Health Assess Part 7

A nurse is working in a clinic in a low-income neighborhood and assesses a female adult patient who states that she has a urinary tract infection. The nurse notes that the patient is unkempt, wearing stained clothing, and has a strong body odor. The patient mentions that she was evicted from her apartment two weeks ago. Which nursing diagnosis would the nurse most likely identify for this patient? • Caregiver role strain related to fatigue • Impaired skin integrity related to neurologic deficits • Deficient fluid volume related to possible urinary tract infection • Self-care deficit related to possible homelessness • When preparing to obtain information about a patient's mental and psychosocial status, which of the following would the nurse need to do first? • Question the patient about his or her usual lifestyle and behaviors. • Perform a neurologic examination to determine any deficits. • Check the patient's level of consciousness for changes. • Explain the purpose of the exam and types of questions. • A nursing student has been assigned to the care of a patient whose history suggests the need for a mental status assessment. This patient most likely has a history of health problems affecting what body system? • Respiratory • Neurologic • Cardiovascular • Renal • The nurse begins the physical examination of a newly admitted patient by assessing the patient's mental status. What is the nurse's best rationale for performing the mental status exam early in the assessment? • The patient will be less anxious early, providing the nurse with more accurate and reliable data. • The exam can provide clues about the validity of the patient's responses now and throughout. • The exam provides data about mental health problems that the patient may be afraid to report. • The patient's fears about having a serious illness may be alleviated by the results of the exam. • A patient's recent episode of becoming lost near his home has prompted the nurse to use the Saint Louis University Mental Status (SLUMS) Assessment Tool. The nurse should begin this assessment by asking what question? • ìHow would you respond if someone said that you might have dementia?î • ìCan I ask you some questions about your memory?î • ìDo you generally consider yourself to be an intelligent person?î • ìI want to ask you some questions to see if you have Alzheimer's.î • Assessment of a patient who has suffered a recent stroke reveals that he is unresponsive to all stimuli and his eyes remain closed. The nurse documents the patient's level of consciousness as which of the following? • Obtunded • Stupor • Coma • Lethargy • An emergency department nurse has utilized the Confusion Assessment Method (CAM) in the assessment of a 79-year-old patient with a new onset of urinary incontinence. This assessment tool will allow the nurse to confirm the presence of what health problem? • Delirium • Vascular dementia • Schizophrenia • Psychosis • The nurse is assessing a patient using the Glasgow Coma Scale following an acute hypoglycemic episode and obtains a score of 14. The nurse interprets this as indicating which of the following? • Deep coma • Coma • Obtunded • Alert and oriented • A woman brings her 69-year-old husband to the clinic for an evaluation because he has become increasingly forgetful. Which of the following would lead the nurse to suspect that the patient has Alzheimer's disease? Select all that apply. • ìHe repeats the same story, word for word, over and over again.î • ìHe took a fall when he was replacing a light bulb last month.î • ìI have to balance the checkbook now because he just won't do it.î • ìIf I don't tell him when to shower, he won't and will fight me on it.î • ìHe got lost walking to the pharmacy around the corner the other day.î • As part of a mental status assessment, the nurse asks a patient to draw the face of a clock. This will allow the nurse to assess which of the following domains of mental status? • Concentration and orientation • Perceptions and thought processes • Visual perceptual and constructional ability • Expressions and feelings • A nurse who provides care on a medical unit utilizes the Alcohol Use Disorders Identification Test (AUDIT) as part of the standard admission protocol. After obtaining a score of 9 from a recently admitted patient, the nurse should recognize the possibility of which of the following? • Hazardous and harmful alcohol use • Imminent liver disease • Acute pancreatitis • Alcoholism • A nurse is assessing a patient who is exhibiting decorticate posturing. Which of the following would the nurse observe? • Extended upper extremities • Internally rotated lower extremities • Pronated forearms • Flexed hands at the side of the body • The nurse observes a patient's entire body posture to be somewhat stiff, with his shoulders elevated upward toward the ears. The nurse would most likely interpret this to indicate that the patient is experiencing which of the following? • Confusion • Anxiety • Powerlessness • Restlessness • A nurse is reviewing a depression questionnaire completed by a patient. Which of the following would the nurse interpret as being suggestive of depression? • ìOccasionally I feel like my attention wanders.î • ìI haven't noticed any change in my appetite.î • ìIt usually takes me over an hour to fall asleep.î • ìI might wake up once during the night but not often.î • A gerontologic nurse is assessing the speech of an older adult patient. Which of the following would the nurse characterize as an expected assessment finding? • Repetition • Rapid speech • Moderate pace • Loud tone • A nurse asks a patient the following question: ìWhat do you do if you have pain?î The nurse is assessing which of the following aspects of cognitive function? • Orientation • Judgment • Abstract reasoning • Memory • A nurse is providing care for a patient who has hepatic encephalopathy secondary to chronic alcohol abuse. The nurse's assessment reveals that the patient often provides incorrect answers to assessment questions. As well, the patient makes statements that are not grounded in reality. What nursing diagnosis is suggested by these assessment data? • Impaired Verbal Communication related to hepatic encephalopathy AMB confusion • Acute Confusion related to hepatic encephalopathy • Ineffective Health Maintenance related to alcohol abuse AMB decreased cognition • Ineffective Coping related to alcohol abuse • A patient has presented to the emergency department (ED) with a lower leg laceration that she suffered ìwhile I was on a bender last night.î The nurse recognizes the need to screen for alcohol use and will implement the CAGE questionnaire. What question will the nurse ask during this assessment? • ìHave you ever experienced a memory blackout after drinking?î • ìHave you ever vomited blood after drinking alcohol?î • ìHave you ever been treated for alcohol abuse?î • ìHave you ever felt guilty about your alcohol use?î • A woman has accompanied her 80-year-old husband to a scheduled clinic visit and expresses concern about subtle declines in his cognition. Which of the following principles should guide the nurse's assessment of the patient's mental status? • The nurse must modify the cognitive assessment to exclude assessments requiring reading or writing. • The nurse should first explain to the couple that senility is expected among adults over age 80. • The nurse must differentiate between age-related changes and the signs and symptoms of dementia. • The nurse must explain that the results of the assessment will be used to determine if admission to long-term care is necessary. • The intensive care nurse is working with a patient who has increased intracranial pressure secondary to a traumatic brain injury. The nurse is performing the hourly assessment of the patient's level of consciousness and observes that the patient's eyes are closed. How should the nurse first stimulate the patient to assess for arousability? • Gently shake the patient's right shoulder and then his left shoulder. • Rub the patient's sternum with the knuckles. • Speak to the patient clearly from a close distance. • Press down on one of the patient's nail beds. • A nurse is conducting a mental status assessment of a 70-year-old male patient who is being treated for depression. When assessing the patient's facial expression and eye contact, the nurse should consider which of the following? • The nurse should inform the patient that his facial expression is being assessed. • Reduced eye contact is an age-related physiological change. • Facial expression should be disregarded if the patient has a diagnosed mental illness. • Eye contact is strongly influenced by cultural norms. • A 21-year-old woman has been admitted to the emergency department following an accident that is suspected of being a suicide attempt. When assessing the patient's perceptions, what question should the nurse ask the patient? • ìHow would you describe your health these days?î • ìAre you able to smell and taste as well as you've been able to in the past?î • ìIf you found a stamped envelope on the street, what would you do?î • ìCan you tell me the circumstances surrounding your accident?î • A nurse in the emergency department is utilizing the SAD PERSONAS assessment guide during the mental status assessment of a patient. What is the most likely rationale for the nurse's choice of this assessment tool? • The patient may have a high risk for suicide. • The patient may have major depression. • The patient may have schizophrenia or psychosis. • The patient may be using alcohol excessively. • An 88-year-old woman has been admitted to the acute medical unit for the treatment of a urinary tract infection that is thought to be progressing to urosepsis. When assessing the patient's orientation, how should the nurse best gauge the patient's orientation to time? • ìCan you tell me approximately what time it is right now?î • ìAre you able to tell me today's date?î • ìCan you tell me the date and the day of the week?î • ìAre you able to tell the month and the year that we're in?î • During the mental status assessment of a new patient, the nurse has asked the patient to describe some of the similarities and differences between a tennis ball and a soccer ball. Despite adequate time and cuing, the patient is unable to state any similarities or differences. The nurse should document what assessment finding? • A deficit in practical intelligence • An inability to follow directions accurately • A deficit in abstract reasoning • A lack of spatial orientation • The nurse is assessing an older adult patient's mental status. Consistently, the patient pauses after the nurse poses a question, but then the patient provides a response that is correct or appropriate. How should the nurse best interpret this characteristic of the patient? • Slight delays in mental processing are normal in older adults. • The patient may be trying to anticipate the nurse's desired response. • The patient is displaying a sign of early Alzheimer's disease. • The patient may be experiencing an early sign of delirium.