Beaeve54

LOC Correct Answer - Alert- responsive and fully able to respond by opening eyes and attending to a normal tone of voice and speech; answers questions spontaneously and appropriately Lethargy- client is able to open eyes and respond but is drowsy and falls asleep easily Stupor- Requires vigorous or painful stimuli (pinching tendon or rubbing sternum) to elicit a brief response; may not be able to respond verbally Coma- No response can be achieved from repeated painful stimuli; involves abnorm...

a charge nurse is discussing mental status examination with a newly licensed nurse. which of the following statements by the newly licensed nurse indicates an understanding of the teaching (select all that apply) a. to assess cognitive ability, I should ask the client to count backward by sevens b. to assess affect, I should observe the cient's facial expression c. to assess language ability, I should instruct the client to write a sentence d. to assess remote memory, I should h...

A charge nurse is discussing mental status examination with a newly licensed nurse. Which of the following statements made by the newly licensed nurse indicates and understanding of the teaching? (Select all that apply). A. "To assess cognitive ability, I should ask the client to count backwards by seven." B. "To assess affect, I should observe the client's facial expression." C. "To assess language ability, I should instruct the client to write a sentence." D. "To assess remote mem...

Why would you expect a patient who has been using cocaine to have HTN? Correct Answer - Cocaine is a stimulant that increases blood pressure. It also increases heart rate, body temperature, energy levels, and metabolism. Cocaine decreases appetite Why should the RN report a rash on a patient taking Lamotrigine? Correct Answer - Lamotrigine is an anticonvulsant medication that is used as a mood stabilizer. The nurse should identify that a rash is a potentially life-threatening adverse effect ...

A school nurse is assessing a school-age child who experienced the traumatic loss of a parent 8 months ago. Which of the filling findings should the nurse identify as an indication that the child is experiencing post-traumatic stress disorder (PTSD)? A. Clinging behaviors directed toward a teacher B. Increased time spent sleeping C. Intense focus on school work D. Lack of interest in an upcoming holiday Correct Answer - D. Lack of interest in an upcoming holiday A nurse is caring for a gr...

projection Correct Answer - a nurse on a mental health unit is providing care for a client diagnosed with schizophrenia. the client is experiencing delusional thinking. Which of the following defense mechanisms is the client using? Your are having Very frightening thoughts. Correct Answer - A client diagnosed with schizophrenia says to the nurse, " they lied about me and are trying to poison my food" which of the following is a therapeutic response? "tell me who would do such a thing" b...

Mental Status Examination (MSE) includes: Correct Answer - - Level of Consciousness - Physical Appearance - Behavior - Cognitive and Intellectual abilities Level of Consciousness Correct Answer - - Alert - Lethargy - Stuporous - Comatose Alert Correct Answer - The client is responsive and able to fully respond by opening her eyes and attending to a normal tone of voice and speech. She answers questions spontaneously and appropriately. Lethargic Correct Answer - The client is abl...

methods to collect data Correct Answer - observation, interview, physical examination, and collaboration levels of consciousness Correct Answer - alert: awake and responsive lethargic: eyes can open, but super drowsy stuporous: vigorous/painful stimuli to elicit brief response comatose: unconscious, does not respond to painful stimuli decorticate rigidity Correct Answer - flexion and internal rotation of upper extremity joints and legs decerebrate rigidity Correct Answer - neck and ...

It is important to ask this during assessment? Correct Answer - - Perception of own health/beliefs about illness and wellness - how the client passes time - use of substances/disorders - cultural beliefs and practices -spiritual bliefs Mental Status Exam (MSE) Correct Answer - used to describe LOC -alert -lethargy -stupor -coma MSE what is alert? Correct Answer - client is responsive and answers questions spontaneously and appropriately MSE what is lethargy? Correct Answer - ope...

Difference between spirituality and religion Correct Answer - Spirituality- client's internal values, sense of morality, and how he views the purpose of life. Religion- client's beliefs according to an ORGANIZED set of patterns of worship and rituals What 4 areas does the Mental Status Exam (MSE) cover? Correct Answer - 1. LOC 2. Physical appearance 3. Behavior 4. Cognitive/Intellectual abilities 4 levels of consciousness Correct Answer - alert, lethargic, stuporous, comatos...