history and research
Awareness of professional organizations and standards
- A professional quality in nursing that involves acting with knowledge, responsibility, and awareness of standards.
Professionalism
- What are the four phases of the interview process?
Pre-Introductory Phase
Introductory Phase
Working Phase
Summary and Closing Phase
- The phase of the interview where data is gathered before meeting the patient.
Pre-Introductory Phase
- The phase of the interview where rapport is built and expectations are explained.
Introductory Phase
- The phase of the interview where most data collection occurs.
Working Phase
- The phase of the interview where findings are summarized and future steps are discussed.
Summary and Closing Phase
- What are common thought process disorders?
Blocking
Confabulation
Neologism
Circumlocution
Circumstantiality
Loosening association
Flight of ideas
Word salad
Echolalia
Clanging
- A thought disorder characterized by sudden stops in speech.
Blocking
- A thought disorder where a person fabricates stories to fill memory gaps.
Confabulation
- A thought disorder involving the creation of new words.
Neologism
- What are common thought content disorders?
Phobia
Hypochondriasis
Obsession
Compulsion
Delusion
- An irrational, persistent fear of an object or situation.
Phobia
- A disorder characterized by excessive worry about having a serious illness.
Hypochondriasis
- A false, fixed belief resistant to reasoning or facts.
Delusion
- What are the non-modifiable risk factors for mental health issues?
Increasing age
Genetic predisposition
Family history of mental illness
- What are the modifiable risk factors for mental health issues?
Chronic diseases
Head trauma
Smoking
Late initiation of hormone therapy
- What are the methods of examination (assessment techniques)?
Inspection
Palpation
Percussion
Auscultation
- What are the types of palpation?
Light Palpation
Moderate Palpation
Deep Palpation
Deep Bimanual Palpation
- What are the parts of the hand used for palpation?
Palmar Surface
Dorsal Surface
Ulnar Surface
- What are the psychomotor skills in nursing?
Hands-on skills for providing comfort, assessing patients, and performing procedures.
- What are the critical thinking skills required in nursing?
Accurate clinical decision-making
Questioning assumptions
Exploring perspectives
Applying knowledge ethically
- What is the role of teaching in nursing?
Providing patients and families with accurate, complete, and relevant health information.
- What biographical data is collected during health assessment?
Name
Address
Phone Number
Sex
Date & Place of Birth
Nationality
Marital Status
Religion
Education Level
Occupation
- What are the methods for collecting history of present illness (HPI)?
COLDSPA
PQRSTU
- What does COLDSPA stand for?
Character
Onset
Location
Duration
Severity
Pattern
Associated Factors
- What does PQRSTU stand for?
Provocative/Palliative
Quality
Radiation/Region
Severity
Timely
Understanding of Patient’s Perception
- What are the components of past personal health history?
Childhood Illness
Adult Illnesses
Surgeries
Hospitalizations
Immunizations
Allergies
Diagnostic Tests
- What does GPTPAL stand for in obstetric history?
Gravida
Parity
Term
Preterm
Abortion
Living Children
- What is Naegele’s Rule used for?
Estimating the Expected Date of Delivery (EDD).
- What is the purpose of family history in health assessment?
Identifies hereditary health conditions using a genogram.
- What is the purpose of environmental history?
Assesses a patient’s surroundings for physical, psychological, and social risk factors.
- What are the risk factors for mental health issues?
Non-Modifiable Risk Factors:
- Age
- Genetics
- Family history
Modifiable Risk Factors:
- Diabetes
- Hypertension
- Head trauma
- Smoking
- Late hormone therapy
- What client education should be provided for mental health?
Engaging in mentally stimulating activities
Maintaining a healthy lifestyle
Avoiding head trauma risks
Following a heart-healthy diet
- What are the positions for physical examination?
Dorsal Recumbent
Supine
Sitting
Lithotomy
Sims
Prone
Semi-Fowler’s
High-Fowler’s
- What are the components of a mental status examination (ABCT)?
A – Appearance: Posture, grooming, hygiene
B – Behavior: Facial expressions, speech, mood
C – Cognition: Orientation, memory
T – Thought Process: Logical flow of ideas
- What are common thought process disorders?
Blocking
Confabulation
Neologism
Circumlocution
Circumstantiality
Loosening Association
Flight of Ideas
Word Salad
Echolalia
Clanging
- A thought disorder characterized by sudden stops in speech.
Blocking
- A thought disorder where a person fabricates stories to fill memory gaps.
Confabulation
- A thought disorder involving the creation of new words.
Neologism
- What are common thought content disorders?
Phobia
Hypochondriasis
Obsession
Compulsion
Delusion
- An irrational, persistent fear of an object or situation.
Phobia
- A disorder characterized by excessive worry about having a serious illness.
Hypochondriasis
- A false, fixed belief resistant to reasoning or facts.
Delusion
- What are common perception disorders?
Hallucination
Illusion
- A sensory perception disorder where a person sees, hears, or feels something that isn’t real.
Hallucination
- A misinterpretation of a real external stimulus.
Illusion
- What are the key assessments for suicide risk?
ALWAYS SCREEN FOR SUICIDAL THOUGHTS in patients showing signs of severe distress.
- What are the components of the Glasgow Coma Scale (GCS)?
Eye Opening Response
Verbal Response
Motor Response
- How is eye opening response scored in GCS?
4 – Spontaneous
3 – To sound
2 – To pain
1 – No response
- How is verbal response scored in GCS?
5 – Oriented
4 – Confused
3 – Inappropriate words
2 – Incomprehensible sounds
1 – No response
- How is motor response scored in GCS?
6 – Obeys commands
5 – Localizes pain
4 – Withdraws from pain
3 – Abnormal flexion (Decorticate)
2 – Abnormal extension (Decerebrate)
1 – No response
- What is the total score range for GCS?
15 – Best response (Fully alert)
9-12 – Moderate brain injury
3-8 – Severe brain injury (Coma)
- What does a GCS score of 3 indicate?
Deep coma or brain death
- What does a GCS score of 15 indicate?
Normal, fully conscious individual
- What does a GCS score of ≤8 indicate?
The patient is in a coma and may require intubation
- What does GPTQL stand for in obstetric history?
Gravida
Parity
Term
Preterm
Abortion
Living
- What does Gravida (G) refer to in GPTQL?
The number of times a woman has been pregnant, regardless of the outcome
- What does Parity (P) refer to in GPTQL?
The number of pregnancies carried to viable gestational age (≥20 weeks)
- What does Term (T) refer to in GPTQL?
The number of pregnancies carried to full term (≥37 weeks)
- What does Preterm (P) refer to in GPTQL?
The number of pregnancies delivered before 37 weeks but after 20 weeks
- What does Abortion (A) refer to in GPTQL?
The number of pregnancies that ended before 20 weeks, either spontaneously (miscarriage) or induced
- What does Living (L) refer to in GPTQL?
The number of children currently alive
- What are the possible outcomes in a GPTQL score of G3P2T2P0A1L2?
- G3: The woman has been pregnant three times
- P2: Two pregnancies reached viability
- T2: Two were full-term
- P0: No preterm births
- A1: One miscarriage or abortion
- L2: Two children are currently alive
- What are the three major assessment techniques in physical examination?
Inspection
Palpation
Percussion
Auscultation
- What is the order of examination techniques?
Normal: Inspection → Palpation → Percussion → Auscultation
For Abdomen: Inspection → Auscultation → Percussion → Palpation
- What are the types of palpation?
Light Palpation
Moderate Palpation
Deep Palpation
Bimanual Palpation
- What are the parts of the hand used for palpation?
Palmar Surface: Detects vibration
Dorsal Surface: Assesses temperature
Ulnar Surface: Assesses fremitus (vibration from speech)
- What are the components of the mental status examination (ABCT)?
A – Appearance: Posture, grooming, hygiene
B – Behavior: Facial expressions, speech, mood
C – Cognition: Orientation, memory
T – Thought Process: Logical flow of ideas
- A nurse is assessing an elderly patient who appears disheveled, with poor hygiene and a flat affect. The patient is unable to recall events from earlier in the day and reports hearing voices. What is the most appropriate action?
a) Assume the patient is experiencing dementia
b) Ask the patient if the voices are telling them to harm themselves
c) Report the findings as normal for aging
d) Ignore the hallucinations since they are not distressing the patient
b) Ask the patient if the voices are telling them to harm themselves
- During a health assessment, the patient states, “I feel worthless, and nothing matters anymore.” What should the nurse do first?
a) Document the statement and continue the assessment
b) Ask the patient directly if they have thoughts of self-harm
c) Encourage the patient to focus on positive aspects of life
d) Tell the patient their feelings will improve over time
b) Ask the patient directly if they have thoughts of self-harm
- A nurse is performing a mental status examination using the ABCT method. Which of the following is an example of assessing the “C” component?
a) Noting the patient’s facial expressions
b) Checking the patient’s ability to recall recent events
c) Observing the patient’s posture and grooming
d) Evaluating the patient’s speech for clarity
b) Checking the patient’s ability to recall recent events
- A patient with a history of schizophrenia repeatedly makes up new words that have no meaning. What term best describes this speech pattern?
a) Echolalia
b) Neologism
c) Flight of ideas
d) Clang association
b) Neologism
- A nurse is conducting an assessment using the COLDSPA method. The patient describes a dull, aching pain in their lower back that started two weeks ago and worsens when standing for long periods. Which letter of COLDSPA is addressed when the patient describes what makes the pain worse?
a) Character
b) Onset
c) Duration
d) Pattern
d) Pattern
- A 28-year-old pregnant woman reports that her last menstrual period was on March 10. Using Naegele’s Rule, what is her estimated due date?
a) December 17
b) December 10
c) December 3
d) January 10
b) December 17
- A nurse is palpating a patient’s abdomen and notices a rigid, board-like texture. What is the priority action?
a) Continue palpating to determine the cause
b) Stop the palpation and notify the provider immediately
c) Ask the patient if they recently ate a large meal
d) Document the findings and monitor for pain
b) Stop the palpation and notify the provider immediately
- A patient with severe depression and suicidal thoughts is admitted for care. What is the highest priority in the nurse’s assessment?
a) Evaluating the patient’s coping mechanisms
b) Checking for access to means of self-harm
c) Assessing the patient’s social support system
d) Asking about the patient’s past trauma
b) Checking for access to means of self-harm
- A nurse is assessing a patient’s cognitive function. Which of the following would indicate an abnormal finding?
a) The patient correctly identifies the season and location
b) The patient repeats a series of numbers backward
c) The patient is unable to recall three words after five minutes
d) The patient is aware of their birthday and family members
c) The patient is unable to recall three words after five minutes
- A patient is unable to understand or express language but is alert and able to follow commands. Which condition does this describe?
a) Dysarthria
b) Aphasia
c) Agnosia
d) Ataxia
b) Aphasia
- A patient who was recently diagnosed with diabetes appears withdrawn and repeatedly states, “I don’t know how to take care of myself.” What is the nurse’s best response?
a) “You need to focus on learning how to manage your condition.”
b) “What part of your care feels overwhelming to you?”
c) “I will ask your doctor to refer you to a specialist.”
d) “Many people feel this way at first, but you’ll adjust over time.”
b) “What part of your care feels overwhelming to you?”
- Which of the following statements by a nurse demonstrates professional integrity during an assessment?
a) “I cannot share that information because it is confidential.”
b) “I will do my best to ensure your privacy is protected.”
c) “I can tell you what another patient experienced in a similar case.”
d) “It’s okay, you can tell me anything, and I will keep it a secret.”
b) “I will do my best to ensure your privacy is protected.”
- A patient suddenly stops speaking mid-sentence and stares into space. After a few seconds, they resume talking as if nothing happened. Which disorder does this behavior suggest?
a) Clang association
b) Blocking
c) Loosening of associations
d) Flight of ideas
b) Blocking
- A nurse is educating a patient on lifestyle changes to reduce their risk of stroke. Which modifiable risk factor should the nurse emphasize?
a) Family history
b) Genetics
c) Smoking
d) Gender
c) Smoking
- A nurse is assessing a patient’s level of consciousness using the Glasgow Coma Scale (GCS). Which finding is most concerning?
a) A GCS score of 15
b) A GCS score of 9
c) A GCS score of 6
d) A GCS score of 12
c) A GCS score of 6
- A pregnant woman visits the clinic for her prenatal checkup. Her obstetric history includes three previous pregnancies: one full-term birth, one preterm birth at 34 weeks, and one miscarriage at 12 weeks. All of her children are alive. What is her GPTAL documentation?
a) G3 P2 T1 P1 A1 L2
b) G3 P2 T2 P0 A1 L2
c) G3 P3 T1 P1 A1 L2
d) G3 P2 T1 P1 A0 L2
a) G3 P2 T1 P1 A1 L2
- A patient has been pregnant five times. She delivered two full-term babies, one preterm baby at 32 weeks, and had two miscarriages before 20 weeks. Three of her children are alive. What is her GPTAL documentation?
a) G5 P3 T2 P1 A2 L3
b) G5 P4 T2 P1 A2 L3
c) G5 P3 T3 P0 A2 L3
d) G5 P3 T2 P1 A2 L2
a) G5 P3 T2 P1 A2 L3
- A woman who is currently pregnant has had two previous pregnancies. One resulted in a miscarriage at 10 weeks, and the other was a full-term birth. Her child is alive. What is her GPTAL documentation?
a) G3 P1 T1 P0 A1 L1
b) G3 P2 T1 P1 A1 L1
c) G2 P1 T1 P0 A1 L1
d) G3 P1 T0 P1 A1 L1
a) G3 P1 T1 P0 A1 L1
- A patient has had six pregnancies. She delivered four full-term infants, one preterm baby at 35 weeks, and had one miscarriage. Five of her children are still living. What is her GPTAL documentation?
a) G6 P5 T4 P1 A1 L5
b) G6 P4 T3 P1 A1 L5
c) G6 P5 T4 P1 A0 L5
d) G6 P5 T3 P2 A1 L5
a) G6 P5 T4 P1 A1 L5
- A pregnant woman comes for her first prenatal visit. She has a history of three previous pregnancies: one full-term birth, one preterm birth at 30 weeks, and one stillbirth at 39 weeks. Two of her children are alive. What is her GPTAL documentation?
a) G4 P3 T2 P1 A0 L2
b) G4 P2 T1 P1 A1 L2
c) G4 P3 T2 P1 A0 L2
d) G4 P3 T1 P2 A0 L2
c) G4 P3 T2 P1 A0 L2
- A patient arrives at the ER after a car accident. She opens her eyes when spoken to, is disoriented when answering questions, and withdraws her hand when painful stimuli is applied. What is her GCS score?
a) 9
b) 10
c) 12
d) 8
b) 10
- A comatose patient is unresponsive to verbal commands, shows abnormal extension in response to pain, and does not open their eyes. What is their GCS score?
a) 6
b) 7
c) 8
d) 5
a) 6
- A patient involved in a severe head injury is being assessed for their level of consciousness. They open their eyes in response to pain, produce incomprehensible sounds, and have abnormal flexion in response to pain. What is their GCS score?
a) 6
b) 7
c) 8
d) 9
b) 7
- A nurse is assessing a patient with a suspected stroke. The patient obeys commands, speaks coherently, and opens their eyes spontaneously. What is their GCS score?
a) 13
b) 14
c) 15
d) 12
c) 15
- A patient who was intubated due to head trauma is unresponsive to all stimuli, has no eye opening, and no motor response. What is their GCS score?
a) 4
b) 3
c) 5
d) 6
- A pregnant woman reports that her last menstrual period (LMP) was on July 8. Using Naegele’s Rule, what is her expected due date?
a) April 8
b) April 15
c) April 1
d) March 15
b) April 15
- A patient states that her last menstrual period started on November 25. Using Naegele’s Rule, what is her expected date of delivery?
a) September 1
b) August 18
c) September 2
d) August 25
d) August 25
- A woman visits the clinic for prenatal care. She says her last menstrual period was on February 10. When is her estimated due date?
a) November 3
b) November 17
c) December 10
d) November 20
b) November 17
- A nurse is assisting a newly pregnant woman in calculating her expected due date. The patient reports that her last period began on September 5. What is the estimated delivery date?
a) June 12
b) June 5
c) July 5
d) May 29
b) June 12
- A woman with a positive pregnancy test wants to estimate her due date. She recalls that her last menstrual period was on May 22. What is her expected date of delivery?
a) February 29
b) March 1
c) February 15
d) February 22
d) February 29
