362 exam 4

Health history of a child

Surgeries, significant illnesses, allergies, birth method, immunizations, developmental milestones

Which area in the brain is primarily responsible for the production of speech and the coordination of the muscles involved in speech production?

Broca's Area (Frontal Lobe)

Retractions above the clavicles and between and below the ribs in children are signs of A) Normal respiratory inhalation and exhalation in children B) A sign of gastrointestinal distress C) An indication of respiratory distress or difficulty breathing D) A symptom of a skin condition

C) An indication of respiratory distress or difficulty breathing

Infant Skin Presentations:normal

clean, dry, and intact with pink and warm extremities

example of thought content

compulsions, obsessions, phobias, anxieties

Preschool child- developmental focus

concrete: feel, see, touch& smell *many "why" questions

What question should the nurse ask in order to assess an adolescent's risk factors for obesity and deficient nutritional status? a. "How often do you exercise or engage in physical activity?" b. "Do you often skip meals or snacks?" c. "Are you satisfied with your current weight?" d. "What do you eat in a typical day?"

d. "What do you eat in a typical day?"

A nurse makes a well-baby visit to a client who delivered 30 days ago. What medical term will the nurse use to describe this baby? a. Neonate b. Toddler c. Newborn d. Infant

d. Infant

Examples of Perception

delusions, hallucinations

When is development the fastest?

during infancy

main focus of assessment of toddler's developement

engagement *play is extremely important

infant physical assessment

examine on lap, approach slowly & reduce stimulation -perform as much as possible but be flexible -use toys and mobiles for distractions -no head to toe- key is flexibility

CAM: Inattention

feature 2: checks if someone can pay attention and focus. The assessor might ask them to do tasks like spelling a word backward or counting backward by sevens. Trouble doing these tasks could suggest delirium, a state of confusion. This step helps spot delirium and guide treatment.

hydrocephalus

fluid in the brain

Cephalocaudal

head to toe

Health maintanence

immunizations & meds

active suicidal ideation

includes details on how to commit the act

Which of the following is the most important skill a nurse needs when conducting a mental status assessment?

Effective listening skills

Components of mental health assessment

Appearance & behavior, speech & language, Mood &affect, thought & perceptions, Cognitive function, higher cognitive functions

A parent of an ill infant states, "We gave him ibuprofen for a fever, and he had an allergic reaction." Which response would be most appropriate?

"Describe what happens to him when he takes ibuprofen."

thoughts and perceptions

-Thought process -Thought content -Perceptions -Insight and judgement

infant neuro assessment

-fontanel -size and shape of head -motor function- posture, tone, and muscle strength -motility including symmetry of movements

Birth history includes

-the mothers health during pregnancy -the labor and birth -the infants condition immediately after birth -concurrent crises during pregnancy -prenatal attitudes towards pregnancy

infant includes what age?

1 month to 1 year

assessing infant's eyes

1 month- most infants can fixate on an object 2 months-most infants can follow an object 3 months-most infants can reach towards a visual stimulus

toddler

1-3 years

Delirium vs Dementia

1. Delirium- Acute, dramatic onset, common causes= illness, toxin, withdrawal, usually reversible. Poor attention and fluctating arousal level. Causes: UTI, meds, prolonged stays in hospital 2. Dementia: Chronic, insidious onset, usually not reversible, attention usually unaffected and normal arousal level. Causes:brain injury, MS, infection, various diseases

infant respiratory rate

30-60 breaths/min

Infant should be able to lift head and front part of their chest with weight of arms by how many months?

4 months

Infant's head lag should be absolutely gone by how old?

6 months

What is the average number of wet diapers/day for an infant?

6-10 diapers/day

school age children

6-12 years

infant abnormal respiratory findings

>60, nasal flaring, retracting, grunting, audible wheezing, no breath sounds, cyanosis, stridor

A nursing instructor is discussing mental health assessments with students. In what situations would the instructor tell the students an acute mental health assessment is necessary?

A situation that involves danger of harm to self or others

jaundice

A yellowing of the skin and eyes

The triage nurse is assessing a 7 year old child brought to the emergency department complaining of abdominal pain. Which findings would prompt the nurse to have the child evaluated as soon as possible? (Select all that apply.) a. Acute intense pain with vomiting b. Child isolates pain in right lower quadrant c. Diffuse mild pain with no fever d. Child unable to stand due to pain e. Normal gait without facial grimacing

A, B, D

anterior fontanelle closes by...posterior by..

AF: 12-18 months PF : 6-8 weeks

The nurse asks a client to explain the saying, "People in glass houses shouldn't throw stones." Which of the following is the nurse assessing?

Abstract reasoning

A nurse assigns an Apgar score to a newborn baby at 5 minutes after delivery. Which parameter should the nurse recognize as an abnormal finding?

Apical pulse is less than 100 beats per minute

insight & judgement

Are decisions and actions based on reality?

Which approach is recommended for conducting a pediatric physical assessment to optimize cooperation and minimize discomfort? select all that apply A) Ask young children for permission before proceeding with each step B) Prioritize listening to the throat, ears, and genitalia first C) Giving choices such as "Should I listen to your tummy first or listen to your heart first?" D) Begin with the least invasive assessment, such as listening to the heart or abdomen, and save assessments of the throat, ears, and genitalia for last E) Apologize for taking the blood pressure before doing it.

C) Giving choices such as "Should I listen to your tummy first or listen to your heart first?" D) Begin with the least invasive assessment, such as listening to the heart or abdomen, and save assessments of the throat, ears, and genitalia for last

What is a useful tool when assessing a client for alcohol abuse?

CAGE

SLUMS exam; What is it and scoring

CHECKS SHORT TERM MEMORY LOSS (DEMENTIA) 11 items measures cognition, including orientation, short term memory, calculations, naming of animals, clock drawing, geometric figures 27-30=normal in person w/ h.s. diploma 21-26=mild neurocognitive disorder 0-20=dementia

CIWA

Clinical Institute Withdrawal Assessment score>8 benzo for alcohol withdrawal

When depression goes undiagnosed, what consequences occur eight times more frequently than in the general population?

Death

An emergency department nurse has utilized the Confusion Assessment Method (CAM) in the assessment of a 79-year-old client with a new onset of urinary incontinence. This assessment tool will allow the nurse to confirm the presence of what health problem?

Delirium

delusions vs hallucinations

Delusions are mostly false beliefs rooted in the mind that seem real, but are not. Hallucinations are sensory-driven incidents that involve hearing or seeing something that isn't reality based.

An adult client who had a baby 2 weeks ago is brought to the ED because her boyfriend has noticed she has not been herself since they brought the baby home. The client's appearance is unkempt, her hair is a mess, and she appears not to have bathed for several days. What could these findings reflect?

Depression

Plagiocephaly

Flattening or asymmetry of the head *common with developmental delays

Biological risk factors of mental illness

Genetics, brain chemistry & chronic illness

A nurse is having difficulty getting a 14-year-old child to "open up" during the health interview. What strategy is most likely to enhance the nurse's communication with this child?

Give the child some control over the course and content of the interview.

Asking the patient if they know what "the squeaky wheel gets the cheese" means is testing what functions?

Higher cognitive function

Why do you listen for a full minute in infants?

Infants may have irregular breathing patterns compared to adults

appearance and behavior

Level of consciousness Posture & motor behavior Dress, grooming, and personal hygiene Facial expression Manner, Affect and relationship to people & things

A nursing student has been assigned to care for a client whose history suggests the need for a mental status assessment. This client most likely has a history of health problems affecting what body system?

Neurologic

Are pediatric patients just "little adults"?

No, they are physically and developmentally different.

cognitive function

Orientation=person, place, time, situation attention=serial 7s (count backwards), spell word backwards memory=give 3 words and ask them later in convo,new learning abilities

CAGE questionnaire

Substance/drug abuse Cut down, Annoyance when criticized, Guilty Feeling Eye opening *add "or drugs: to each question to ID issues w/ drug use

speech and language

Quantity, rate, volume, articulation, fluency

When assessing a client, the nurse notes that he is delusional. The nurse would know that delusional thinking can lead to what?

Suicide

Confusion Assessment Method (CAM)

Requires features 1 and 2 and either 3 or 4: 1. Acute change in mental status and fluctuating course - Hours to Days 2. Inattention 3. Disorganized thinking or 4. Altered level of consciousness

environmental risk factors

Stress, living arrangement, work

The nurse begins the physical examination of a newly admitted client by assessing the client's mental status. What is the nurse's best rationale for performing the mental status exam early in the assessment?

The exam can provide clues about the validity of the client's responses now and throughout.

Which are normal changes associated with aging? select all that apply a. thinning of skin b. reduced healing ability c. pain d. dementia

Thinning of skin Reduced healing ability **NOT PAIN & DEMENTIA

What is an appropriate action by a nurse when asking a child about the presence of pain?

Use a pain scale appropriate for the child's developmental level

As part of a mental status assessment, the nurse asks a client to draw the face of a clock. The nurse is assessing which of the following?

Visual perceptual and constructional ability

Do vital signs change with age?

Yes! HR decreases with age, RR decreases, BP increases, temp remains same

electroconvulsive therapy (ECT)

a biomedical therapy for severely depressed patients in which a brief electric current is sent through the brain of an anesthetized patient *adverse effects=short term memory loss SLUMS tests check this

Biopsychosocial Model

a model of health that integrates the effects of biological, behavioral, and social factors on health and illness *created at U of R

Pseudoparkinsonism

a reaction to medications that imitates the symptoms and appearance of Parkinson's disease

passive suicidal ideation

a wish to be dead but does not include active planning about how to commit suicide

macrocephaly

abnormally large head

microcephaly

abnormally small head

During a health history, the nurse notes that an older client answers common questions with hesitancy and gaps in the flow and rhythm of words. What should the nurse now focus the assessment on to obtain more information about this finding?

aphasia

During assessment of a 2 year old child, which assessment by the nurse would best indicate possible hydrocephalus? a. Measurement of fontanelle bulging b. Measuring Head circumference c. Observation of developmental delays d. Evaluation of abnormal eye movements or strabismus (crossed eyes)

b. Measuring Head circumference

It is often difficult to assess the location of pain in a child because generally children cannot a. Provide verbal descriptions of their pain location. b.isolate their pain c. Identify the exact area of discomfort. d. Pinpoint where they feel the pain.

b.isolate their pain

school age children- developmental focus

begins to understand relationships of events, parts; enjoys accomplishments, people pleasing

mental health risk factors

biological, environmental factors, & life experiences

Acrocyanosis

blueness of the extremities

Which type of benign birth mark does not slowly fade with time?

cate-au-lait

CAM: Alerted Level of Consciousness

checks if someone is awake and aware of their surroundings. It involves observing their ability to respond appropriately to questions and commands. If they're not fully alert or responsive, it could indicate a problem, like delirium. This step helps assess someone's overall mental state.

CAM: Disorganized thinking

checks if someone's thoughts make sense and if they can communicate clearly. The assessor may ask questions or engage in conversation to see if the person can think and speak coherently. Confusion or difficulty organizing thoughts may suggest delirium or another cognitive issue. This step helps evaluate someone's mental clarity and coherence.

preschool child

child from 3 to 5 years of age

Higher cognitive functions

level of intelligence assessed by vocabulary, knowledge base, calculations, and abstract thinking

aphasia

loss of ability to understand or express speech

past history includes

medical, surgical, social, family, cultural, immunizations

infant primitive reflexes

moro (Startle)- 2 months rooting (suck) 4 months grasp -5-6 months Babinski-12 months

Pallor and Mottling

mottled blue skin

obsession vs compulsion and examples of each

obsession=intruding thought- ridding of germs compulsion=action to release the obsession (washing hands

Where is an infant best assessed during visit?

on parent's lap

Types of therapies for psychological disorders

psychodynamic, humanistic, cognitive, behavioural, biological *CBT & DBT

hypotonia

reduced muscle tone or tension

family history

risk factors, genetics, foster care vs traditional

When interviewing an adolescent, which health issue would be least appropriate to discuss with the client while a parent is present?

sexuality

thought blocking

stopping abruptly in the middle of a sentence or train of thought; sometimes client is unable to continue the idea- helps ID if client is having hallucinations

sutures & fontanelles: abnormal findings

sunken or bulging fontanelles overriding or separated sutures

cognitive function

the mental capacity to acquire knowledge

life experiences risk factors

trauma, abuse/neglect, loss/grief, substance abuse

Mental Health Assessment-indications

unexplained physical symptoms, multiple physical or somatic symptoms, chronic pain (6+months, recent stress, reported difficult encounter, low self-rating of overall health, high use of healthcare services, substance use