Mental Health ATI Chapter 1-5
the client is responsive and able to fully respond by opening her eyes and attending to a
normal tone of voice and speech. she answers questions spontaneously and
appropriately - Answers -alert
the client is able to open her eyes and respond but is drowsy and falls asleep readily -
Answers -lethargy
the client requires vigorous or painful stimuli, such as pinching a tendon or rubbing the
sternum, to elicit a brief response. she may not be able to respond verbally - Answers -
stupor
this occurs when a client is comatose
it is flexion and internal rotation of upper-extremity joints and legs. - Answers -
decorticate rigidity
this occurs when a patient is comatose
neck and elbow extension, wrist and finger flexion - Answers -decerebrate rigidity
for immediate memory, what should you ask the client? - Answers -repeat a series of
numbers or a list of objects
for recent memory, what should you ask the patient? - Answers -to recall recent events,
such as visitors from the current day or the purpose of the current mental health
appointment or admission
for remote memory, what should you ask the client? - Answers -ask the client to state a
fact from his past that is verifiable, such as birth date or his mother's maiden name
this test examines the client's cognitive status by evaluating the following:
orientation to time and place
attention span and ability to calculate by counting backward by seven
registration and recalling of objects
language, including naming of objects, following of commands, and ability to write -
Answers -mini-mental state examination
this examination is used to obtain a baseline assessment of a client's level of
consciousness, and for ongoing assessment. eye, verbal, and motor response is
evaluated, and a number value based on that response is assigned. the highest value is
15, which indicates that the client is awake and responding appropriately. a score of 7
or less indicates that the client is in a coma - Answers -glasgow coma scale
, what is HEADSS that evaluates risk factors in the adolescents? - Answers -home
education/employment
perr group activities
drugs
sexuality
suicide/depresison
standardized assessment tooles that are appropriate for the older adult population,
include:
-
-
-
- - Answers -geriatric depression scale
michigan alcoholism screening test
mini-mental status exam
pain assessments
the DSM-5 published by the American Psychiatric Association, is used for what? -
Answers -as a diagnostic tool to identify mental health diagnoses. used by mental
health professionals for clients who have mental health disorders
Nurses use the DSM-5 in the mental health setting to identify? - Answers -diagnoses
and diagnostic criteria to guide assessment
identify nursing diagnoses
and to plan, implement, and evaluate care
What are some cognitive and behavioral therapies? - Answers -modeling
operant conditioning
systematic desensitization
a charge nurse is discussing mental status examinations with a newly licensed nurse.
Which of the following statements by the newly licensed nurse indicates a need for
further teaching?
A. to assess cognitive ability, i should ask the client to count backward by 7
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 - Answers -
D. this statement requires further teaching. asking the client to repeat a list of objects is
appropriate to assess immediate, rather than remote, memory.
a nurse is planning care for a client who has a mental health disorder. which of the
following is appropriate to include as a psychobiological intervention?
A. assist the client with systematic desentiziation therapy
the client is responsive and able to fully respond by opening her eyes and attending to a
normal tone of voice and speech. she answers questions spontaneously and
appropriately - Answers -alert
the client is able to open her eyes and respond but is drowsy and falls asleep readily -
Answers -lethargy
the client requires vigorous or painful stimuli, such as pinching a tendon or rubbing the
sternum, to elicit a brief response. she may not be able to respond verbally - Answers -
stupor
this occurs when a client is comatose
it is flexion and internal rotation of upper-extremity joints and legs. - Answers -
decorticate rigidity
this occurs when a patient is comatose
neck and elbow extension, wrist and finger flexion - Answers -decerebrate rigidity
for immediate memory, what should you ask the client? - Answers -repeat a series of
numbers or a list of objects
for recent memory, what should you ask the patient? - Answers -to recall recent events,
such as visitors from the current day or the purpose of the current mental health
appointment or admission
for remote memory, what should you ask the client? - Answers -ask the client to state a
fact from his past that is verifiable, such as birth date or his mother's maiden name
this test examines the client's cognitive status by evaluating the following:
orientation to time and place
attention span and ability to calculate by counting backward by seven
registration and recalling of objects
language, including naming of objects, following of commands, and ability to write -
Answers -mini-mental state examination
this examination is used to obtain a baseline assessment of a client's level of
consciousness, and for ongoing assessment. eye, verbal, and motor response is
evaluated, and a number value based on that response is assigned. the highest value is
15, which indicates that the client is awake and responding appropriately. a score of 7
or less indicates that the client is in a coma - Answers -glasgow coma scale
, what is HEADSS that evaluates risk factors in the adolescents? - Answers -home
education/employment
perr group activities
drugs
sexuality
suicide/depresison
standardized assessment tooles that are appropriate for the older adult population,
include:
-
-
-
- - Answers -geriatric depression scale
michigan alcoholism screening test
mini-mental status exam
pain assessments
the DSM-5 published by the American Psychiatric Association, is used for what? -
Answers -as a diagnostic tool to identify mental health diagnoses. used by mental
health professionals for clients who have mental health disorders
Nurses use the DSM-5 in the mental health setting to identify? - Answers -diagnoses
and diagnostic criteria to guide assessment
identify nursing diagnoses
and to plan, implement, and evaluate care
What are some cognitive and behavioral therapies? - Answers -modeling
operant conditioning
systematic desensitization
a charge nurse is discussing mental status examinations with a newly licensed nurse.
Which of the following statements by the newly licensed nurse indicates a need for
further teaching?
A. to assess cognitive ability, i should ask the client to count backward by 7
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 - Answers -
D. this statement requires further teaching. asking the client to repeat a list of objects is
appropriate to assess immediate, rather than remote, memory.
a nurse is planning care for a client who has a mental health disorder. which of the
following is appropriate to include as a psychobiological intervention?
A. assist the client with systematic desentiziation therapy
