Ch. 6 Assess: Assessing Mental Status and Substance Abuse

SLUMS tool for dementia

Orientation Remembering 5 objects Answering a money question Count backwards Clock drawing Shape identification Recall elements of a short story

What should be assessed first with older adults

Assess vision & hearing 1st

Lethargy (abnormal levels of consciousness)

Client opens eyes, answers questions, and falls back asleep

Coma (abnormal levels of consciousness)

Client remains unresponsive to all stimuli; eyes stay closed.

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

Alzheimer's Disease (characteristics)

Etiology: Early onset, familial (genetic) Onset: slow Course: chronic Mood: Early depression Speech: intact until later orientation: lost in familiar places Memory: recent lost first , and then remote

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 The mental status examination is a central aspect of the psychiatric assessment process that assesses current cognitive and affective functioning through data collection on appearance, behavior, level of consciousness, speech, thought content and processes, cognitive ability, mood and affect, insight, and judgment. This assessment relies almost exclusively on observation rather than inquiry and is expected to change during treatment.

When does the nurse screen for alcohol and drug use?

Every patient/every patient history Screening for alcohol and drug use is part of every patient history.

non-modifiable risk of dementia

Increasing age - Genetic predisposition andfamily history - Latino or African American descent due to higher vascular

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.

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 The client's age is used as a reference point with which the client's psychosocial developmental level can be compared. Age is not used to assess long-term memory, the ability to cope with mental disorders, or the likelihood of participating in a healthy lifestyle.

Assessment of Children and Adolescents

• Screen for cognitive, language, social, and gross and fine motor developmental delays - Child meets normal parameters for age - DDST screening tool for achievement of milestones • Assess stressors, coping skills, and common childhood fears; suicide risk assessmen

Which statement represents a clanging speech pattern?

"Peas are good. Trees are wood. I'd leave if I could." Speech with choice of words based on sound rather than meaning, as in rhyming and punning is referred to as clanging. Neologisms are invented or distorted words with highly idiosyncratic meanings. Echolalia is associated with the repetition of words or phrases. A pattern of speech that lacks association is said to tangential.

Alzheimer's v. Typical Age‐Related Changes

*Signs of Alzheimer's -poor judgement and decision making -inability to manage a budget - Loosing track of the date or season -Difficulty having a conversation - Misplacing things and being unable to retrace steps *Signs of Old Aging -Making a bad decision once in a while - Missing a monthly payment -Forgetting which day it is and remembering later -sometimes forgetting which word to use -Losing things from time to time

Hygiene (mental status)

- Client is clean and groomed appropriately for occasion (based on developmental, socioeconomic level and

modifiable risk of dementia

- Hypertension/ cholesterol - Head trauma - Smoking - Dysrhythmias, depression - HR

Symptoms of dementia (General)

- Memory loss - Challenges in problem solving - Difficulty completing tasks - Confusion with time or place - Trouble understanding visual images or spatial relationship - New problems with words - Decreased or poor judgment - Misplacing things or losing ability to retrace steps - Withdrawal from work or social activities -Changes in mood or personality

Normal level of consciousness

- Normally client is alert and oriented to person (name of self/family), place time and date

Abnormal facial expression (mental status)

- Reduced eye contact is seen in depression or apathy; extremes of emotions (happiness, anger, fright may be seen in anxious clients - With Parkinson's disease may have a mask‐like, face. - Inappropriate facial expressions (smiling when expressing sad thoughts) may indicate mental illness. - Drooping or marked facial asymmetry may occur with Bell's palsy or stroke.

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.

Which Glasgow Coma Score indicates the client is in a deep coma?

3 A Glasgow Coma Scale score indicates the client is in a deep coma. All other scores indicate some impairment with a score of 15 being no impairment.

Stupor (abnormal levels of consciousness)

: Client awakens to vigorous shake or painful stimuli but returns to unresponsive sleep

Perform full MSE if:

A brief screening exam suggests anxiety or depression or cognitive impairment Family members express concern related to behavioral changes (memory loss or inappropriate social interaction) Diagnosis of brain lesions, aphasia or other related symptoms **Perform MSE early in head to toe exam to determine validity of client's information

DSM‐5 Definition of Mental Disorder

A mental disorder is a behavioral or psychological syndrome or pattern that occurs in individuals; reflects underlying pathology with clinically significant consequences (distress or disability)

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. Correct response:

what is often an acute symptom of illness in older adults ?

Change in cognition in a frail older adult is often a symptom of acute illness

Observe behavior and affect (Mental Status)

Client is cooperative and purposeful in interactions with others; affect is appropriate for the client's situation

Facial expression (mental status)

Client maintains eye contact appropriate to culture.

Obtunded (abnormal levels of consciousness)

Client opens eyes to loud voice, responds slowly with confusion, and seems unaware of environment.

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.

Assessment of Child‐bearing Woman (abnormal)

Denial of pregnancy, withdrawal, depression, or psychosis may be seen with a client with psychological problems

Assessment of Newborn and Infants

Developmental screening for cognitive, language, social and gross and fine motor developmental delays - Infant should meet normal parameters for age - Denver Developmental Screening tool is used to determine achievement of milestones

Which of the following 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

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

Observe dress and grooming (Mental Status)

Dress is appropriate for occasion and weather; varies with age, SES, developmental and culture

Client Education for Dementia/Alzheimer's Disease

Engage in mentally challenging activities - Maintain healthy aging behaviors • Healthy weight • Avoid tobacco use and excessive alcohol intake • Stay socially connected • Exercise body and mind - Avoid activities that increase head trauma risk - Ask about HRT - Heart healthy diet/exercise

Vascular Dementia

Etiology: Cardiovascular or cerebrovascular disease onset: Often abrupt following CVA or TIA Course: Chronic, irreversible, Fluctuating progression Mood: Labile/ Swings Speech: May have aphasia orientation: Lost in familiar place memory: Recent is lost first, and then remote

Delirium

Etiology: Drug toxicity & interactions, acute disease; trauma; chronic disease, fever, fluids/electrolytes onset: Rapid, acute onset, A harbinger of medical illness Course:Symptoms are fully reversible with treatment Mood: Variable Speech: Fluctuates Orientation: fluctuates Memory: Impaired recent AND remote

Understanding the glasgow scale

GCS score of 15 indicates an optimal level of consciousness. GCS score of less than 15 indicates some impairment in the level of consciousness. A score of 3, the lowest possible score, indicates deep coma

The nurse needs to assess the visual, perceptual, and constructional ability of a client. Which of the following assessments should the nurse use?

Have the client draw the face of a clock Having the client draw the face of a clock is one way to assess visual, perceptual, and constructional ability. The SLUMS exam tests cognitive function. Giving directions to the client to perform a series of tasks, such as picking up and manipulating a pencil, is an assessment of concentration. Asking the client today's date is an assessment of orientation.

A nurse performs an admission assessment and notices that a client's speech is slow and the client has difficulty answering some of the questions. How can the nurse differentiate the cause of the client's slow speech?

Have the client read a few sentences out loud Speech is influenced by experience, education level, and culture. If the client is having trouble with speech, the nurse should ask the client to name objects in the room, read from printed material, or write a sentence. Asking about education level may intimidate the client and project judgment by the nurse. Giving the client a history form to read silently will not assist in assessing speech. Assessing hearing does not help with assessing the ability of the client to formulate words

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. Anticipatory grieving occurs prior to change. There is no evidence of fear or mental status change.

A client opens the eyes and answers questions however falls back asleep within seconds. How should the nurse document this assessment finding?

Lethargy

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.

Assessment of Child‐bearing Woman

Observe behaviors (normal range from ambivalence in 1st trimester; introspective and energetic in 2nd trimester to restlessness and labile moods 3rd trimester

The nurse participates in a health fair being sponsored by a local community. Which information being provided is a protective factor against substance abuse? Select all that apply.

Parental monitoring Academic competence Strong neighborhood activities Antidrug use policies at the schools The National Institute on Drug Abuse recommends protective factors to prevent substance abuse, which include parental monitoring, academic competence, strong neighborhood attachment, and antidrug policies at the schools. After school employment opportunities are not identified as protective factors to prevent substance abuse.

A patient with a nursing diagnosis of disturbed sensory perception would be expected to exhibit what characteristics?

Poor concentration, irritability, agitation, change in behavior

After assessing a patient, the nurse noted the following: he was tearful, he tried to kill himself before coming into the hospital, he had no immediate plan for another suicide attempt, he was unable to concentrate, and he reported having trouble sleeping and having little or no appetite. The nurse also noted that the patient's appearance was unkempt, that he spoke in a low monotone, and that he was unable to establish and maintain eye contact. Based on this information, which nursing diagnoses would be the most appropriate?

Risk for Suicide His history of a recent suicide attempt in conjunction with his signs of depression such as difficulty sleeping, lack of appetite, and inability to concentrate put him at risk for suicide. The information described in the nurse's observations does not support ineffective role performance, infection, or self-mutilation.

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 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.

Aging has common forms of decline that are often MISTAKEN for dementia true or false ?

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 Many assess mental status at the beginning of a head-to-toe assessment because it provides clues regarding the validity of the subjective information provided by the client throughout the examination. This assessment is not done first because it takes less energy for the nurse to complete it. This assessment can be quite lengthy. It is not done first because the client may become fatigued.

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?" To assess judgment ability in a client, the nurse should ask the client what he or she does when in pain. Asking about the first job and the last hospitalization helps in assessing remote memory. Asking the client about the difference between an apple and an orange elicits abstract reasoning.

CAGE is ?

has also been found to be an efficient screening test to detect alcohol dependence in trauma center populations. It is recommended that CAGE be used with alcohol testing to identify at-risk clients (Soderstrom et al., 1997

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

in coma

Dementia

is a set of symptoms associated with loss of cognitive function

If a nurse suspects that a client is depressed, asking the client about any suicidal thoughts

is important and will not stimulate the thought of suicide Many clinicians avoid the topic of self-harm or suicide because they worry that broaching it will implant the idea in the client's mind. There is little risk that talking about suicide with someone who is not already thinking about it will prompt him or her to do it. Consequently, the issue should be prioritized and directly addressed with clients who are or may be depressed.

Glasgow coma scale

is useful for clients who are unresponsive or are not responding to questions.

During an examination, the patient has incomprehensible, illogic speech that changes abruptly from one topic to another. The nurse should refer this patient for further evaluation of

schizophrenia

• Scoring: One "yes" on CAGE suggests ?

suggests a possible alcohol problem. More than one "yes" answer

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

suicide Other risk factors are prior suicide attempts; delusional or psychotic thinking; family history of suicide, mental disorders, or substance abuse; family violence, including physical or sexual abuse; firearms in the home; and incarceration.

With a change in orientation what is lost first , what is lost last ?

time is lost first, and person is lost last

You CANNOT DIRECTLY MEASURE MENTAL STATUS true or false ?

true

the mental status exam is incorporated with the health history true or false ?

true

Depression is NOT more common in older age true or false ?

true HOWEVER symptoms of depression manifest as change in cognition and physical symptoms

The nurse notes that an 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 to describe this client's speech?

wernickes aphasia

What does CAGE stand for

• C Have you ever tried to cut back on your use? • A Have you ever been annoyed/angered when questioned about your use? • G Have you ever felt guilt about your use? • E Have you ever had an eye‐opener to get started in the morning?

objective observation of mental status

• Observe posture, gait & body movements - Client should appear relaxed, with shoulders & back erect when standing or sitting. Gait is rhythmic and coordinated, symmetric arm swing Abnormal: Slumped posture may indicate powerlessness, depression or organic brain disease Bizarre movements may be seen in schizophrenia or a side effect of meds