Health Assessment chapter 9

A nurse is the pairing to discuss the cycle of violence with a group of women who have been victims of the abuse. Which of the following will the nurse include as part of phase 3 of this cycle?

A reconciliation period

The nurse is assessing a client using the Glasgow coma scale following an acute hypoglycemic episode and obtains a score of 14. The nurse interprets this as indicating which of the following?

Alert and oriented

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 focused assessment want to obtain more information about this finding?

Aphasia

Which total score would indicate cognitive impairment?

20

When providing care to a victim of abuse, which of the following would the nurse do?

Allow the woman to participate in her care.

During the mental status assessment of a new client the nurses asked the client to describe some of the similarities and differences between a tennis ball and a soccer ball. Despite the adequate Time and cuing, the client is unable to state any similarities or differences. The nurse should document what assessment finding?

A deficit in abstract reasoning

A home health nurse visits an 80 year old client with mild Alzheimer's disease who recently moved in with a caregiver. Which observations would cause the nurse to suspect neglect. Select all that appy. client makes frequent eye contact. clients clothes are soiled. clients prescriptions have expired. client has lost 10 pounds in the past two months. client is hesitant to speak when the caregiver is present.

Clients clothes are soiled. clients prescriptions have expired. client has lost 10 pounds in the past two months. client is hesitant to speak when the caregiver is present.

The nurse uses the mini mental state examination to assess a client. For which reason is this assessment tool most likely used?

Dementia

Which of the follow are cues that a person may have dementia? Select all that apply. • Disorientation •looking to a family member to answer questions directed to the client. •repeatedly failing to follow instructions. •serving as a "good historian" •finding the right words easily.

Disorientation looking to a family member to answer questions directed to the client. repeatedly failing to follow instructions.

The nurse or parents to assess a child for abuse. Which strategy should the nurse use for this interview? select all that apply. use open ended questions. use closed ended questions. be calm and avoid showing distaste offer a reward for answering question. used terms for body parts that the child uses.

Do use open ended questions becalm and avoid showing to distaste. used terms for body part is that the child usee.

The nurse is admitting a client 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 nurse is assessing an elderly client who may be a victim of elder miss treatment which of the following are examples of elder miss treatment? Select all that apply. failure to provide adequate nutrition to an elder. shoving an elder into a wheelchair. administering The wrong medication to an elder inadvertently. forcing an elder to perform a sexual act. having an elder sign financial documents without an understanding of what is being signed.

Failure to provide adequate nutrition to an elder. shoving an elder into a wheelchair. forcing an elder to perform a sexual act. having an elder sign financial documents without an understanding of what is being song.

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 thought process?

Flight of ideas

The nurse is screening an older adult client who is exhibiting signs of depression. Which screening tool would be best for the nurse to use during this assessment?

Geriatric Depression Scale

A client has presented to the emergency department with a lower leg laceration that she suffered, " while I was on a bender last night." The nurse recognizes the need to screen for alcohol use and will implement the CAGE questionnaire. What question will the nurse ask during this assessment?

Have you ever felt guilty about your alcohol use?

Which of the following assessment questions is most likely to allow the nurse to assess a clients judgment?

How do you plan to meet your responsibilities at work?

A nurse is conducting a mental status assessment of a 70-year-old male client who is being treated for depression. What would the nurse consider when assessing the clients facial expression and eye contact?

IContact is strongly influenced by cultural norms.

After performing a comprehensive assessment on a client, The nurse discovers the client has a long history of alcohol use disorder. What is the best action of the nurse?

Implement the CIWA Scale

A nurse has begun a new job at a mental health facility. The supervisor is explaining to the nurse the features included in the definition of a mental disorder, according to the DSM5. Which of the following should the supervisor mention to the nurse? is a behavioral or psychobiological syndrome or pattern that occurs in an individual. reflects an underlying psychobiological dysfunction. is an acceptable response to common stressors and losses. results in clinically significant distress or disability. is primarily a result of social deviance or conflicts with society.

Is a behavioral or psychological syndrome or pattern that occurs in an individual. reflects an underlying psychobiological dysfunction. results in clinically significant distress or disability.

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

Memory and attention

The nurse notes that an adolescent male has ptosis on the left eye. what should the nurse expect at the reason for this finding?

Nerve damage caused by repeated eye injuries.

A nurse assesses an 80-year-old client and documents the following findings based on the findings what action should the nurse take? making poor decisions occasionally. forgetting what day it is but easily reoriented. losing things from time to time occasionally having difficulty finding the right word

Record these as normal findings

The nurse utilizes the depression questionnaire on a client who has recently moved to long term care facility. The total score is 22. What would the nurse do next?

Refer to further evaluation.

The nurse is conducting a health history of a client at the local community mental health clinic. Which assessment tool would the nurse administer to determine the suicide risk for the client?

SAD PERSONAS

The nurse is assessing an older adult client mental status. Consistently, the client pauses after the nurse poses a question, but then the client provides a response that is correct or appropriate. How should a nurse first interpret this characteristic of the client?

Slight delays in mental processing are normal an older adults

The intensive care nurse is working with a client who has increased intracranial pressure secondary to a traumatic brain injury. The nurse is performing the hourly assessment of the clients level of consciousness and observes that the clients eyes are closed. How should the nurse first stimulate the client to assess for arousabiliy?

Speak to the client clearly from a close distance.

Which of the following would be most important for a nurse to keep in mind when assessing a client for possible physical abuse?

The abuse may start any time during a relationship.

A community nurse makes a scheduled home visit for a family of five, which includes the parents and three young children, on a hot, humid summer day. Which of the following observations would make the nurse suspect abuse?

The children are wearing long sleeve shirts and pants.

The nurse assesses an older adult using the mini mental status exam. The total score obtained is 24. Which interpretation by the nurse is correct?

The client is cognitively intact

A nurse in the emergency department is utilizing the SAD PERSONAS assessment guide during the mental status assessment of a client. What is most likely rationale for the nurses choice of this assessment tool?

The client may have a high risk for suicide

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

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

The nurse suspects that a female client is the victim of abuse what physical assessment finding cause the nurse to come to this conclusion? Select all that apply welts across the back bruises around the wrist bruising around the left eye and neck Tanlines around the chest and lower abdomen healing circular wounds around the inner thighs

Welts across the back. bruises around the wrist. bruising around the left eye and neck. healing circular wounds around the inner thighs.

The nurse notes that are older client speaks rapidly and uses words that make no sense or communicate any clear meaning. When documenting this finding, The nurse should use which term describes the client speech?

Wernicke's aphasia

As part of the mental status elimination, a nurse assesses the cognitive abilities of a client. which question should the nurse ass to assess the judgment ability in the client?

What do you do if you have pain?