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The client is responsive and able to fully respond by opening their eyes and
attending to a normal tone of voice and speech. What is the level of
consciousness? - CORRECT ANSWERS-Alert
The client is able to open their eyes and respond but is drowsy and falls asleep
readily. What is the level of consciousness? - CORRECT ANSWERS-Lethargic
The client requires vigorous or painful stimuli (pinching a tendon or rubbing the
sternum) to elicit a brief response. They might not be able to respond verbally.
What is the level of consciousness? - CORRECT ANSWERS-Stuporous
The client is unconscious and does not respond to painful stimuli. What is the
level of consciousness? - CORRECT ANSWERS-Comatose
How to test a client's immediate memory - CORRECT ANSWERS-Ask the client to
repeat a series of numbers or a list of objects
How to test a client's recent memory - CORRECT ANSWERS-Ask the client to recall
recent events, such as visitors from the current day, or the purpose of the
current mental health appointment or admission
How to test a client's remote memory - CORRECT ANSWERS-Ask the client to state a
fact from his past that is verifiable, such as his birth date or his mother's maiden
name
,How to assess a client's ability to calculate - CORRECT ANSWERS-Ask the client to
count backward from 100 in sevens
How to assess a client's ability to think abstractly - CORRECT ANSWERS-Ask the
client to interpret something complex such as, "A bird in the hand is worth two
in the bush."
Glasgow coma scale - CORRECT ANSWERS-Used to obtain a baseline assessment of
a client's level of consciousness; highest score is 15 and indicates that the client
is awake and responding appropriately; a score of 7 or less indicates that the
client is in a coma
Serious mental illness - CORRECT ANSWERS-Includes disorders classified as severe
and persistent mental illnesses; clients often have difficulty with ADLs; can be
chronic or recurrent
A charge nurse is discussing mental status exams with a newly licensed nurse.
Which of the following statements by the newly licensed nurse indicates an
understanding of the teaching? (Select all that apply)
A. "To assess cognitive ability, I should ask the client to count backward by
sevens."
B. "To assess affect, I should observe the client's facial expression."
C. "To assess language ability, I should instruct the client to write a sentence."
D. "To assess remote memory, I should have the client repeat a list of objects."
,E. "To assess the client's abstract thinking, I should ask the client to identify our
most recent presidents." - CORRECT ANSWERS-A. Counting backward by sevens is
an appropriate technique to assess a client's cognitive ability.
B. Observing a client's facial expression is appropriate when assessing affect.
C. Writing a sentence is an indication of language ability.
Remote language is tested by asking the client to state a fact from his past that
his verifiable (date of birth). Abstract thinking is tested by asking the client to
interpret something.
A nurse is planning care for a client who has a mental health disorder. Which of
the following actions should the nurse include as a psychobiological
intervention?
A. Assist the client with systematic desensitization therapy.
B. Teach the client appropriate coping mechanisms.
C. Assess the client for comorbid health conditions.
D. Monitor the client for adverse effects of the medications. - CORRECT ANSWERS-
D. Monitoring for adverse effects of medications is an example of a
psychobiological intervention.
Systematic desensitization is cognitive and behavioral. Teaching coping
mechanisms is a counseling or health teaching. Assessing for comorbid
conditions is health promotion and maintenance.
, A nurse in an outpatient mental health clinic is preparing to conduct an initial
client interview. When conducting the interview, which of the following actions
should the nurse identify as the priority?
A. Coordinate holistic care with social services.
B. Identify the client's perception of her mental health status.
C. Include the client's family in the interview.
D. Teach the client about her current mental health disorder. - CORRECT ANSWERS-
B. Assessment is the priority action. Identifying the client's perception of her
mental health status provides important information about the client's
psychosocial history.
A nurse is told during change of shift report that a client is stuporous. When
assessing the client, which of the following findings should the nurse expect?
A. The client arouses briefly in response to a sternal rub.
B. The client has a glasgow coma scale score less than 7.
C. The client exhibits decorticate rigidity.
D. The client is alert but disoriented to time and place. - CORRECT ANSWERS-A. A
client who is stuporous requires vigorous or painful stimuli to elicit a response.
B & C occur with comatose patients.
A nurse is planning a peer group discussion about the DSM-5. Which of the
following information is appropriate to include in the discussion? (Select all that
apply)