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NUR 2092 Health Assessment Exam 2 Study Guide Rasmussen
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Exam 2Module 3 thru Module 5 (chps 5,8,9,10,11,12)
75 questions
Mental Status Assessment: Chapter 5
Main headings (components) of the mental status assessment
- Appearance, behavior, cognition and thought processes
Orientation status
- Use direct questioning to verify
Ex:
Time: day of week, date, year, season
Place: where person lives, address, phone number, present location, type of building, name
of city and state
Person: own name, age, who examiner is, type of worker
4 unrelated words test
- Highly sensitive and valid memory test
- Requires more effort than recall of personal or historic events and avoids danger of unverifiable
recall.
- The ability to learn new information.
-->asked at intervals of 5, 10, & 30 minutes
- Pick four words with semantic and phonetic diversity; ask person to remember the four words
- To be sure the person understood him or her repeat the words
- Ask for the recall of four words at 5, 10, and 30 minutes.
- Normal responses for person younger than 60 is an accurate 3- or 4- word recall after 5, 10 and
30 minutes.
Denver II screening test
- Denver ii screening test: gives a chance to interact directly with child to assess mental status.
For children Denver II helps identify those who many be slow to develop in behavioral, language,
cognitive and psychosocial areas.
- Denver articulation screening examination
MMSE-what does it test?
- Concentrates only on cognitive functioning Ex: (detects dementia, delirium, and to differentiate
these from psychiatric mental illness.
Mini cog tests
, - Reliable and quick instrument to screen for cognitive impairment in healthy adults
- Consists of three-item recall test and clock-drawing test
- Tests person’s executive function, including ability to plan, manage time, and organize activities,
and working memory
- Those with no cognitive impairment or dementia can recall the three words and draw a
complete, round, closed clock circle with all face numbers in correct position and sequence and
hour and minute hands indicating time you requested.
CAGE test
-
Affect versus Mood
- Judge by body language and facial expression and by direct questioning.
- Mood should be appropriate to person’s place and condition and should change appropriately
with topics; person is willing to cooperate.
Suicide attempt risk screening
- Assess for possible risk for harm if the person expresses feelings of sadness, hopelessness,
despair, or grief
- Begin with more general questions and proceed if you hear affirmative answers.
Ex: it’s very difficult to question people about possible suicidal wishes for fear of invading
privacy, don’t skip any questions because it can impose a greater risk to patient, and you can buy
time so the person can be helped to find an alternate remedy.
Abnormal findings:
Altered level of consciousness
Speech disorders
Mood and affect abnormalities
Anxiety disorders
Delirium, depression, and dementia
Thought process abnormalities
Thought content abnormalities
Perception abnormalities
Characteristics of eating disorders
Childhood mental disorders
, Depression:
- In aging adults, Grief and despair surrounding these losses can affect mental status and can
result in disability, disorientation, or depression.
- Depression should be suggested during the initial screening
- Medications can cause side effects and which are depression
- depression are the two most common mental health disorders seen in individuals seeking health
care.
Hallucination
- seeing things that are not there
GAD-general anxiety disorder screenings
- Consists of 7 itemized scale
- Higher the score, greater the likelihood.
- First 2 questions relate to core anxiety.
- Greater or equal than 3 indicates diagnosis.
Know what the following disorders are: Social Phobia, Compulsive disorder, PTSD, Anxiety
- Social phobia: A persistent and irrational fear of being in social situations. Person anticipates
being judged or criticized, feeling or looking foolish, feeling embarrassment, being unable to
answer questions, or being unable to remember the lines or notes
- Compulsive disorder: A pattern of recurrent obsessions (intrusive, uncontrollable thoughts) and
compulsions (repetitive ritualistic actions) done to decrease anxiety and prevent a catastrophe
(e.g., contamination [fear of germs], violence, perfectionism, and superstitions).
- PTSD: This follows a traumatic event outside the range of usual human experience involving
actual or threatened death (e.g., military combat, natural disaster [flood, tornado, earthquake],
plane or train accident, violence [mugging, rape, bombing]).
- Anxiety: apprehensive form the anticipation of a danger whose source is unknown
Know how to assess mental status in children
-
Level of consciousness range
- Person is awake, alert, aware of stimuli from environment and within self, and responds
appropriately and reasonably soon to stimuli.
Behavior:
- Glasgow Coma Scale is useful in testing consciousness in aging persons in whom confusion is
common.
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