Chapter 8: Assessing General Status and Vital Signs

Which assessment notation describes a client's level of consciousness?

"Client was alert and cooperative during the assessment." Alertness or state of awareness of the environment is associated with level of consciousness

When assessing the client's ability to make sound judgments, what question should the nurse ask?

"How do you plan to pay rent if you lose your job?" The nurse can usually assess judgment by noting the client's responses to family situations, jobs, use of money, and interpersonal conflicts. what would you do if..? What do you do when?

Which of the following questions would be most helpful in beginning an initial assessment interview for a patient who has just been admitted to a psychiatric inpatient unit?

"What brings you into the hospital today?" Open-ended questions are most helpful when beginning the interview because they allow the nurse to observe how the patient responds verbally and nonverbally. They also convey caring and interest in the person's well-being, which helps to establish rapport.

As part of the mental status examination, a nurse assesses the cognitive abilities of a client. Which question should the nurse ask to assess the judgment ability in the client?

"What do you do if you have pain?"

During the first assessment of the client, the nurse assesses the blood pressure in both arms. Which of the following findings is an acceptable variation?

118/78 mm Hg in the right arm and 122/80 mm Hg in the left arm Usually, there is a difference in pressure of 5 mm Hg and sometimes up to 10 mm Hg between arms. Pressure difference of more than 10 to 15 mm Hg between arms suggests arterial compression or obstruction on the side with the lower pressure.

A nurse has just assessed a client using the St. Louis University Mental Status (SLUMS) exam. From his health record, the nurse sees that the client graduated from high school. Which of the following scores would indicate mild cognitive impairment in this client?

25 For clients with a high school education a score of 20-27 on the SLUMS exam indicates mild cognitive impairment (MCI) and for clients with less than high school education a score of 14-19 indicates MCI. For clients with a high school education a score of 1-19 indicates dementia and for clients with less than high school education a score of 1-14 indicates dementia.

The client has been admitted for depression. What should the nurse include in the admission mental status assessment? Select all that apply.

A recent loss New physiological impairment History of a stroke The mental status assessment should include questions related to loss; and change in physiological status, including history of a stroke. Headache and fluid intake would not be part of the mental status assessment but may play a role in the client's mental status.

The nurse is completing a mental health assessment. When the nurse asks the patient to interpret a proverb, the nurse is assessing which of the following?

Abstract reasoning To test abstract reasoning and comprehension, the nurse might give the patient a proverb to interpret. To test attention and concentration, the nurse asks the patient, without a pencil or paper, to start with 100 and subtract 7 until reaching 65 or start with 20 and subtract 3. There are four spheres of memory to check: recall, or immediate, memory; short-term memory; recent memory; and long-term, or remote, memory. Insight and judgment are related concepts that involve the ability to examine thoughts, conceptualize facts, solve problems, think abstractly, and possess self-awareness. Insight is the person's awareness of his or her own thoughts and feelings and ability to compare them with the thoughts and feelings of others.

When the nurse asks the client to explain similarities and differences between objects, what cognitive ability is being tested?

Abstract reasoning. Abstract reasoning is the ability to compare objects. For example, "How are an apple and orange the same? How are they different?" Also, asking to explain a proverb. For example, "A rolling stone gathers no moss" or "A stitch in time saves nine."

When the nurse asks the client to explain similarities and differences between objects, what cognitive ability is being tested?

Abstract reasoning. Abstract reasoning is the ability to compare objects. For example, "How are an apple and orange the same? How are they different?" Also, asking to explain a proverb. For example, "A rolling stone gathers no moss" or "A stitch in time saves nine."

Which abnormal skin color should a nurse anticipate assessing on a dark-skinned client?

Ashen gray The skin of a dark-skinned client with cyanosis would be ashen gray. The skin tone would appear yellowish in a light-skinned client if the client had jaundice. A beige-pink skin tone would be a normal finding for the light-skinned client. A reddish skin tone could be related to fever, sunburn, or infection.

A nurse obtains a pulse rate on an adult client of 56 beats per minute. What is the correct term that the nurse should use to document this finding?

Bradycardia A heart rate or pulse of 60 beats per minute is termed bradycardia. Normal heart rate for the adult is between 60 and 100 beats per minute. Tachycardia describes a heart rate over 100 beats per minute. Hypocardia refers to a heart that is not beating with enough force.

A 72-year-old man comes to the clinic with his daughter for a follow-up visit after a recent hospitalization. He had been admitted to the local hospital for speech problems and weakness in his right arm and leg. On admission his MRI showed a small stroke. The client was in rehabilitation for 1 month following his initial presentation. He is now walking with a walker and has good use of his arm. His daughter complains, however, that everyone is still having trouble communicating with him. The nurse asks the client how he thinks he is doing. Although it is hard to make out his words, the nurse believes the client's answer is "well . . . fine . . . doing . . . okay." His prior medical history involved high blood pressure and coronary artery disease. He is a widower and retired handyman. He has three children who are healthy. He denies tobacco, alcohol, or drug use. He has no other current symptoms. On examination he is in no acute distress but does seem embarrassed when it takes him so long to answer. Blood pressure is 150/90; other vital signs are normal. Other than his weak right arm and leg, physical examination findings are unremarkable. What disorder of speech does he have?

Broca's aphasia In Broca's aphasia, clients articulate very slowly and with great effort. Nouns, verbs, and important adjectives are usually present, and only small grammatical words are dropped from speech. Broca's area is on the lateral portion of the frontal lobes.

The nurse asks the client to draw the face of a clock with numbers and hands and to make it read 3 o'clock. What is tested by the completion of this task?

Constructional ability

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

Death Failure to diagnose depression can have fatal consequences—suicide rates among patients with major depression are eight times higher than in the general population.

A older adult client is brought to the clinic by the client's daughter who voices concerns about changes in her parent's mental status. What behavior would the nurse look for to formulate a plan of care for dementia in this client?

Defers to family members to answer questions directed to the client Some cues that a client may have dementia include seeming disoriented, being a "poor historian," deferring to a family member to answer questions directed to the client, repeatedly and apparently unintentionally failing to follow instructions, having difficulty finding the right words or using inappropriate or incomprehensible words, and having difficulty following conversations.

Which clients are most at risk for depressive symptoms?

Divorced patients Females Chronically ill patients Watch carefully for depressive symptoms, especially in patients who are young, female, single, divorced or separated, seriously or chronically ill, or bereaved. Those with a prior history or family history of depression are also at risk.

The nurse is admitting a patient to the mental health unit with a diagnosis of attempted suicide. Which is the best question for the nurse to ask first?

Do you have any thoughts of wanting to harm or kill yourself?

A nurse has been asked to complete a mental status examination of a psychiatric-mental health client. Which of the following is included in this assessment?

Evaluation of insight and judgment

A 29-year-old woman comes to the office. During history taking, the nurse notices that the client is speaking very quickly and jumping from topic to topic so rapidly that it is difficult to follow her. The nurse can find some connections between ideas, but it is difficult. Which word best describes this thought process?

Flight of ideas This represents flight of ideas, because the ideas are connected in some logical way. Derailment, or loosening of associations, has more disconnection within clauses.

A nurse notes that the pulse rate of a client is less than 60 beats per minute. Which question is appropriate for the nurse to ask the client in regards to this finding?

Have you been sitting for a long time?"

The client has a Glasgow Coma Score of 7. The nurse understands this client is considered to be what?

In coma A Glasgow Coma Score of 3 indicates a deep coma. A score of 7 indicates the client is in a coma. Higher scores indicate minimal or no impairment.

The client states her husband died a few months ago and she has not been the same since. Which nursing diagnosis is most appropriate?

Ineffective coping Ineffective coping would be most appropriate. Not Anticipatory grieving because this occurs prior to change.

What aspect of cognitive function is the nurse assessing when asking, "What will you do if you feel the need to use cocaine again?"

Judgment Questions, such as "What will you do if you feel the need to use cocaine again?" assess the individual's judgment and ability to solve problems

During the health-history interview, which of the following components of cognitive function can the nurse quickly assess?

Memory and attention While gathering the health history, it is possible to quickly discern the client's level of alertness and orientation, mood, attention, and memory. As the history unfolds, the nurse will learn about the client's insight and judgment and any recurring or unusual thoughts or perceptions. Calculation, behaviour, and abstract thinking are less likely to emerge during this phase of assessment.

The nurse assesses the client to have a Glasgow Coma score of 15. The nurse anticipates what degree of impairment?

None A Glasgow Coma Score of 15 would indicate no impairments. All other scores indicate some degree of impairment up to and including deep coma.

Assessment of the pulse amplitude is accomplished by which of the following?

Palpating the flow of blood through an artery The pulse amplitude describes the quality of the pulse in terms of its fullness and reflects the strength of left ventricular contraction. It is assessed by the feel of the blood flowing through an artery.

The client is brought to the clinic by his son, who states, "My father just doesn't seem to be able to function as well as he used to." When assessing this client the nurse is aware that she will be a what?

Patient advocate The nurse may assess the change in the patient and will be the advocate and detective, determining when the change occurred and what was new in the treatment.

The nurse begins the health history with a focus on the client's mental status. Why does the nurse ask for the client's age?

Provides a reference point for psychosocial developmental level

A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow?

Reading is erroneously high. The bladder of the cuff should enclose at least two-thirds of the adult limb. If the cuff is too narrow, the reading could be erroneously high because the pressure is not being transmitted evenly to the artery.

The nursing instructor talks with the student nurse on the adult psychiatric unit. The student tells the instructor that cradle cap appears to be around a specific client's face. The instructor explains that this may be an indication of long-term lack of care as a consequence of what disorder?

Schizophrenia Cradle cap around the face of adults indicates long-term lack of care and is often seen in clients with schizophrenia.

Susanne is a 27-year-old woman who has had headaches, muscle aches, and fatigue for the last 2 months. The nurse has completed a thorough history, examination, and laboratory workups, the results of which are normal. What would the next action be?

Screening for depression Although the nurse may consider referrals to help with diagnosis and treatment of this client, screening is a time-efficient way to recognize depression. This will allow her to be treated more expediently. The nurse may tell the client that no answer is clear yet, but also that he or she will not stop investigating until the client has gotten the help she needs. Research has shown that health care providers routinely fail to screen for depression.

The patient states, "I don't know why God as abandoned me; I am a good person." The nurse suspects the patient is at risk for:

Suicide Other terms to know: The patient who does not experience a sense of hope for the future may be at risk for suicide. Confabulation refers to making up answer to cover for not knowing. Psychosis occurs when the patient has difficulty distinguishing reality from internal perceptions. Delusions are false beliefs the person holds despite lack of supportive evidence.

A nurse is assessing the blood pressure of a client using the Korotkoff's sounds technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record?

There is an auscultatory gap An auscultatory gap is a period during which sound disappears. An auscultatory gap can range as much as 40 mm Hg. A widening in the diameter of the artery takes place in the phase II of the Korotkoff's sounds technique. An adult diastolic pressure takes place in the phase IV of the Korotkoff's sounds technique.

A patient experiencing a manic episode may begin to sing or dance.

True

The nurse completes the mental health assessment before continuing with a head-to-toe assessment. Why did the nurse use this approach?

Validates the information the client provides during the rest of the assessment

the nurse is assessing a client's respiratory rate. Which of the following should the nurse do to ensure accuracy of this assessment?

Watch chest movement before removing the stethoscope after counting the apical beat

During an assessment the nurse becomes concerned that a client is at risk for suicide. What information in the client's health history caused the nurse to have this concern? Select all that apply.

Widower Male gender Caucasian race Has hemodialysis treatments 3 times a week Risk factors for suicide include being single or a widow/widower, male gender, and Caucasian race. Clients undergoing hemodialysis often have depression and suicide ideation.

The CAGE assessment is used by the nurse to determine if further assessment is needed. The nurse may assess that it is highly likely the client has a problem and would seek additional assessments if the client

answered "yes" to three of the four CAGE questions. The CAGE assessment is a quick questionnaire used to determine if an alcohol assessment is needed. If two or more of these questions is answered yes, then further assessment is advised.

While conducting an assessment the nurse suspects that a client is making up things in response to specific questions. What behavior is this client demonstrating?

confabulation Confabulation is the fabrication of facts or events in response to questions in order to fill in the gaps from impaired memory. Derailment is tangential speech with shifting topics that are loosely connected or unrelated. Perseveration is persistent repetition of words or ideas. Flight of ideas is an almost continuous flow of accelerated speech with abrupt changes from one topic to the next.

An elderly client is seen by the nurse in the neighborhood clinic. The nurse observes that the client is dressed in several layers of clothing, although the temperature is warm outside. The nurse suspects that the client's cold intolerance is a result of

decreased body metabolism. Research has shown that for older adults, normal body temperature values for all routes are consistently lower than values reported in younger populations.

A client known to a health clinic arrives wearing soiled clothing with matted hair and streaks of dirt on the face and hands. What should this client's appearance suggest to the nurse?

depression Grooming and personal hygiene may deteriorate in depression.

The nurse is preparing to assess an adult client in the clinic. The nurse observes that the client is wearing lightweight clothing that is worn and soiled, although the temperature is below freezing outside. The nurse anticipates that the client may be

lacking adequate finances. When you meet the client for the first time, observe any significant abnormalities in the client's skin color, dress, hygiene, posture and gait, physical development, body build, apparent age, and gender. If you observe abnormalities, you may need to perform an in-depth assessment of the body area that appears to be affected.

An auditory hallucination is considered an alteration in which component of the mental health assessment? auditory (sense of hearing)

perceptions Perception is the sensory awareness of objects in the environment and their interrelationships (external stimuli). Perception also refers to internal stimuli such as dreams or hallucinations. Thought processes involve the logic, coherence, and relevance of a client's thought as it leads to selected goals or how people think.