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51 Cards in this Set
- Front
- Back
t or f |
when assessing the mental status of an older client, be sure to check vision and hearing before assuming that the have a mental problem |
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when assessing level of consciousness always begin with the least noxious stimulus:____, ______, to _______ |
verbal, tactile to painful |
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What do clients with lesions of the corticospinal tract do when stiumulated |
they draw hands up to the chest (decorticate or abnormal flexor posture) |
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what do clients with lesions of the diencephalon, midbrain, or pons do when stimulated |
they extend arms and legs, arch neck, and rotate hands and arms internally (decerebrate or abnormal extensor posture) |
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the Glasgow Coma Scale (GCS) are used for clients who are |
at risk for rapid deterioration of the nervous system or ICU pts. |
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GCS score of _____ indicates an optimal level of consciousness |
14 |
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A GCS score of 3, the lowest possible, indicates a |
deep coma |
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the GCS cannot be used to assess a |
verbal score in intubated or aphasic pts |
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Slumperd posture may reflect feelings of powerlessness or hopelessness characteristic of |
depression or organic brain disease |
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Bizarre body movements and behavior may be noted in |
schizophrenia or may be a side effect of drug therapy or other activity |
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Clients may elevate their shoulders toward their ears and hold the entire body stiffly when they are |
tense or anxious |
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Uncooperative, bizarre behavior may be seen in |
the angry, mentally ill, or violent client |
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anxious clients are often
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fidgety and restless
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Incongruent behavior may be seen in clients who are |
in denial of problems or illness |
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prolonged, euphoric laughing is typical of |
mania |
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Unusually meticulous grooming and finicky mannerisms may be seen in |
OCD |
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poor hygiene and inappropriate dress may be seen with |
organic brain syndrome |
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Bizarre dress may be seen in |
schizophrenia or manic disorders |
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extreme unilateral neglect may result from a _____ due to a _____ |
lesion; cerebral vascular accident (CVA) |
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Uncoordinated clothing, extremely light clothing, or extremely warm clothing for the weather conditions may be seen on |
mentally ill, grieving, depressed, or poor cliens; or in clients w/ heat or cold intolerances. |
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soiled clothing may indicate |
homelessness, vision deficits in older adults or mental illness |
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Clients wearing long sleeves in warm weather may be |
protecting themselves from the sun or covering up needle marks secondary to drug abuse |
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extremely loose clothing held up by pins or a belt may suggest |
recent weight loss |
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t or f |
Asians and Native Americans have fewer sweat glands and, there- fore, less obvious body odor than most Caucasians and black Africans, who have more sweat glands |
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Clients with mask-like expressionless face may have |
parkinson’s disease |
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Staring watchfulness appears in |
metabolic disorders and anxiety. |
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Drooping or gross asymmetry occurs with |
neurologic disorder or injury (e.g., Bell’s palsy or stroke) |
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Slow, repetitive speech is characteristic of
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depression or parkinson’s disease
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Loud, rapid speech may occur in manic phases of |
bipolar disorder |
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Disorganized speech, consistent (nonstop) speech, or long peri ods of silence may indicate |
mental illness or a neurologic disorder (e.g., dysarthria, dysphasia, speech defect, garbled speech) |
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what tests should be done if client has difficulty with speech |
1. ask client to name objects in the room 2. ask client to read from printed material appropriate to their educational level 3. ask client to write a sentence |
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Flat affect, euphoria, anxiety, fear, ambivalence, irritability, depression, and/or rage are all examples of |
altered mood expressions |
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Eccentric moods not appropriate to the situation are seen in |
schizophrenia |
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Expression of elation and grandiosity, high energy level, and engagement in high-risk but pleasurable activities is seen in |
manic phases |
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Quick Inventory of Depressive Symptomatology (Self-Report) is used to determine if the client |
is at risk for depression and needs to be referred to a doctor (0-5 score = no risk) |
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questions such as“Tell me more about what you just said” or “Tell me what your understanding is of the current situation or your health.” are used to |
observe thought process and perception |
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Confabulation (making up of answers to cover for not knowing) is seen in |
Korsakoff’s syndrome. |
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Clients undergoing hemodialysis often have |
depression and suicidal ideation |
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the SAD PERSONS Suicide Risk Assessment is used to determine |
the risk factors the client may have that might put him at risk for suicide |
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10th leading cause of death in the US |
suicide |
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suicide is 4 times more prevalent in |
men |
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Orientation to time is usually lost ____- and orientation to person is usually lost ____- |
first; last |
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reduced degree of orientation may be seen with |
organic brain disordersor psychiatric illness such as withdrawal from chronic alcohol use or schizophrenia. |
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Inability to recall recent events is seen in |
delirium, dementia, depression, and anxiety. |
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Inability to recall past events is seen in |
cerebral cortex disorderes |
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Inability to recall words after a delayed period is seen in |
anxiety, depression, or Alzheimer's disease |
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older adults considerations |
Clients older than 80 should recall two to four words after 5 minutes and pos- sibly after 10 and30 minutes with hints that prompt recal |
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when assessing abstract reasoning, if client has limited education, what other alternatives can be used |
note their ability to joke or use puns |
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Inability to compare and contrast objects correctly or interpret proverbs correctly is seen in |
schizophrenia, mental retardation, delirium, and dementia. |
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Use the SLUMS Dementia/Alzheimer’s test Exam if |
time is limited and a quick measure is needed to evaluate cognitive function. |
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t or f |
the SLUMS and CAM test level of orientation, memory, speech, and cognitive functions but not mood, feelings, expres- sions, thought processes, or perception |