Chapter 16 Neuro/Mental Status Alterations

The school nurse recognizes that the most common type of visual disorder in children is:

Nearsightedness (refractive error)

Receptive aphasia

Patients can not understand anything. Use a picture board with simple images.

An appropriate nursing diagnosis for a child with a cognitive dysfunction who has limited ability to anticipate danger:

Risk for injury

What are the components of a sensory function assessment?

Sensation of pain, tempature, position, vibration, and touch.

What are the two types of motor skills? How do we assess for each?

Fine motor (smaller movements, touch finger to nose) Gross motor( larger movements, balance on one foot)

if there are signs that may indicate that the child is not able to hear well. The nurse explains that the parents should be alert to the child:

Having delayed speech development.

The nurse is caring for a patient who is hospitalized with cognitive impairment. The following interventions will assist the patient in orientation:

Keep a photo of the family in the room. Use a clock on the wall. Avoid moving the patient from room to room. Have the nurse introduce himself or herself to the patient.

The nurse is caring for a patient who suffered a stroke on the right side of the brain. The nurse is careful to implement what safety measures?

Leave on a light in the bathroom at night for good visibility. Place the call light on the patients right side. Make sure there are no trip hazards in the patients room.

A Glasgow Coma Scale(GCS) is used for what purpose?

Levels of consciousness, looking at responses. Are they alert? do they keep their eyes open? Eyes, Verbal, Motor

The nurse is caring for a patient with expressive aphasia. Which interventions will assist the nurse in communicating with the patient?

Use Simple phrases. Use yes/no questions. Use a picture board. Be patient and unrushed.

The nurse is caring for a patient with receptive aphasia. Which interventions will assist the nurse in communication with the patient?

Use simple phrases. Stand in front of the patient. Use a picture board. Be patient and unrushed.

The nurse is assessing a patient for a potential gustatory impairment. This may be indicated if the patient has a(n):

Weight loss

A patient in a rehabilitation facility has experienced a cerebral vascular accident (CVA/stroke) that has left the patient with an expressive aphasia. The nurse anticipates that this patient will:

Be unable to speak or write

What type of patients require a full neurological assessment?

Any patient who had an accident to the head, or trauma, stroke.

Expressive aphasia

Can understand what you are saying, but can not (EXPRESS) speak or write to you. Ask yes or no questions.

A mini-mental state examination(MMSE) is used for what purpose?

Cognitive ability, can they follow directions, can they remember things. Used often for older adults.

What are the two types of Aphasia's?

Expressive and Receptive

Behavior and appearance

wearing and appropriate attire (weather) is the patient wandering or acting aggressive