Topic Resources The patient’s attention span is assessed first; an inattentive patient cannot cooperate fully and hinders testing. Any hint of cognitive decline requires examination of mental status ( see
Examination of Mental Status
Examination of Mental Status
Orientation to time, place, and person Attention and concentration Memory Verbal and mathematical abilities Judgment Reasoning Loss of orientation to person (ie, not knowing one’s own name) occurs only when obtundation, delirium Delirium Delirium is an acute, transient, usually reversible, fluctuating disturbance in attention, cognition, and consciousness level. Causes include almost any disorder or drug. Diagnosis is clinical... read more , or dementia Dementia Dementia is chronic, global, usually irreversible deterioration of cognition. Diagnosis is clinical; laboratory and imaging tests are usually used to identify treatable causes. Treatment is... read more is severe; when it occurs as an isolated symptom, it suggests malingering. The patient is asked to do the following:
Spatial perception can be assessed by asking the patient to imitate simple and complex finger constructions and to draw a clock, cube, house, or interlocking pentagons; the effort expended is often as informative as the final product. This test may identify impersistence, perseveration, micrographia, and hemispatial neglect. Praxis (cognitive ability to do complex motor movements) can be assessed by asking the patient to use a toothbrush or comb, light a match, or snap the fingers. Click here for Patient Education  Copyright © 2022 Merck & Co., Inc., Rahway, NJ, USA and its affiliates. All rights reserved. A nurse is collecting data about a client’s respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields? A: Vesicular (Vesicular sounds are soft and low-pitched) A nurse employs a thorough, systematic method for obtaining OBJECTIVE data about a client. Which of the following methods should the nurse us to collect this information? A: Physical Examination (Physical findings are objective and the nurse should collect this information in a systematic way. A nurse is assisting a provider with performing thoracentesis to remove pleural fluid. How should the nurse position the client? A: Leaning forward over a pillow. A nurse is preparing to insert an NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure? A: “Raise your index finger if you need to pause during the insertion.” A nurse is performing a mental-status exam for a client who has manifestations of dementia. Which of the following directions should the nurse give the client when evaluating the client’s ability to think abstractly? A: Discuss the meaning of a common proverb. (Evaluates clients ability to think abstractly.) A nurse is presenting an in-service session about nutrition. Which of the following simple sugars should the nurse identify as the carb found in milk? A: LACTOSE (Sugar found in milk) A nurse is assisting with teaching a newly licensed nurse about pain management in clients age of 65 and older. Which of the following pieces of information should the nurse include? A: Clients who are 65 or older are reluctant to report pain. (Might not want to bother or anger caregivers and might believe that pain is expected.) A nurse in an oncology clinic is collecting data for a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicate she is experiencing psychological distress? A: “I keep having nightmares about my upcoming surgeries.” A nurse is assisting with the admission of a client to the medical unit and asks if he has advance directives. The client states “I have a document with me that names someone who can make health care decisions for me if i am not able.” The nurse should identify that the client is referring to which of the following documents?A: Durable Power of Attorney Document (names a When performing a mental status examination MSE The nurse should include which of the following data?The mental status exam should include the general awareness and responsiveness of the patient. Additionally, one may also include the orientation, intelligence, memory, judgment, and thought process of the patient. At the same time, the patient's behavior and mood should undergo assessment.
When assessing aging adults you know that one of the first things that should be assessed before making judgments about their mental status is?It takes a bit longer for the brain to process information and react to it. When assessing aging adults, the nurse knows that one of the first things that should be assessed before making judgments about their mental status is: 1. the presence of phobias.
When charting general appearance and behavior documentation may include which of the following?When charting general appearance and behavior, documentation may include which of the following? Rationale: general appearance and behavior represent objective data that the nurse obtains through observation. The other assessments are subjective data based on conversation with the patient.
For which associated complication should a nurse monitor the client experiencing Guillain Barre Syndrome?During the course of GBS, the nurse will need to assess and monitor the patient for respiratory infections including pneumonia. The nurse will need to assess for problems associated with immobility related to muscle weakness and paralysis.
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A nurse is caring for a client who has dementia. when performing a mental status examination
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