Exam 2 Study Set - Health Assessment

Which question best assesses recall memory? "What is your occupation?" "What was the name of your high school?" "Who is the president of the United States?" "About what time were you brought to the hospital?"

"About what time were you brought to the hospital?" Asking about the time of admission assesses recall/recent memory and can be verified with the medical record.

When obtaining the history of present illness, which questions should the nurse ask a mother who reports her child had a seizure? "Have you ever had a seizure?" "Did your child have a high fever?" "Did your child lose consciousness?" "What did your child do or say after the seizure?" "Has your child had any head trauma in the past?"

"Did your child have a high fever?" "Did your child lose consciousness?" "What did your child do or say after the seizure?"

The nurse is preparing a questionnaire to assess stress incontinence in a patient. Which is the most important question that should be asked by the nurse? "Are you urinating more often than usual?" "Do you have any difficulty controlling your urine?" "Do you have any trouble starting the urine stream?" "Do you accidentally urinate when you sneeze, laugh, cough, or bear down?"

"Do you accidentally urinate when you sneeze, laugh, cough, or bear down?"

Which question related to personal/social history should the nurse ask a patient who reports feelings of loneliness and difficulty sleeping? "Do you have anyone living with you?" "Do you have a history of depression?" "Are you having nausea and vomiting?" "What medications are you currently taking?"

"Do you have anyone living with you?" Asking about the patient's living situation and support systems is an important part of the personal/social history related to the symptoms of loneliness and difficulty sleeping.

A patient reports weakness and changes in gait. Which question should the nurse ask the patient regarding family history related to these symptoms? "Have you ever had a seizure?" "What kind of pain are you having?" "Does your mother or father have Parkinson Disease?" "Do you have family members with allergies?"

"Does your mother or father have Parkinson Disease?" It is important to ask about specific diseases when a patient presents with any change in neurologic function.

A pregnant patient comes for a prenatal visit. The nurse assesses the patient and suspects domestic violence. Which statements by the nurse help to obtain complete information from the patient? "Just tell me what happened to you; hiding information will not help you." "If you avoid talking about your condition, I will have to talk to your family." "Domestic violence is very common in our society; I want to ask you about this." "How long has your husband been abusing you, and why have you not complained to the police?" "Domestic violence may have serious health care consequences; do you want to talk about it?"

"Domestic violence is very common in our society; I want to ask you about this."

A pregnant patient comes for a prenatal visit. The nurse assesses the patient and suspects domestic violence. Which statements by the nurse help to obtain complete information from the patient? "Just tell me what happened to you; hiding information will not help you." "If you avoid talking about your condition, I will have to talk to your family." "Domestic violence is very common in our society; I want to ask you about this." "How long has your husband been abusing you, and why have you not complained to the police?" "Domestic violence may have serious health care consequences; do you want to talk about it?"

"Domestic violence is very common in our society; I want to ask you about this." "Domestic violence may have serious health care consequences; do you want to talk about it?"

An elderly patient sustains a hip fracture from a fall. Which question should the nurse ask about the patient's medical/surgical history. "Do you regularly exercise?" "Have you broken any other bones in the past?" "Has anyone in your family had any fractures?" "Have you had any personality changes over the past 6 months?"

"Have you broken any other bones in the past?" Asking about previous fractures will provide pertinent information related to the medical history.

About which types of trauma should the nurse ask the patient as part of the medical/surgical history related to the neurologic system? "Are you currently dizzy" "When did you fracture your femur?" "Have you experienced a concussion recently? "Which pain medications are you currently taking?"

"Have you experienced a concussion recently?" The nurse should ask the patient about any head injury, especially one resulting in a concussion, as part of the medical/surgical history related to the neurologic system.

When obtaining the personal/social history, which question would the nurse ask a patient who reports changes in sense of smell? "What hobbies do you enjoy?" :"Do you have any food allergies?" "Have you had a change in sleep pattern?" "How many packs of cigarettes do you smoke per week?"

"How many packs of cigarettes do you smoke per week?" Asking about smoking can provide additional information about the factors contributing to the change in sense of smell and is part of the personal/social history.

While assessing a patient, the nurse finds that the patient is an "at-risk" drinker. Which statement by the patient led the nurse to conclude this? "I drink 5 alcoholic drinks per week." "I drink 6 alcoholic drinks per week." "I drink 1 alcoholic drink per occasion." "I drink 4 alcoholic drinks per occasion."

"I drink 4 alcoholic drinks per occasion."

Which instruction would the nurse give to a patient while performing the Romberg test? "Walk heel to toe across the room." "Pronate and supinate the hands rapidly." "Run the heel of the foot down the opposite shin." "Stand with feet together and eyes open then closed."

"Stand with feet together and eyes open then closed."

A patient reports a history of alcoholism. Which question related to personal/social history should the nurse ask during a neurologic examination? "Do you have any pain?" "What kind of alcohol do you drink" "When was your last drink of alcohol?" "What medications do you take regularly?"

"When was your last drink of alcohol?" It is important to ask about the last time the patient drank alcohol in order to assess the patient's current cognitive state.

After performing the Four Unrelated Words Test for a patient, the nurse concludes that the patient has Alzheimer dementia. What must be the word recall score of this patient? 0 1 2 3 4

0 or 1. If a person has Alzheimer dementia, the patient can hardly remember one word and would score 0 or 1. If the person can repeat 2, 3, or 4 words on average, it indicates that the person does not have any memory loss.

When should an infant be tested for language development skills using a one-word sentence? 1 year 2 years 4 weeks 6 weeks

1 yea. language development skills in 1-year-old infants can be easily assessed using one-word sentences. At the age of 2 years, language development can be assessed using multiword sentences. At the age of 4 weeks, language development can be assessed by observing the differentiated crying of an infant. At the age of 6 weeks, language development can be assessed by cooing to the infant.

What is the maximum score of the Short Michigan Alcoholism Screening Test- Geriatric Version (SMAST-G)? 10 12 40 67

10. The Short Michigan Alcoholism Screening Test- Geriatric Version (SMAST-G) includes 10 questions with a maximum score of 10.

The nurse is performing the Mini-Mental State Examination (MMSE) in a patient and confirms that the patient has mild cognitive impairment. What must be the score given to this patient? 7 22 25 27

22. A person with mild cognitive impairment can score between 18 and 23 on this questionnaire. Therefore, a score of 22 in the MMSE questionnaire indicates that the patient has mild cognitive impairment. A score of 7 in the MMSE scale indicates that the patient has severe cognitive impairment. A person who scores 25 or 27 has no cognitive impairment.

The nurse is assessing a patient who is undergoing withdrawal therapy for alcohol abuse by using the Clinical Institute Withdrawal Assessment (CIWA). The nurse sees tremors in the patient and observes that the patient cannot extend the arms. What would be the CIWA score of the patient during this assessment? 0 1 4 7

7. Alcohol withdrawal causes tactile disturbances, tremors, and autonomic hyperactivity. If the patient has severe tremors and cannot extend the arms, the nurse should give a score of 7. A score of 0 indicates no tremors in the patient. The nurse should give a score of 1 if the patient has invisible tremors. A score of 4 indicates moderate tremors and the ability to extend the arms.

The nurse is assessing a patient using the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar). The patient indicates constantly hearing voices. What score does the nurse give to the patient for auditory hallucinations? 1 4 5 7

7. The CIWA-Ar is used to assess alcohol withdrawal symptoms in patients. Based on the severity of a patient's hallucinations, the score range is 4 to 7. If the patient is continuously hearing voices, then the patient receives a score of 7. The score is given as 1 if the patient hears mild harsh voices which are frightening. A score of 4 indicates that the patient has moderately severe hallucinations. A score of 5 indicates the patient is having severe hallucinations.

What are the common causes of liver cirrhosis? Tuberculosis Alcohol abuse Viral hepatitis Illicit drug use Alcohol withdrawal

Alcohol abuse Viral hepatitis

The nurse is assessing a patient using the Alcohol Use Disorders Identification Test (AUDIT) questionnaire. What does the nurse assess by asking questions 1 to 3 of the AUDIT questionnaire? Dependence Drinking behavior Alcohol consumption Adverse effects from alcohol

Alcohol consumption

4 components of a Mental Health Assessment - App Beh Cog Tho

Appearance, behavior, cognitive, thought processes

The nurse observes a student nurse who is assessing pain perception in a patient. Which action of the student nurse needs correction? Using a sharp edge of a tongue blade to test pain Discarding the tongue blade after the assessment Maintaining a 2-second gap between each pain stimulus Applying the tongue blade on the patient's body in a systematic order

Applying the tongue blade on the patient's body in a systematic order

The nurse would ask the patient to subtract 8 from 50, then subtract 8 from that number, and so on until the answer is 2, as part of which cognitive assessment? Writing ability Arithmetic calculation Attention span Judgement

Arithmetic calculation

The mini-mental state examination is used to assess cognitive function changes over time and evaluates which cognitive functions? Attention Articulation Recall Language Judgement

Attention Recall Language

A patient experiencing alcohol withdrawal has normal levels of serum protein gamma glutamyl transferase (GGT). During the follow-up visit a month later, however, the GGT levels are increased. What could be the reason for this? Chronic heavy drinking Relapse of alcohol dependency Nonalcoholic liver disease Alcohol abstinence for 15 days Alcohol abstinence for 4-5 weeks

Chronic heavy drinking Nonalcoholic liver disease Elevated levels of GGT after a period of normal levels indicate that alcoholism has relapsed in the patient. They also indicate that the patient may have nonalcoholic liver disease, which is unrelated to alcohol consumption.

Which of the following basic functions should the nurse test first in an assessment of mental status? Behavior Consciousness Judgment Language

Consciousness

When assessing the trigeminal nerve (CN V), which aspects should the nurse evaluate? Corneal reflex Facial atrophy Facial sensation Strength of the jaw Location of the nose

Corneal reflex The nurse should evaluate the corneal reflex when assessing the trigeminal nerve (CN V) because the trigeminal nerve innervates the muscles of the face. Facial atrophy The nurse should evaluate the presence of facial atrophy to assess the trigeminal nerve (CN V) because the trigeminal nerve innervates the muscles of the face. Facial sensation The nurse should evaluate facial sensation to assess the trigeminal nerve (CN V) because the trigeminal nerve innervates the muscles of the face. Strength of the jaw The nurse should evaluate the strength of the jaw to assess the trigeminal nerve (CN V) because the trigeminal nerve innervates the muscles of the face.

While assessing a patient with lower motor neuron lesion, the nurse sees that the patient has an asymmetric smile and is unable to wrinkle the forehead. Damage to which cranial nerve could cause these findings? Cranial nerve II (optic nerve) Cranial nerve III (oculomotor nerve) Cranial nerve VII (facial nerve) Cranial nerve VIII (auditory nerve)

Cranial verve VII (facial nerve)

While performing an assessment, the nurse notes the absence of corneal, abdominal, and cremasteric reflexes on the right side of the patient's body. The patient shows spastic paralysis on the left side of the body. What is the probable reason for this condition? Defect in cranial nerve IX Demyelination of neurons Lower motor neuron damage Damage to the corticospinal tract

Damage to the corticospinal tract

While assessing a battered woman, the nurse gives the calendar to the woman and asks her to mark the approximate dates of abuse during the past year. Which assessment technique is the nurse performing? Visual assessment Danger assessment Routine assessment Abuse assessment screen

Danger assessment

The nurse is caring for a patient who has resting tremors and abnormally slow movement. The nurse also observes flat expression, reduced eye blinking, and slouched posture in the patient. What reason does the nurse expect for these findings in the patient? Damage to the cerebral cortex Damage to the corticospinal tract Degeneration of the upper motor neurons Degeneration of the dopamine-containing neurons

Degeneration of the dopamine-containing neurons

While examining an adult patient, the nurse suspects that the patient is experiencing physical neglect. Which symptoms does the nurse expect to find in the patient? Humiliation Dehydration Malnutrition Social isolation Skin breakdown

Dehydration Malnutrition Skin breakdown

The patient tells the nurse, "I am the almighty and your creator. You all must do as I say; I am your ruler." Which thought content abnormality does the patient exhibit? Delusions Obsessions Compulsions Hypochondriasis

Delusions

Which mental disorder causes a gradual decrease in the patient's cognitive functioning? Delirium Dementia Depression Anxiety disorder

Dementia

The nurse is caring for a patient with generalized anxiety disorder. Which associated physiologic complications does the nurse expect in the patient? Diarrhea Tachypnea Nausea Sweating Sleep disturbance

Diarrhea Tachypnea Sleep disturbance

The nurse is assessing a patient undergoing alcohol withdrawal therapy. The nurse uses the Clinical Institute Withdrawal Assessment (CIWA) and finds that the patient's scores are 6, 5, and 6 on 3 consecutive days. Which nursing intervention would be appropriate for the patient? Assess the patient every hour Assess the patient every 4 hours Discontinue the assessment Stop the scheduled medication

Discontinue the assessment

As part of a comprehensive mental health history, the nurse should note patient behavior that conveys which characteristics? Docility Shyness Insensitivity Extroversion Hatefulness

Docility Insensitivity

Why are older adults at a higher risk of developing complications related to alcohol abuse when compared to their younger counterparts? Due to less muscle mass Due to impaired kidney function Due to potential drug interactions Due to reduced stomach capacity Due to increased hepatic activity

Due to less muscle mass Due to impaired kidney function Due to potential drug interactions

The nurse, while palpating the rectum, feels small nodules in the center. These nodules are firm and nontender. Which disorder does the nurse suspect? Rectal polyps Early carcinoma Ischiorectal abscess Internal hemorrhoids

Early carcinoma

While assessing an older adult patient, the nurse finds that the patient is distressed and mumbles. The nurse also observes that the patient is showing withdrawal from normal activities. What is the most likely reason for this patient's behaviors? Sexual abuse Physical abuse Financial abuse Emotional abuse

Emotional abuse

A drug-addicted patient gives birth to a baby in the hospital and the nurse measures the newborn's weight at 2400 g (5.3 lbs). What risk factors could affect this infant? Diabetes Failure to thrive Developmental delays Psychological disorders Sudden infant death syndrome (SIDS)

Failure to thrive Developmental delays

The nurse would evaluate primary and cortical sensory functions by having the patient identify sensory stimuli in which parts of the body? Feet Hands Lower legs Lower arms Shoulders

Feet Hands Lower legs Lower arms

The nurse should use which tests to assess the accuracy of the patient's movements? Hand-to-toes test Finger to nose test Finger to finger test Ear to shoulder test Heel to shin test

Finger-to-nose test The nurse should evaluate the ability of the patient to touch a finger to the nose to assess the accuracy of the patient's movements. Finger-to-finger test The nurse should evaluate the ability of the patient to touch a finger to another finger to assess the accuracy of the patient's movements. Heel-to-shin test The nurse should evaluate the ability of the patient to touch the heel to the shin to assess the accuracy of the patient's movements.

Which cortical sensory function would the nurse assess by drawing a number 8 on the patient's hand? Stereognosis Graphesthesia Superficial pain Extinction phenomenon

Graphesthesia Graphesthesia, or the ability to identify writing on the skin, is the cortical sensory function assessed by drawing a number 8 on the patient's hand.

Which sensory elements should the nurse assess when evaluating the acoustic nerve (CN VIII)? Taste Smell Hearing Balance Sensitivity to touch

Hearing The nurse would assess the patient's hearing when evaluating the acoustic nerve (CN VIII). Balance The nurse would assess the patient's balance when evaluating the acoustic nerve (CN VIII).

About which illnesses would the nurse ask a patient as part of the medical/surgical history related to the neurologic system? Asthma Heart disease Rhinitis (hay fever) Irritable bowel syndrome

Heart disease The nurse should ask the patient about chronic cardiovascular problems, including heart disease, as part of the medical/surgical history related to the neurologic system.

A physically abused woman is undergoing treatment for a wound caused by a sharp knife. How does the nurse document this finding? Incision Avulsion Abrasion Laceration

Incision

The nurse is caring for a patient with a history of cannabis abuse who is reported to have reddened eyes, dry mouth, and tachycardia. What behaviors does the nurse expect in the patient? Jittery feeling Slurred speech Impaired memory Increased perceptions Social withdrawal

Increased perceptions Social withdrawal

While conducting an assessment, the nurse finds that a patient has nausea, vomiting, and malaise. The nurse also observes tremors of the tongue and eyelids. Which additional findings would the nurse expect to discover in a patient experiencing sedative withdrawal? Insomnia Loss of appetite Grand mal seizures Desire to smoke Orthostatic hypotension

Insomnia Grand mal seizure Orthostatic hypotension

During an examination of a 6-year-old child, the nurse suspects that the child is being maltreated. On communication, the nurse finds that the family of the child has been socially isolated recently. Which immediate manifestation of maltreatment would the nurse observe in the child? Lacerations Substance abuse Suicidal tendency Mental retardation

Lacerations

Which elements of the face should the nurse assess when evaluating the facial cranial nerve (CN VII) for motor function? Lips Eyes Nose Cheeks Forehead

Lips The nurse would assess the lips by asking the patient to purse the lips and blow when evaluating the facial cranial nerve (CN VII) for motor function. Eyes The nurse would assess the ability of the patient to squeeze the eyes shut when evaluating the facial cranial nerve (CN VII) for motor function. Cheeks The nurse would assess the ability of the patient to puff out the cheeks when evaluating the facial cranial nerve (CN VII) for motor function. Forehead The nurse would assess the forehead by asking the patient to raise the eyebrows when evaluating the facial cranial nerve (CN VII) for motor function.

While assessing the laboratory reports of a patient, the nurse finds an increase in the level of gamma glutamyl transferase (GGT). Which conditions does the nurse identify as potential causes for increased levels of GGT? Liver disease Alcohol relapse Alcohol abstinence Chronic alcohol drinking Occasional alcohol drinking

Liver disease Alcohol relapse Chronic alcohol drinking Gamma glutamyl transferase (GGT) is an enzyme that transfers gamma-glutamyl functional groups and is an important biomarker of alcohol drinking.

During a prenatal visit, the nurse finds that the patient is physically abused by the spouse. Which complication will the nurse expect in the patient's newborn? Malnutrition Dehydration Low birth weight Mental retardation

Low birth weight

The nurse is caring for a patient whose score on the Mini-Mental State Examination (MMSE) was 26. How should the nurse interpret the patient's score on the MMSE? Presence of mild dementia Severe cognitive impairment No cognitive impairment Impaired thought process

No cognitive impairment. Scores between 24 and 30 indicate no cognitive impairment; Scores that occur with dementia are classified as follows: 18-23 = mild cognitive impairment; 0-7 = severe cognitive impairment.

Which signs and symptoms does the nurse expect to find in a patient with prostate cancer? SELECT ALL THAT APPLY Pain during urination Weak stream of urine Fever, chills and malaise Presence of blood in the urine Dull, achy pain in the anal region

Pain during urination Weak stream of urine Presence of blood in urine

Which superficial reflexes should the nurse evaluate? Bicep Plantar Achilles Abdominal Cremasteric

Plantar, abdominal, cremasteric

A patient reports having difficulty sleeping and concentrating. During the interview, the nurse finds out that the patient's father died suddenly in an accident that the patient witnessed a few days earlier. The nurse observes that the patient gets startled even at the sound of knock on the door. Which condition does the nurse suspect in this patient? Panic attack Specific phobia Generalized anxiety disorder Posttraumatic stress disorder (PTSD)

Posttraumatic stress disorder (PTSD)

As part of a comprehensive mental health history, the nurse should assess which components of the patient's body language? Posture Grooming Facial expressions Eye contact Hearing

Posture Facial Expressions eye contact

Which foods should the nurse include in the patient's diet to reduce the risk of colon cancer? Eggs Meat Prunes Cereals Wheat germ

Prunes Cereals Wheat germ

Which aspects of involuntary movements should the nurse assess as part of a coordination and fine motor skills evaluation? Rate Quality Rhythm Symmetry Affected body parts

Rate The nurse should assess the rate of the patient's involuntary movements as part of the evaluation of coordination and fine motor skills. Quality The nurse should assess the quality of the patient's involuntary movements as part of the evaluation of coordination and fine motor skills. Rhythm The nurse should assess the rhythm of the patient's involuntary movements as part of the evaluation of coordination and fine motor skills. Affected body parts The nurse should assess the body parts affected by the patient's involuntary movements as part of the evaluation of coordination and fine motor skills.

Match the specific patient assessment with the related cognitive ability. Relating the meaning of a specific metaphor Writing his or her name and address Unbuttoning his or her shirt Following a set of commands Analogies Attention span Execution of motor skills Writing ability

Relating the meaning of a specific metaphor Analogies Writing his or her name and address Writing ability Unbuttoning his or her shirt Execution of motor skills Following a set of commands Attention span

The nurse asks the patient to close the eyes and then traces the number 5 on the patient's palm. The patient is unable to identify the number even after repeated attempts. This finding could indicate damage to what part of the patient's brain? Cerebellum Sensory cortex Cranial nerve XII Dorsal spinothalamic tract

Sensory cortex

Which elements of the pupils should be evaluated as part of the assessment of the cranial nerves of the eyes? Size Equality Color Drooping Response to Light

Size The nurse should evaluate the size of the pupils as part of the assessment of the cranial nerves of the eyes. Equality The nurse should evaluate the equality of the pupils as part of the assessment of the cranial nerves of the eyes. Response to Light The nurse should evaluate the response of the pupils to light as part of the assessment of the cranial nerves of the eyes.

The nurse is caring for a pregnant woman who is admitted to the emergency department with suspected abuse. Which assessment finding would be the direct result of blunt force trauma? Slap marks Skin tears Pelvic pain Depression

Slap marks

The nurse is caring for an adolescent patient who is febrile. The nurse finds that the patient is anxious and has an irregular heartbeat and tremors. What does the nurse identify as the basis for these findings? Alcohol abuse Stimulant abuse Alcohol withdrawal Stimulant withdrawal

Stimulant abuse

Which aspect of the tongue should the nurse evaluate as part of the hypoglossal (CN XII) nerve assessment? Length Strength Color Taste

Strength. The nurse would assess the strength of the tongue as part of the evaluation of the hypoglossal nerve (CN XII) because the hypoglossal nerve innervates the tongue.

In which ways should the nurse test the pupils for response to light as part of the assessment of the cranial nerves of the eyes? Swinging flashlight test Direct response to light Indirect response to light Consensual response to light Constriction to accommodation

Swinging flashlight test The swinging flashlight test is used to test the patient's response to light as part of the assessment of the cranial nerves of the eyes. Direct response to light The nurse should test the pupils for response to direct light by shining a penlight into one pupil and evaluating for constriction. Consensual response to light The nurse should test the pupils for consensual response to light by shining a penlight into one eye and evaluating the opposite eye for consensual constriction.

When evaluating the vagus nerve (CN X), the nurse should inspect which aspect of the palate and uvula? Size Color Shape Symmetry

Symmetry When evaluating the vagus nerve (CN X), the nurse should inspect the symmetry of the palate and uvula because the vagus nerve provides motor supply to the pharynx.

Which elements should be assessed to evaluate the vagus nerve (CN X)? Taste Smell Sight Gag reflex Swallowing

Taste The nurse should test the patient's ability to identify sour and bitter tastes on either side of the tongue to evaluate the vagus nerve Gag reflex The nurse should assess the patient's gag reflex to evaluate the vagus nerve (CN X). Swallowing The nurse should assess the patient's ability to swallow to evaluate the vagus nerve (CN X).

Which elements of the patient's primary sensory function would the nurse assess? Temperature Joint position Graphesthesia Superficial pain Superficial touch

Temperature The nurse would assess the ability to sense temperature changes when evaluating the patient's primary sensory function. Joint position The nurse would assess the ability to sense changes in the position of joints when evaluating the patient's primary sensory function. Superficial pain The nurse would assess the ability to sense superficial pain when evaluating the patient's primary sensory function. Superficial touch The nurse would assess the ability to sense superficial touch when evaluating the patient's primary sensory function.

The nurse is assessing a physically abused patient with a blunt injury on the hand. Which assessment finding would make the nurse suspect that the injury happened 18 hours ago? The bruise is red. The bruise is purple. The bruise is greenish brown. The bruise is brownish yellow.

The bruise is purple.

A child is brought to the hospital with bruises on the soles of the feet and on the back. After the treatment, the nurse observes that the child does not want to return home and cowers when the parents return. What is the most likely reason for this child's behavior? The child is abused at home. The child is being bullied at school. The child is scared of the hospital. The child is in shock from the injury.

The child is abused at home.

While examining an 8-month-old infant, the nurse observes a palmar grasp reflex. What does the nurse infer from this finding? It is a normal finding. The infant may have a nerve injury. The infant may have a frontal lobe lesion. The infant may have occipital lobe damage.

The infant may have a frontal lobe lesion.

A patient reports a loss of pain and temperature sensation in the right lumbar region. The patient has also lost the sensations of vibration and position discrimination on the left side of the lumbar region. What does the nurse understand from these findings? The patient has chorea. The patient has flaccid quadriplegia. The patient hasperipheral neuropathy. The patient has Brown-Séquard syndrome.

The patient has Brown-Séquard syndrome.

A patient who is admitted for alcohol withdrawal reports a headache. The nurse assesses the patient and gives a score of 3 on the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar). What is the reason the nurse gives this score? The patient has a mild headache. The patient has a very mild headache. The patient has a moderate headache. The patient has a very severe headache.

The patient has a moderate headache.

The patient tells the nurse, "I want a hamburger on Wednesdays I went swimming on Paris love to walk and I can't to sing songs. When will I get to sleep?" What does the nurse infer from the patient's statements? The patient has flight of ideas. The patient has confabulation. The patient has circumstantiality. The patient has loosening associations.

The patient has loosening associations.

The nurse encourages a woman to report her experience with domestic violence to the police. The patient says, "I can't complain about the violence, because it will seem disloyal." The nurse would suspect that the patient is from which cultural background? The patient is African American. The patient is Hispanic. The patient is Native American. The patient is Alaska Native. The patient is American Indian.

The patient is African American. The patient is Native American

What are the common consequences of age-related hearing loss in an older adult patient? The patient may develop anxiety. The patient may be frustrated. The patient may become aggressive. The patient may become socially isolated. The patient may develop suspicious behavior.

The patient may be frustrated. The patient may become socially isolated. The patient may develop suspicious behavior.

A patient reports having a painless, swollen, hard nodule in the left scrotum. On palpation, the nurse finds that the patient has testicular swelling and a hard, solitary nodule. What does the nurse infer from these findings? The patient may have varicocele. The patient may have spermatocele. The patient may have testicular torsion. The patient may have early testicular tumor.

The patient may have early testicular tumor.

When assessing the cremasteric reflex, which area of the patient's body would the nurse assess? Foot Arm Thigh Abdomen

Thigh, The nurse should assess the inner portion of a male patient's thigh to evaluate the cremasteric reflex.

The nurse asks an adult patient, "How many drinks of alcohol make you feel high? Do you sometimes feel the need to cut down on your drinking? Do you sometimes take a drink when you first wake up in the morning?" Which assessment test is the nurse performing in the patient? Cut down, Annoyed, Guilty, Eye-opener (CAGE) questionnaire Alcohol Use Disorders Identification Test (AUDIT) questionnaire Tolerance, Worry, Eye-opener, Amnesia, and Kut down (TWEAK) questionnaire The Short Michigan Alcoholism Screening Test—Geriatric Version (SMAST-G) questionnaire

Tolerance, Worry, Eye-opener, Amnesia, and Kut down (TWEAK) questionnaire

The nurse is assessing a female alcoholic patient with a drowsy, flushed face. Which test should the nurse use to determine alcohol tolerance in the patient? Cut down, Annoyed, Guilty, Eye-opener (CAGE) questionnaire Alcohol Use Disorders Identification Test (AUDIT) questionnaire Tolerance, Worry, Eye-opener, Amnesia, and Kut down (TWEAK) questionnaire The Short Michigan Alcoholism Screening Test—Geriatric Version (SMAST-G) questionnaire

Tolerance, Worry, Eye-opener, Amnesia, and Kut down (TWEAK) questionnaire

The nurse should assess rapid rhythmic alternating movements by asking the patient to make which movements? Snap the fingers Clap the hands together Touch a thumb to a finger Bend one finger backward Alternately turn the palms of the hands up and down

Touch a thumb to a finger The nurse can assess the patient's rapid rhythmic alternating movements by asking the patient to touch a thumb to a finger. Alternately turn the palms of the hands up and down The nurse can assess the patient's rapid rhythmic alternating movements by asking the patient to alternate turning the palms of the hands up and down.

TRUE or FALSE Mental status is a person's emotional (feeling) and cognitive (knowing) function.

True

Which type of assessment of the cranial nerves of the eyes should the nurse perform in order to evaluate cranial nerve II? Visual acuity test Visual fields test Taste identification Odor identification Ophthalmologic examination

Visual acuity test The nurse should perform a visual acuity test to evaluate cranial nerve II, as it is a cranial nerve of the eyes that transmits information to the brain. Visual fields test The nurse should perform a visual fields test to evaluate cranial nerve II, as it is a cranial nerve of the eyes that transmits information to the brain. Ophthalmologic examination The nurse should perform an ophthalmologic examination to evaluate cranial nerve II, as it is a cranial nerve of the eyes that transmits information to the brain.

Which questions should the nurse ask a patient who has sustained a head injury to assess orientation? "What year is it?" "What is your birth date?" "Where are you right now?" "What is your home address?" "Who brought you to the hospital?"

What year is it?" "Where are you right now?" "What is your home address?"

The Mini-Mental State Examination is a simplified scored assessment of ___________ functions—not mood or thought processes

cognitive

The MMES is used to detect de_______ and del_______ and to differentiate these from _____________ mental illness.

dementia, delirium, psychiatric

Behavior assessment includes: name all four

level of consciousness, facial expression, speech and articulation, mood and affect,

The full mental status examination is a systematic check of emotional and cognitive functioning. Its purpose is to determine _____ health strengths and ______ skills and to screen for dysfunction.

mental, coping

aging, a slower response time may affect new learning. Also, age-related physical changes must be considered when assessing ____ ___________

older patients

Cognitive functions include: check __________, attention ____, recent ________, _________ memory, and new _________

orientation, span, memory, remote, learning

Developmental-Infant & Children: Consider growth and development: Consciousness, language, attention span, and abstract thinking all develop ____ ______. Consider these elements from a ____________ perspective.

over time, developmental

Appearance assessment includes: (select all that apply) posture, body movements, fashion sense, dress, grooming, hygiene

posture, body movements, dress, grooming, hygiene

Developmental-Aging adult Slower _________ ____ Difficult with _____-____ memory Long-term ______ preserved Sensory changes affect ______ _______ Dep_______ Consider ________ _____ Infection, Sepsis, B12, and _______ levels

response time; short-term; memory; mental status; depression; urinary tract, sodium

Before assessing an older adult's mental status, check _________ status and ________ deficits, if possible. Two handy tools are the _________ Coma Scale and the _____-Cog tests

sensory, correct, Glasgow, Mini

Thought processes: ask questions to evaluate _______ processes, thought _______, and per_________. Also screen for __________ disorders, dep________, and ___________ thoughts

thought, content, perceptions. anxiety, depression, suicidal

For pediatric patients, the mental status assessment focuses on the child's behavioral, cognitive, and psychosocial development.. true or false

true