Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
1
Q

mental disorder

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

organic disorders

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

psychiatric mental illness

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

the four main headings of mental status assessment:

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

aphasia

A

impairment of language ability secondary to brain damage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

brain lesions

A

trauma, tumor, cerebrovascular accident or stroke

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

attention span

A

ability to concentrate-noting completes a thought without wandering

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

assessing recent memory

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

confabulates

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

assessing word comprehension

A

ask person to name object in room

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

assessing reading

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

assessing writing

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

thought processes

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

thought content

A

what person says should be consistent and logical

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

perceptions

A

an awareness of objects through the five senses

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

When the person expresses feelings of sadness, hopelessness, despair, or grief, it is important to assess.

A

any possible risk of physical harm to himself or herself

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

when screening for suicidal thoughts, begin with..

A

more general questions; if you hear affirmative answers, continue with more specific probing questions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Mini-Mental State Exam (MMSE)

A

o Concentrates only on cognitive functioning, not on mood or thought processes
o 11 questions, 5 to 10 minutes to administer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

the Mini-Mental State Exam (MMSE) can detect

A

dementia and delirium and differentiate from psychiatric mental illness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

normal for the Mini-Mental State Exam (MMSE) is…

A

average 27;

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

scores between what numbers on the Mini-Mental State Exam (MMSE) indicare no cognitive impairment

A

scores between 24 and 30 indicate no cognitive impairment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

what should be assessed before any aspect of mental status?

A

sensory status (vision and hearing changes)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Glasgow Coma Scale is useful in..

A

testing consciousness in aging persons in whom confusion is common

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Mini-Cog

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

what does a Mini-Cog consist of

A

o Consists of three-item recall test and clock-drawing test

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

what id normal for the mini-cog test

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

alert

A

Awake or readily aroused; oriented, fully aware of external and internal stimuli and responds appropriately; conducts meaningful interpersonal interactions.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Lethargic or Somnolent

A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

obtunded

A

(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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Stupor or Semi-coma

A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

coma

A

completely unconscious, no response to pain or to any external or internal stimuli

40
Q

dysphonia

A

impairment or change in voice quality that affects the ability to speak or sing

41
Q

Dysarthria

A

slow, slurred speech

42
Q

global aphasia

A

affects receptive and expressive language skills (written and verbal) as well as auditory and visual comprehension

43
Q

Broca’s aphasia

A

expressive language impairment - speaking and writing

44
Q

Wernicke’s aphasia

A

receptive aphasia - difficult time understanding written and spoken language - speech lacks content or meaning

45
Q

Delerium

A

confused thinking and reduced awareness of surroundings

46
Q

Dementia

A

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
Q

depression

A

persistently depressed mood or loss of interest in activities that affects daily life

48
Q

panic attack

A

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
Q

agoraphobia

A

An irrational fear of being in places or situations where escape might be difficult.

50
Q

specific phobia

A

a pattern of debilitating fear when faced with a particular object or situation.

51
Q

social anxiety disorder

A

A persistent and irrational fear of being in social situations.

52
Q

Generalized Anxiety Disorder (GAD):

A

A pattern of excessive worrying and morbid fear about anticipated “disasters” in the job, personal relationships, health, or finances.

53
Q

Obessive-Compulsive Disorder (OCD)

A

A pattern of recurrent obsessions (intrusive, uncontrollable thoughts) and compulsions (repetitive ritualistic actions) done to decrease anxiety and prevent a catastrophe.

54
Q

PTSD (Post Traumatic Stress Disorder)

A

This follows a traumatic event outside the range of usual human experience involving actual or threatened death.

55
Q

Three most frequently abused prescription opioid pain relievers were products using the following:

A

-Oxycodone
-Hydrocodone
-Methadone

56
Q

Prescription Drug Abuse occurs when…

A

an individual takes medication that was prescribed for someone else or takes medication in a manner that is different from that prescribed

57
Q

Older adults have numerous characteristics that increase risk of alcohol use including:

A

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
Q

If patient is currently intoxicated or going through substance withdrawal, collecting any history data is..

A

difficult and unreliable

59
Q

R-R-R-R

A

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
Q

AUDIT tool will help

A

detect less severe alcohol problems (hazardous and harmful drinking) as well as alcohol abuse and dependence disorders

61
Q

AUDIT covers three domains

A

o Alcohol consumption
o Drinking behavior or dependence
o Adverse consequences from alcohol

62
Q

AUDIT-C

A

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
Q

CAGE questionnaire

A

cut down, annoyed, guilty, eye opener

64
Q

Screening women for alcohol problems

A

TWEAK questions help identify at-risk drinking in women, especially pregnant women

65
Q

TWEAK

A

-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
Q

SMAST-G questionnaire

A

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
Q

what is the most commonly used biochemical marker of alcohol drinking

A

Serum protein, gamma glutamyl transferase (GGT)

68
Q

Breath alcohol analysis (Breathalizer)

A

detects any amount of alcohol in end of exhaled air following a deep inhalation until all ingested alcohol is metabolized

69
Q

blood alcohol concentration (BAC)

A

the basis for a legal interpretation of drinking

70
Q

CIWA-Ar Tool for assessment of withdrawal

A

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
Q

Intoxication

A

Ingestion of substance produces maladaptive behavioral changes because of effects on the central nervous system

72
Q

abuse

A

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
Q

dependence

A

Physiologic dependence on substance

74
Q

tolerance

A

Requires increased amount of substance to produce same effect

75
Q

withdrawal

A

Cessation of substance produces syndrome of physiologic symptoms

76
Q

Intimate partner violence defined by the Centers for Disease Control and Prevention

A

-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
Q

as mandatory reporters of abuse you need only have

A

Suspicion that elder abuse and/or neglect may have occurred in order to generate a call to the authorities

78
Q

Physical abuse

A

violent acts that result or could result in injury, pain, impairment, or disease

79
Q

Physical neglect

A

failure of family or caregiver to provide basic goods and services such as food, shelter, health care, and medications

80
Q

Psychological abuse

A

behaviors that result in mental anguish

81
Q

Psychological neglect

A

failure to provide basic social stimulation

82
Q

Financial abuse

A

intentional misuse of elderly person’s financial and material resources

83
Q

Financial neglect

A

failure to use elderly person’s assets to provide needed services

84
Q

Complications from injuries or bleeding from trauma

A

changes in circulatory homeostasis and fluctuations in blood pressure and pulse, shock, and death

85
Q

Infections can progress to

A

generalized sepsis, then death in immunocompromised aging patients

86
Q

Assault, or stress leading up to or following assault, can contribute to

A

cardiac complications

87
Q

STIs and related complications for younger women are present in

A

older sexually assaulted women

88
Q

Abuse of the elderly often is coupled with

A

neglect

89
Q

Caregivers caring for elderly persons may struggle with their own severe physical and cognitive health challenges leading to

A

caregiver role strain

90
Q

Routine, universal screening for IPV means the following

A

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
Q

Alerts women that questions about domestic violence are coming and makes sure they

A

know they are not being singled out for these questions

92
Q

If a woman answers yes to any of the Abuse Assessment Screen (AAS) questions, then ask questions to

A

assess how recent and how serious the abuse was

93
Q

Important components of physical examination of known survivor of IPV or elder abuse include the following:

A

Complete head-to-toe visual examination, especially if patient is receiving health services for reported abuse

94
Q

Health evaluations for known or suspected elder abuse and neglect should include baseline laboratory tests, including:

A

complete blood count with platelet level,
-basic blood chemistries,
-serum liver function tests,
-coagulation panel,
-urinalysis

95
Q

Danger Assessment (DA)

A

The more yes answers, the more serious the danger of the woman’s situation

96
Q

IPV Factors among Ethnic and Racial Minorities: Legal Regulations

A

-societal stressors
-Legal regulations
-Lack of access
-Cultural values and gender roles

97
Q

Documentation of IPV, child abuse, and elder abuse must include the following:

A

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)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions