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NSG 316 TOPIC 1-5 > TOPIC 14 > Flashcards

TOPIC 14 Flashcards

1
Q

mental status

A

a person’s emotional and cognitive functioning
strikes a balance between good and bad days, allowing person to function socially and occupationally

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1
Q

mental disorder

A

an illness that affects a person’s thoughts, emotions, and behaviors

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2
Q

organic disorders

A

Due to brain disease of known specific organic cause (e.g., delirium, dementia, alcohol and drug intoxication and withdrawal)

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3
Q

psychiatric mental illness

A

organic etiology has not yet been established (e.g., anxiety disorder or schizophrenia)

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4
Q

when do you perform a full mental status examination

A

when any abnormality in affect or behavior is discovered and in certain situations

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5
Q

mental status: aging adult

A

o Older adulthood contains more potential for losses
o Grief and despair surrounding theses losses can affect mental status and can result in disability, disorientation, or depression
o Chronic diseases such as heart failure, cancer, diabetes, and osteoporosis include fear of loss of life

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6
Q

the four main headings of mental status assessment:

A

A-B-C-T
-Appearance
-Behavior
-Cognition
-Thought processes

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7
Q

aphasia

A

impairment of language ability secondary to brain damage

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8
Q

brain lesions

A

trauma, tumor, cerebrovascular accident or stroke

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9
Q

when is a full mental status examination necessary

A

-Patients whose initial screening suggests an anxiety disorder or depression
-Behavioral changes, such as memory loss, inappropriate social interaction
-Brain lesions
-Aphasia
-Symptoms of psychiatric mental illness, especially with acute onset

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10
Q

what things does the nurse ask about when determining the orientation of a client?

A

-time(day of the week, date, year, season)
-place(where person lives, address, phone number, present location, type of building, name of city and state)
-person(own name, age, who examiner is, type of worker)

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11
Q

attention span

A

ability to concentrate-noting completes a thought without wandering

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12
Q

assessing recent memory

A

Assess in context of interview by 24-hour diet recall or by asking time person arrived at agency

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13
Q

confabulates

A

makes up plausible explanation for his actions without intention to deceive, to fill in gaps of memory loss

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14
Q

assessing remote memory

A

In the context of the interview, ask verifiable past events;
describe past health, the first job, birthday and anniversary dates, and historical events that are relevant for that person

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15
Q

Remote memory is lost when

A

cortical storage area for that memory is damaged, such as in Alzheimer disease, dementia, or any disease that damages cerebral cortex

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16
Q

the four unrelated words test

A

Pick four words with semantic and phonetic diversity; ask person to remember the four words
have him or her repeat the words
Ask for the recall of four words at 5, 10, and 30 minutes

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17
Q

what is a normal response of the four unrelated words test for a person younger than 60

A

an accurate 3- or 4-word recall after 5, 10, and 30 minutes

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18
Q

assessing word comprehension

A

ask person to name object in room

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19
Q

assessing reading

A

ask person to read available print; be aware that reading is related to educational level

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20
Q

assessing writing

A

ask person to make up and write a sentence; note coherence, spelling, and parts of speech

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21
Q

thought processes

A

Way person thinks should be logical, goal directed, coherent, and relevant; should complete thoughts

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22
Q

thought content

A

what person says should be consistent and logical

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23
Q

perceptions

A

an awareness of objects through the five senses

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24
When the person expresses feelings of sadness, hopelessness, despair, or grief, it is important to assess.
any possible risk of physical harm to himself or herself
25
when screening for suicidal thoughts, begin with..
more general questions; if you hear affirmative answers, continue with more specific probing questions
26
Mini-Mental State Exam (MMSE)
o Concentrates only on cognitive functioning, not on mood or thought processes o 11 questions, 5 to 10 minutes to administer
27
the Mini-Mental State Exam (MMSE) can detect
dementia and delirium and differentiate from psychiatric mental illness
28
normal for the Mini-Mental State Exam (MMSE) is...
average 27;
29
scores between what numbers on the Mini-Mental State Exam (MMSE) indicare no cognitive impairment
scores between 24 and 30 indicate no cognitive impairment
30
what should be assessed before any aspect of mental status?
sensory status (vision and hearing changes)
31
Glasgow Coma Scale is useful in..
testing consciousness in aging persons in whom confusion is common
32
Mini-Cog
a reliable, quick, and easily available instrument to screen for cognitive impairment in healthy adults -o Tests person's executive function, including ability to plan, manage time, and organize activities, and working memory
33
what does a Mini-Cog consist of
o Consists of three-item recall test and clock-drawing test
34
what id normal for the mini-cog test
no cognitive impairment or dementia can recall the three words and draw a complete, round, closed clock circle with all face numbers in correct position and sequence and hour and minute hands indicating time you requested
35
alert
Awake or readily aroused; oriented, fully aware of external and internal stimuli and responds appropriately; conducts meaningful interpersonal interactions.
36
Lethargic or Somnolent
Not fully alert; drifts off to sleep when not stimulated; can be aroused to name when called in normal voice but looks drowsy; responds appropriately to questions or commands but thinking seems slow and fuzzy; inattentive; loses train of thought; spontaneous movements are decreased.
37
obtunded
(Transitional state between lethargy and stupor; some sources omit this level.) Sleeps most of time; difficult to arouse—needs loud shout or vigorous shake; acts confused when is aroused; converses in monosyllables; speech may be mumbled and incoherent; requires constant stimulation for even marginal cooperation.
38
Stupor or Semi-coma
Spontaneously unconscious; responds only to persistent and vigorous shake or pain; has appropriate motor response (i.e., withdraws hand to avoid pain); otherwise can only groan, mumble, or move restlessly; reflex activity persists.
39
coma
completely unconscious, no response to pain or to any external or internal stimuli
40
dysphonia
impairment or change in voice quality that affects the ability to speak or sing
41
Dysarthria
slow, slurred speech
42
global aphasia
affects receptive and expressive language skills (written and verbal) as well as auditory and visual comprehension
43
Broca's aphasia
expressive language impairment - speaking and writing
44
Wernicke's aphasia
receptive aphasia - difficult time understanding written and spoken language - speech lacks content or meaning
45
Delerium
confused thinking and reduced awareness of surroundings
46
Dementia
group of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform ADL's
47
depression
persistently depressed mood or loss of interest in activities that affects daily life
48
panic attack
a defined period of intense fear, anxiety, and dread accompanied by signs of dyspnea, choking, chest pain, increased heart rate, palpitations, nausea, and sweating.
49
agoraphobia
An irrational fear of being in places or situations where escape might be difficult.
50
specific phobia
a pattern of debilitating fear when faced with a particular object or situation.
51
social anxiety disorder
A persistent and irrational fear of being in social situations.
52
Generalized Anxiety Disorder (GAD):
A pattern of excessive worrying and morbid fear about anticipated "disasters" in the job, personal relationships, health, or finances.
53
Obessive-Compulsive Disorder (OCD)
A pattern of recurrent obsessions (intrusive, uncontrollable thoughts) and compulsions (repetitive ritualistic actions) done to decrease anxiety and prevent a catastrophe.
54
PTSD (Post Traumatic Stress Disorder)
This follows a traumatic event outside the range of usual human experience involving actual or threatened death.
55
Three most frequently abused prescription opioid pain relievers were products using the following:
-Oxycodone -Hydrocodone -Methadone
56
Prescription Drug Abuse occurs when...
an individual takes medication that was prescribed for someone else or takes medication in a manner that is different from that prescribed
57
Older adults have numerous characteristics that increase risk of alcohol use including:
o Liver metabolism and kidney functioning decrease, (increases availability of alcohol in blood for longer periods) o Less tissue mass means increased alcohol concentration in blood o multiple medications that can interact adversely with alcohol o Drinking alcohol increases risk of falls, depression, and gastrointestinal problems
58
If patient is currently intoxicated or going through substance withdrawal, collecting any history data is..
difficult and unreliable
59
R-R-R-R
o Risk of bodily harm: drinking and driving, operating machinery, swimming? o Relationship trouble: family or friends? o Role failure: interference with home, work, or school obligations? o Run-ins with law: arrests or other legal problems?"
60
AUDIT tool will help
detect less severe alcohol problems (hazardous and harmful drinking) as well as alcohol abuse and dependence disorders
61
AUDIT covers three domains
o Alcohol consumption o Drinking behavior or dependence o Adverse consequences from alcohol
62
AUDIT-C
Shorter version of AUDIT for acute and critical care units - screening test for heavy drinking and/or active abuse Score: 3 or above = heavy or at-risk drinking
63
CAGE questionnaire
cut down, annoyed, guilty, eye opener
64
Screening women for alcohol problems
TWEAK questions help identify at-risk drinking in women, especially pregnant women
65
TWEAK
-Tolerance: how many drinks can you hold? Or how many drinks does it take to make you feel high? -Worry: have close friends or relatives complained about your drinking? -Eye-opener: do you sometimes take a drink in morning when you first get up? -Amnesia: has a friend or family member told you about things you said but could not remember? -Kut down: do you sometimes feel the need to cut down?
66
SMAST-G questionnaire
for older adults who report social or regular drinking of any amount of alcohol. low risk response is 0 or 1 point. (10 questions)
67
what is the most commonly used biochemical marker of alcohol drinking
Serum protein, gamma glutamyl transferase (GGT)
68
Breath alcohol analysis (Breathalizer)
detects any amount of alcohol in end of exhaled air following a deep inhalation until all ingested alcohol is metabolized
69
blood alcohol concentration (BAC)
the basis for a legal interpretation of drinking
70
CIWA-Ar Tool for assessment of withdrawal
o Nausea vomiting o Tremor o Paroxysmal sweats o Anxiety o Agitation o Tactile disturbances o Auditory disturbances o Visual disturbances o Headache o Orientation and clouding of sensorium
71
Intoxication
Ingestion of substance produces maladaptive behavioral changes because of effects on the central nervous system
72
abuse
Daily use needed to function, inability to stop, impaired social and occupational functioning, recurrent use when it is physically hazardous, substance-related legal problems
73
dependence
Physiologic dependence on substance
74
tolerance
Requires increased amount of substance to produce same effect
75
withdrawal
Cessation of substance produces syndrome of physiologic symptoms
76
Intimate partner violence defined by the Centers for Disease Control and Prevention
-Physical or sexual violence, use of physical force, or threat of such violence -Psychological or emotional abuse or coercive tactics after/prior physical violence between persons: Spouses, nonmarital partners, former spouses
77
as mandatory reporters of abuse you need only have
Suspicion that elder abuse and/or neglect may have occurred in order to generate a call to the authorities
78
Physical abuse
violent acts that result or could result in injury, pain, impairment, or disease
79
Physical neglect
failure of family or caregiver to provide basic goods and services such as food, shelter, health care, and medications
80
Psychological abuse
behaviors that result in mental anguish
81
Psychological neglect
failure to provide basic social stimulation
82
Financial abuse
intentional misuse of elderly person's financial and material resources
83
Financial neglect
failure to use elderly person's assets to provide needed services
84
Complications from injuries or bleeding from trauma
changes in circulatory homeostasis and fluctuations in blood pressure and pulse, shock, and death
85
Infections can progress to
generalized sepsis, then death in immunocompromised aging patients
86
Assault, or stress leading up to or following assault, can contribute to
cardiac complications
87
STIs and related complications for younger women are present in
older sexually assaulted women
88
Abuse of the elderly often is coupled with
neglect
89
Caregivers caring for elderly persons may struggle with their own severe physical and cognitive health challenges leading to
caregiver role strain
90
Routine, universal screening for IPV means the following
Asking every woman at every health care encounter if she has been abused by a husband, boyfriend, or other intimate partner or ex-partner
91
Alerts women that questions about domestic violence are coming and makes sure they
know they are not being singled out for these questions
92
If a woman answers yes to any of the Abuse Assessment Screen (AAS) questions, then ask questions to
assess how recent and how serious the abuse was
93
Important components of physical examination of known survivor of IPV or elder abuse include the following:
Complete head-to-toe visual examination, especially if patient is receiving health services for reported abuse
94
Health evaluations for known or suspected elder abuse and neglect should include baseline laboratory tests, including:
complete blood count with platelet level, -basic blood chemistries, -serum liver function tests, -coagulation panel, -urinalysis
95
Danger Assessment (DA)
The more yes answers, the more serious the danger of the woman's situation
96
IPV Factors among Ethnic and Racial Minorities: Legal Regulations
-societal stressors -Legal regulations -Lack of access -Cultural values and gender roles
97
Documentation of IPV, child abuse, and elder abuse must include the following:
o Detailed, nonbiased progress notes o Use of injury maps o Photographic documentation in health record o Other aspects of abuse history, including reports of past abusive incidents, can be paraphrased with use of partial direct quotations o Written documentation of histories of IPV and elder abuse needs to be verbatim but within reason o Critical to document exceptionally poignant statements made by victim that identify perpetrator and severe threats of harm made by perpetrator

NSG 316 TOPIC 1-5 (13 decks)

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