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The nurse completes and admission assessment primarily to:
Which statement by the patient is an example of subjective data?
Which data collection method is best when assessing for subjective data associated with a patient’s anxiety?
Observation is the deliberate use of all senses and involves more than just inspection. It includes looking, scanning, scrutinizing, and appraising. Although the nurse makes inferences based on data collected by observation, this is not as effective as interviewing that allows you to identify subjective data associated with the patient’s anxiety.
Subjective bacause it is the patient’s perception and can only be verified by the patient. Subjective data are those adaptations, feelings, beliefs, preferences, and information that only the patient can confirm
Objective data are measurable and checkable
The primary goal of the assessment phase of the Nursing Process is to:
Assessment, Diagnosis, Outcome identification, Planning, Implementation and Evaluation
The patient’s record, lab studies, objective data and subjective data combine to form the:
Which assessment takes priority when engaging in an emergency assessment of a patient?
Mental status change, Acute pain, Acute urinary elimination problems, Untreated medical problems, Abnormal labs, Risks of infection, safety or security
airway, breathing status, circulation
Which of the following is an example of a first-level priority problem?
Which situation is most appropriate for an episodic history?
screening instrument designed to detect developmental delays in infants and preschoolers. It tests four functions: gross motor, language, fine motor and personal-social skills
With the exception of pregnant or lactating women, the young adult has usually completed physical growth by the age of:
When assessing young adults, the nurse will find this population usually has a high level of wellness. However, it is important to direct healthcare education toward activities related to:
Close friends and associates of the single young adult may also be viewed as the individual’s:
A young man’s father and paternal grandfather had MI’s in their 50’s. He has a risk for a future MI. This type of health risk is:
To improve an adult’s health habits, the nurse uses health counseling and:
Visual acuity declines with aging. Presbyopia is a progressive decline in:
A common age-related change in auditory acuity is called:
A baby can sit alone before he or she is able to crawl. This is true because development of gross motor skills:
a. occurs in a cephalocaudal direction.
b. occurs in a distal to proximal direction.
c. is generally the result of a baby’s chronological age.
d. is simply the result of the baby’s increased desire to move.
proceeding or occurring in the long axis of the body especially in the direction from head to tail
An 18-month-old child comes to the well-child clinic for a visit. The nurse notes the following on observation: a rounded “pot belly” abdomen, marked lordosis “sway back,” short slightly bowed legs, and a large head. The nurse concludes that the child:
a. is built like a normal toddler.
b. should be worked up for possible hydrocephalus.
c. may have a vitamin deficiency or some form of malnutrition.
d. probably has delayed physical maturation
a. is built like a normal toddler.
Erikson believes toilet training to be representative of which of his stages?
a. Initiative versus guilt
b. Integrity versus despair
c. Industry versus inferiority
d. Autonomy versus shame and doubt
The nurse performs an assessment of a newly admitted patient. The nurse understands that this admission assessment is conducted primarily to:
The nurse comes to the conclusion that the patient’s elevated temperature, pulse and respirations are significant. Which step of the nursing process is being used when the nurse comes to this conclusion?
The nurse is collecting subjective data associated with a patient’s anxiety. Which assessment method should be used to collect this information?
The nurse collects objective data when the patient states:
things that can be measured, counted, quantified, observed
Which human response identified by the nurse is an example of objective data?
The nurse is assessing a postoperative patient for signs of hemorrhage. Which adaptation is most indicative of shock?
The nurse is teaching a cancer prevention community health class. Which recommended cancer screening guideline for asymptomatic non- risk people should the nurse include?
The nurse is caring for a patient who is experiencing an increase in symptoms associated with Multiple Sclerosis. Which term best describes a recurrence of symptoms associated with a chronic illness?
illeocecal valve between small and large intestine lots of sounds rlq
Which method of examination is used when the nurse takes a patient’s radial pulse:
When assessing for borborygmi, which physical examination method does the nurse use?
When the patient has an irregular pulse the nurse should first monitor the pulse:
The nurse can anticipate a patient’s temperature to be at its highest at:
The information that would be most important to document when taking a blood pressure would be:
Lying to sitting can cause decreased BP (orthostatic hypotension r/t pooling of blood in the extremities. BP falls 25 mm hg systolic and 10 mm Hg and pulse will increase between 10-30. Dehydration and common with patients who are on diuretics.
Which series of vital signs is most reflective of hypovolemic shock?
Which pulse site should not be assessed on both sides of the body at the same time?
When assessing for cyanosis in a dark skinned person, the nurse should assess:
C and oral cavity mucous membranes
Which assessment result would require the nurse to assess the patient further?
When conducting a physical examination, which side do you approach the patient from?
Which adaptation is associated with a vitamin K deficiency?
A= Vit C; C = Vit A; D = thiamine
The vital sign that would change first indicating that a post operative patient had internal bleeding would be the:
A- eventually drops due to decreased metabolic rate; BP not initially as body tries to compensate; C difference between S and D BP…will eventually narrow
When assessing a patient’s strength in preparation for getting out of bed the nurse should:
When a brachial pulse is unable to be palpated, which pulse would indicate adequate brachial flow?
Which can cause urine to appear red?
In an adult, what BP reading would cause concern regarding hypertension?
Which assessment is a subtle indicator of depression?
When planning to care for a patient who has an intolerance to activity, what is the first assessment that should be made by the nurse?
activity intolerance is r/t the inability to maintain adequate Oxygenation to body cells; VS can give us information about body systems
Which is an adaptation to inadequate nutrition?
Which is usually unrelated to a nursing physical assessment?
Which would place a person at risk for hypothermia?
false sense of warmth, inhibits shivering and causes vasodilatation that leads to heat loss form the body
Which is the most common site for assessing the heart rate?
Carotid used in situations where stroke volume so low that peripheral pulse cannot be palpated; temporal used in infants and children
An infant weighs 7 pounds at birth. At the well child visit 6 months later, the nurse would expect the child to weigh:
Normal physical changes that occur during middle adulthood (40-64) include:
Which statement is correct regarding the development of one’s culture?
An example of a person who is heritage consistent would be:
living with the norms of the traditional culture
A woman has lived in the United States for a year now after moving here from Europe. She has learned to speak English and is almost finished with her College degree. She now dresses like her peers and says that her family back home would hardly recognize her. This illustrates:
If an Asian-American woman is experiencing a symptom, such as diarrhea (yin), she is likely to try to treat it with:
An individual who takes the magicoreligious perspective of illness and disease is likely to believe that their illness was caused by:
When performing a physical assessment, the technique the nurse will ALWAYS use first is:
When assessing an older adult, the nurse keeps in mind that which vital sign changes occur with aging?
A patient’s weekly BP readings for 2 months have ranged between 124/84 and 136/88 mm Hg, with an average reading of 126/86 mm Hg. The nurse knows that this BP falls within which blood pressure category?
When examining the infant, the nurse should examine which area first?
After completing an initial assessments on a patient, the nurse has charted that his respirations are eupneic and his pulse is 58. This type of data would be:
Novice nurses, without a background of skills and experience to draw from, are more likely to make their decisions using:
Critical thinking in the expert nurse is greatly enhanced by opportunities to:
The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the:
Expert nurses learn to attend to a pattern of assessment data and to act without consciously labeling it. This is referred to as:
A newly admitted patient is in acute pain, has not been sleeping well and is having difficulty breathing. How should the nurse prioritize these problems?
Which situation is most appropriate for an episodic history?
A 42-year old Asian patient is being seen in the clinic for an initial examination. The nurse knows it is important to include cultural information in his health assessment to:
Put the following patient situations in order according to level of priority:
An 18 month old who makes the statement, “All done,” is using what form of speech?
A Telegraphic speech, according to linguistics and psychology, is speech during the two-word stage of language acquisition in children, which is laconic and efficient.
The name derives from the fact that someone sending a telegram was generally charged by the word. To save money, people typically wrote their telegrams in a very compressed style, without conjunctions or articles. As children develop language, they speak similarly: when a child says "Water now!" it is understood that the child means, "I would appreciate a glass of water, immediately."
A patient is in the hospital with a new diagnosis of Lung Cancer. He is anxious and talks to his oncologist about getting the ‘latest and best treatment out there.’ This reflects which time orientation?
P: Position (Location), Precipitating factors; “Can you point to where it hurts?”
Q: Quality (patient description); quantity (excruciating pain, ask to describe the pain & how would it affect ability to do the daily activities.
R: Region or radiation
S: Severity (e.g. using pain scale), Setting; where the person was or what the person was doing when the symptom started (e.g. This back pain happens every time I sit down to use the comp.''
T: Timing (Duration)
U: Understand patient’s perception
Correct answer: D. The other three choices include medical diagnosis terminology, which is not appropriate in this part of the chart even if voiced by the patient (as in answer B).
Correct answer: A. Because the stem is worded negatively, the correct answer to this item is A. Clinicians have to structure their questions about abuse to assess particular behaviors, rather than the patient’s own assessment of the situation. Many abuse survivors are not aware that the maltreatment that they are experiencing is abuse. The other three choices are consistent with the instructions in your text.
1. The patient has a history of drug abuse and therefore is not reliable.
2. The patient provided consistent information and therefore is reliable.
3. The patient smiled throughout interview and therefore is assumed reliable.
4. The patient would not answer questions concerning stress and therefore is not reliable.
A reliable person always gives the same answers, even when questions are rephrased or are repeated later in the interview.
1.J. M. is 59, male here for “ulcerative colitis.”
2. J. M. came into the clinic complaining of black stools for the past 24 hours.
3. J. M., a 59-year-old male, states he has ulcerative colitis and wants it checked.
4. M. is a 59-year-old male here for having “black stools” for the past 24 hours.
The reason for seeking care is a brief spontaneous statement in the person’s own words that describes the reason for the visit. It states one (possibly two) signs or symptoms and their duration. It is enclosed in quotation marks to indicate the person’s exact words.
1. “Can you point to where it hurts?”
2. “We’ll talk more about that later in the interview.”
3. “What have you had to eat in the last 24 hours?”
4. “Have you ever had any surgeries on your abdomen?”
A final summary of any symptom the person has should include, along with seven other critical characteristics, “Location: specific.” Ask the person to point to the location.
1. “How does your family react to your pain?”
2. “That must be terrible. You probably pinched a nerve.”
3. “I’ve had back pain myself and it can be excruciating.”
4. “How would you say the pain affects your ability to do your daily activities?”
The symptom of pain is difficult to quantify because of individual interpretation. With pain, avoid adjectives and ask how it affects daily activities.
1. Patient denies usual childhood illnesses.
2. Patient states he was a “very healthy” child.
3. Patient states sister had measles, but he didn’t.
4. Patient denies measles, mumps, rubella, chickenpox, pertussis, or strep throat.
Childhood illnesses include measles, mumps, rubella, chickenpox, pertussis, and strep throat. Avoid recording “usual childhood illnesses” because an illness common in the person’s childhood may be unusual today (e.g., measles).
1. P-6, B-4, (S)Ab-2
2. Grav 6, Term 4, (S)Ab 2, Living 4
3. Patient has had four living babies.
4. Patient has been pregnant six times.
Obstetric history includes the number of pregnancies (gravidity), number of deliveries in which the fetus reached term (term), number of preterm pregnancies (preterm), number of incomplete pregnancies (abortions), and number of children living (living). This is recorded: Grav _____ Term _____ Preterm _____ Ab _____ Living _____. For any incomplete pregnancies, record the duration and whether the pregnancy resulted in spontaneous (S) or induced (I) abortion.
1. “Are you allergic to any other drugs?”
2. “How often have you received penicillin?”
3. “I’ll write your allergy on your chart so you won’t receive any.”
4. “Please describe what happens to you when you take penicillin.”
Note both the allergen (medication, food, or contact agent, such as fabric or environmental agent) and the reaction (rash, itching, runny nose, watery eyes, difficulty breathing). With a drug, this symptom should not be a side effect but a true allergic reaction.
2. head trauma.
3. mental illness.
4. fractured bones.
Specifically ask for any family history of heart disease, high blood pressure, stroke, diabetes, blood disorders, cancer, sickle cell anemia, arthritis, allergies, obesity, alcoholism, mental illness, seizure disorder, kidney disease, and tuberculosis.
1. physical findings related to each system.
2. information regarding health promotion practices.
3. an opportunity to teach the patient medical terms.
4 information necessary for the nurse to diagnose the patient’s medical problem.
The purposes of this section are (1) to evaluate the past and current health state of each body system, (2) to double check in case any significant data were omitted in the present illness section, and (3) to evaluate health promotion practices.
1. Skin appears dry.
2. No obvious lesions
3. Denies color change
4. Lesion noted lateral aspect right arm
ANS: 3Remember that the history should be limited to patient statements or subjective data—factors that the person says were or were not present.
1. “Do you perform testicular self-exams?”
2. “Have you ever noticed any pain in your testicles?”
3. “Have you had any problems with passing your urine?”
4. “Do you have any history of sexually transmitted disease?”
Health promotion for a man would include performance of testicular self-examination.
1. “I broke my right leg in a car accident 2 weeks ago.”
2. “The pain is getting less, but I still need to take Tylenol.”
3. “I check the color of my toes every evening just like I was taught.”
4. “I’m able to transfer myself from the wheelchair to the bed without help.”
Functional assessment measures a person’s self-care ability in the areas of general physical health or absence of illness.
1. “This has been a difficult year for you.”
2. “I don’t know how anyone could handle that much stress in 1 year!”
3. “What did you do to cope with the loss of both your husband and mother?”
4. “That is a lot of stress; now let’s go on to the next section of your history.”
Coping and stress management includes kinds of stresses in life, especially in the last year, any change in lifestyle or any current stress, methods tried to relieve stress, and whether these have been helpful.
1. This is necessary to determine the patient’s reliability.
2. Alcohol can interact with all medications and make some diseases worse.
3. The nurse needs to be able to teach the patient about the dangers of alcohol use.
4. It’s not really necessary to have this information unless there is an obvious drinking problem.
Alcohol interacts adversely with all medications; it is a factor in many social problems such as child or sexual abuse, automobile accidents, and assaults; it contributes to many illnesses and disease processes.
1. “Maybe she is just teething.”
2. “I will check her ear for an ear infection.”
3. “Are you sure she is really having pain?”
4. “Please describe what she is doing to indicate she is having pain.”
With a child, ask the parent, “How do you know the child is in pain?” (Pulling at ears alerts parent to ear pain.)
1. “You don’t need to answer if it makes you uncomfortable.”
2. “The use of tobacco during pregnancy could be the cause of your daughter’s pneumonia.”
3. “Knowing about your pregnancy gives us a more complete picture of your daughter’s health.”
Record the mother’s use of alcohol, street drugs, or cigarettes and any x-ray studies taken during pregnancy.
1. The child’s birth weight
2. The age at which he crawled
3. Whether he has had the measles
4. Reactions to previous hospitalizations
Assess how the child reacted to hospitalization and any complications. (If the child reacted poorly, he or she may be afraid now and will need special preparation for the examination that is to follow.)
1. No further MMR immunizations are needed.
2. MMR needs to be repeated at age 4 to 6 years.
3. MMR needs to be repeated every 4 years until age 21.
4. A recommendation cannot be made until physician is consulted.
Because of recent outbreaks of measles across the United States, the American Academy of Pediatrics (2006) is now recommending two doses of the MMR vaccine, one at 12 to 15 months of age and one at age 4 to 6 years
1. last glaucoma exam.
2. frequency of breast self-exam.
3. date of her last electrocardiogram.
4. limitations related to her involvement in sports activities.
When reviewing the cardiovascular system, the health care provider should ask whether there is any limitation of activity or whether the child can keep up with her peers.
1. Family history
2. Review of systems
3. Functional assessment
4. Reason for seeking care
Functional assessment includes interpersonal relationships and home environment.
1. Obstetric history
2. Childhood illnesses
3. General health for the past 20 years
4. Current health promotion activities
It is important for the nurse to recognize positive health measures: what the person has been doing to help himself or herself stay well and to live to an older age.
1. The questions asked are identical for all ages.
2. The interviewer will start incorporating different questions for patients 70 years of age and older.
3. Additional questions to include are reflective of the normal effects of aging.
4. At this age, a review of systems is not necessary—just focus on current problems.
The health history includes the same format as that described for the younger adult as well as some additional questions. These questions address ways in which the activities of daily living may have been affected by normal aging processes or by the effects of chronic illness or disability.
1. “Can you tell me what they look like?”
2. “Don’t worry about it. You are only taking two.”
3. “How long have you been taking each of the pills?”
4. “Would you have your family bring in your medications?”
The person may not know the drug name or purpose. When this occurs, ask the person to bring in the drug to be identified.
1. “Do you wear glasses?”
2. “Are you able to dress yourself?”
3. “Do you have any thyroid problems?”
4. “How many times a day do you have a bowel movement?”
Functional assessment measures how a person manages day-to-day activities. For the older person, the meaning of health becomes those activities that they can or cannot do.
1. It assesses how the individual is coping with life at home.
2. It determines how children are meeting developmental milestones.
3. It can identify any problems with memory the individual may be experiencing.
4. With the elderly, it helps to determine how they are managing day-to-day activities.
The functional assessment, because it emphasizes function, is very important in assessing older people.
1. “It is a sharp, burning pain in my stomach.”
2. “I also have the sweats and nausea when I feel this pain.”
3. “I think this pain is telling me that something bad is wrong with me.”
4. “This pain happens every time I sit down to use the computer.”
The setting describes where the person was or what the person was doing when the symptom started. Statement 1 reflects the patient’s perception, Statement 3 reflects character or quality, and Statement 2 reflects associated factors.
1. The patient is an alcoholic.
2. The patient is annoyed at the questions.
3 The patient should be examined thoroughly for possible alcohol withdrawal symptoms.
4. The nurse should suspect alcohol abuse and continue with a more thorough substance abuse assessment.
The CAGE test is known as the “cut down, annoyed, guilty, and eye-opener” test. If a person answers yes to two or more of the four CAGE questions, the nurse should suspect alcohol abuse and continue with a more complete substance abuse assessment.
1. “Do you use sunscreen while outside?”
2. “I need to see if your skin is warm and dry.”
3. “Have you had any dizziness or headaches?”
4. “When you cough, what color is the sputum you bring up?”
The review of symptoms is not a record of physical findings or objective data. The use of sunscreen is a health promotion item.
1. “Please stay during the interview; you can answer for her if she does not know the answer.”
2. “It would help to interview the three of you together.”
3. “While I interview your daughter, will you step out to the waiting room and complete these family health history questionnaires?”
Interview the youth alone. The parent can wait outside and fill out past health questionnaires.
1. “Why did you come to the United States?”
2. “When did you come to the United States, and from what country?”
3. “What made you leave your native country?”
4. “Are you planning to return to your home?”
Biographic data, such as when the person entered the United States and from what country, are appropriate additions to the health history. The other answers do not reflect appropriate questions.
1. “Where is the headache pain?”
2. “Did you have these headaches as a child?”
3. “On a scale of 1 to 10, how bad is the pain?”
4. “How often do the headaches occur?”
5. “What makes the headaches better?”
6. “Do you have any family history of headaches?”
7. “What do you think is causing these headaches?”
ANS: 1, 3, 4, 5, 7
The mnemonic PQRSTU may help you to remember to address the critical characteristics that need to be assessed: 1) P: Provocative or Palliative; 2) Q: Quality or Quantity; 3) R: Region or Radiation; 4) S: Severity Scale; 5) T: Timing; 6) U: Understand Patient’s Perception. Option 1 reflects “Region.” Option 3 reflects “Severity.” Option 4 reflects “Timing.” Option 5 reflects “Palliative.” Option 7 reflects the patient’s “Understanding.” Options 2 and 6 reflect past history and family history, respectively.
Ways ideas are organized and expressed
What patient is actually saying
Correct Answer: B. According to your textbook, consciousness is the most fundamental of these particular characteristics; therefore, it would be tested first.
Correct answer: C. The other choices are all elements of the interview that contribute to interpretation of the findings of the examination.
Mental status cannot be scrutinized directly like the characteristics of skin or heart sounds. Its functioning is inferred through assessment of an individual’s behavior.
It is difficult to separate and trace the development of just one aspect of mental status. All aspects are interdependent. For example, consciousness is rudimentary at birth because the cerebral cortex is not yet developed. The infant cannot distinguish the self from the mother’s body.
The aging process leaves the parameters of mental status mostly intact. There is no decrease in general knowledge and little or no loss in vocabulary. Response time is slower than in youth. It takes a bit longer for the brain to process information and react to it.
Age-related changes in sensory perception can affect mental status. For example, vision loss (as detailed in Chapter 14) may result in apathy, social isolation, and depression. Hearing changes are common in older adults. This problem produces frustration, suspicion, and social isolation and makes the person look confused
The full mental status examination is a systematic check of emotional and cognitive functioning. The steps described here, though, rarely need to be taken in their entirety. Usually, one can assess mental status through the context of the health history interview.
It is necessary to perform a full mental status examination when any abnormality in affect or behavior is discovered and in the following situation: family members are concerned about a person’s behavioral changes (e.g., memory loss, inappropriate social interaction)
In every mental status examination, note these factors from the health history that could affect the findings: any known illnesses or health problems, such as alcoholism or chronic renal disease; current medications, the side effects of which may cause confusion or depression; the usual educational and behavioral level—note that factor as the normal baseline and do not expect performance on the mental status examination to exceed it; and responses to personal history questions, indicating current stress, social interaction patterns, and sleep habits.
ANS: 1In the mental status examination the sequence of steps forms a hierarchy in which the most basic functions (consciousness, language) are assessed first. The first steps must be accurately assessed to ensure validity for the steps to follow. That is, if consciousness is clouded, then the person cannot be expected to have full attention and to cooperate with new learning. If language is impaired, subsequent assessment of new learning or abstract reasoning (anything that requires language functioning) can give erroneous conclusions.
Grooming and hygiene should be noted. The person is clean and well groomed, hair is neat and clean, women have moderate or no makeup, men are shaved or their beards or moustaches are well groomed. Use care in interpreting clothing that is disheveled, bizarre, or in poor repair because these sometimes reflect the person’s economic status or a deliberate fashion trend.
The nurse can discern the orientation of cognitive function through the course of the interview or can tactfully ask directly. “Some people have trouble keeping up with the dates while in the hospital. Do you know today’s date?” Many hospitalized people normally have trouble with the exact date but are fully oriented on the remaining items.
Judge mood and affect by body language and facial expression and by asking directly, “How do you feel today?” or “How do you usually feel?” The mood should be appropriate to the person’s place and condition and change appropriately with topics.
Ask questions that can be corroborated. This screens for the occasional person who confabulates or makes up answers to fill in the gaps of memory loss. New learning—the Four Unrelated Words Test tests the person’s ability to lay down new memories. It is a highly sensitive and valid memory test.
The Four Unrelated Words Test tests the person’s ability to lay down new memories. It is a highly sensitive and valid memory test. It requires more effort than does the recall of personal or historic events. To the person, say, “I am going to say four words. I want you to remember them. In a few minutes I will ask you to recall them.” After 5 minutes, ask for the four words. The normal response for persons under 60 years is an accurate three- or four-word recall after a 5-, 10-, and 30-minute delay.
A person exercises judgment when he or she can compare and evaluate the alternatives in a situation and reach an appropriate course of action. Rather than testing the person’s response to a hypothetical situation (as illustrated in option 4), the nurse should be more interested in the person’s judgment about daily or long-term goals, the likelihood of acting in response to delusions or hallucinations and the capacity for violent or suicidal behavior.
When the person expresses feelings of sadness, hopelessness, despair, or grief, it is important to assess any possible risk of physical harm to himself or herself. Begin with more general questions. If you hear affirmative answers, continue with more specific questions. A precise suicide plan to take place in the next 24 to 48 hours with use of a lethal method constitutes high risk.
The mental status assessment of infants and children covers behavioral, cognitive, and psychosocial development and examines how the child is coping with his or her environment. Essentially, follow the same A-B-C-T guidelines as for the adult, with special consideration for developmental milestones. The best examination “technique” arises from thorough knowledge of developmental milestones as described in Chapter 2. Abnormalities are often problems of omission (e.g., the child does not achieve a milestone as expected).
For school-age children, ages 7 to 11 years, who have grown beyond the age when developmental milestones are very useful, the Behavioral Checklist is an additional tool that can be given to the parent along with the history.
Many aging persons experience social isolation, loss of structure without a job, a change in residence, or some short-term memory loss. These factors affect orientation and the person may not provide the precise date or complete name of the agency. You may consider aging persons oriented if they know generally where they are and the present period. That is, consider them oriented to time if the year and month are correctly stated. Orientation to place is accepted with the correct identification of the type of setting (e.g., the hospital) and the name of the town.
The Set Test was developed specifically for use with an aging population. The test is easy to administer and takes less than 5 minutes. Ask the person to name 10 items in each of four categories or sets: fruits, animals, colors, and towns (FACT). Do not coach, prompt, or hurry the person.
Lethargic (or somnolent) is when the person is not fully alert, drifts off to sleep when not stimulated, can be aroused when called by name in a normal voice but looks drowsy. He or she responds appropriately to questions or commands, but thinking seems slow and fuzzy. He or she is inattentive and loses the train of thought. Spontaneous movements are decreased.
This illustrates receptive aphasia. Speech is fluent, effortless, and well articulated. Output has many paraphasias (word substitutions that are malformed or wrong) and neologisms (made-up words) and often lacks substantive words. Speech can be totally incomprehensible. Often there is a great urge to speak. Essentially, it is a defect of auditory comprehension. Repetition, reading, and writing are also impaired.
Circumlocution is a roundabout expression, substituting a phrase when one cannot think of the name of the object.
Flight of ideas is demonstrated by an abrupt change, rapid skipping from topic to topic, and practically continuous flow of accelerated speech. Topics usually have recognizable associations or are plays on words.
A phobia is a strong, persistent, irrational fear of an object or situation; the person feels driven to avoid it.
An inappropriate affect is an affect clearly discordant with the content of the person’s speech.
Hallucinations are sensory perceptions for which there are no external stimuli. They may strike any sense: visual, auditory, tactile, olfactory, or gustatory.
Delirium is a disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention. It is also a change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.
A cocaine user’s appearance includes pupillary dilation, tachycardia or bradycardia, elevated or lowered blood pressure, sweating, chills, nausea, vomiting, and weight loss. The person’s behavior includes euphoria, talkativeness, hypervigilance, pacing, psychomotor agitation, impaired social or occupational functioning, fighting, grandiosity, and visual or tactile hallucinations
Major depressive disorder is characterized by one or more major depressive episodes (i.e., at least 2 weeks of depressed mood or loss of interest accompanied by at least four additional symptoms of depression). Dysthymic disorder is characterized by at least 2 years of depressed mood for more days than not, accompanied by additional depressive symptoms.
In posttraumatic stress disorder the person has been exposed to a traumatic event. The traumatic event is persistently re-experienced by recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions; recurrent distressing dreams of the event; and acting or feeling as if the traumatic event were recurring.
Mental status functioning is inferred through assessment of an individual’s behaviors. It cannot be assessed directly like characteristics of the skin or heart sounds.
Attention span is evaluated by assessing the individual’s ability to concentrate and complete a thought or task without wandering. Giving a series of directions to follow is one method used to assess attention span.
Additional tests for persons with aphasia include the following: word comprehension—asking the individual to point to articles in the room or parts of the body; reading—asking the person to read available print; and writing—asking the person to make up and write a sentence.
When the person expresses feelings of hopelessness, despair, or grief, it is important to assess for risk of physical harm to himself or herself. Begin this process with more general questions. If the answers are affirmative, continue with more specific questions.
The MiniMental State Exam is a quick, easy test of 11 questions. It is used for initial and serial evaluations and can demonstrate worsening or improvement of cognition over time and with treatment. It evaluates cognitive functioning, not mood or thought processes. It is a good screening tool to detect dementia and delirium and to differentiate these from psychiatric mental illness.
The development of a memory impairment (inability to learn new information or recall previously learned information) in the absence of other significant cognitive impairments may be due to pathology such as closed head trauma.
Global aphasia is the most common and severe form of aphasia. Spontaneous speech is absent or reduced to a few stereotyped words or sounds, and prognosis for language recovery is poor.
ANS: 2Clanging is word choice based on sound, not meaning, and includes nonsense rhymes and puns
Repetitive behaviors, such as handwashing, are behaviors that the person feels driven to perform in response to an obsession. The behaviors are aimed at preventing or reducing distress or preventing some dreaded event or situation.
Set Test scores of less than 15 indicate dementia. Scores between 15 and 24 show less association with dementia and should be evaluated carefully. No one with a score over 25 has been found to have dementia.
Echolalia occurs when a person imitates or repeats another’s words or phrases, often with a mumbling, mocking, or mechanical tone.
ANS: 1, 3, 4Delirium is a disturbance of consciousness that develops over a short period of time and may be due to a medical condition. Memory deficits may also occur.
MAMA = (MAC – MAMA)24p
Optimal nutritional status is achieved when sufficient nutrients are consumed to support day-to-day body needs and any increased metabolic demands resulting from growth, pregnancy, or illness.
Because of rapid growth, especially of the brain, infants and children younger than 2 years should not drink skim or low-fat milk or be placed on low-fat diets—fat (calories and essential fatty acids) is required for proper growth and central nervous system development.
Breast-feeding is recommended for full-term infants for the first year of life because breast milk is ideally formulated to promote normal infant growth and development and natural immunity.
After a period of slow growth in late childhood, adolescence is characterized by rapid physical growth and endocrine and hormonal changes. Caloric and protein requirements increase to meet this demand. Because of bone growth and increasing muscle mass (and, in girls, the onset of menarche), calcium and iron requirements also increase.
General undernutrition, hypertension, diarrhea, lactose intolerance, osteomalacia (soft bones), scurvy, and dental caries are among the more common nutrition-related problems of new immigrants from developing countries.
Although one may assume that the term “food” is a universal concept, the person should clarify what is meant by the term.
The purposes of the nutritional assessment are to (1) identify individuals who are malnourished or are at risk for development of malnutrition, (2) provide data for designing a plan of care that will prevent or minimize the development of malnutrition, and (3) establish baseline data for evaluating the efficacy of nutritional care.
Parameters used for nutrition screening typically include weight and weight history, conditions associated with increased nutritional risk, diet information, and routine laboratory data.
ANS: 4With this tool, information is collected on how many times per day, week, or month the individual eats particular foods
Gastrointestinal symptoms such as vomiting, diarrhea, or constipation may interfere with nutrient intake or absorption.
Analgesics, antacids, anticonvulsants, antibiotics, diuretics, laxatives, antineoplastic drugs, steroids, and oral contraceptives are among the drugs that can interact with nutrients, impairing their digestion, absorption, metabolism, or use.
With changes in appetite, taste, smell, or chewing or swallowing, the examiner asks about the type of change and when the change occurred.
Because of adolescents’ increased body awareness and self-consciousness, they are prone to develop eating disorders such as anorexia nervosa or bulimia, conditions in which the real or perceived body image does not compare favorably to an ideal image.
Use of small portions, finger foods, simple meals, and nutritious snacks are strategies to improve dietary intake. Foods likely to be aspirated should be avoided (e.g., hot dogs, nuts, grapes, round candies, popcorn).
Socioeconomic conditions frequently have the greatest effect on the nutritional status of the aging adult; these factors should be closely evaluated. Physical limitations, income, and social isolation are frequent problems and can obviously interfere with the acquisition of a balanced diet.
The most commonly used anthropometric measures are height, weight, triceps skinfold thickness, elbow breadth, and arm and head circumferences.
Obesity is defined as greater than 120% of ideal body weight. For this patient, 120% of her ideal body weight, 120 pounds, is 144 pounds. Her current weight of 146 pounds is greater than 120% of ideal body weight.
Release the lever of the calipers while holding the skinfold. Wait 3 seconds and then take a reading. Repeat three times and average the three skinfold measurements.
Mid upper arm circumference estimates skeletal muscle mass and fat stores
Remember that accurate mid upper arm circumerence and triceps skinfold measurements are difficult to obtain and interpret in older adults because of sagging skin, changes in fat distribution, and declining muscle mass.
Mid arm muscle area is a good indicator of lean body mass and skeletal protein reserves. These reserves are important in growing children and are especially valuable in evaluating persons who may be malnourished because of chronic illness, multiple surgeries, or inadequate dietary intake. The equation for calculating mid arm muscle area includes mid upper arm circumference and mid-upper arm muscle circumference.
Instruct the person to extend the right arm forward, perpendicular to the body. Bend the elbow to a 90-degree angle with the palm of the hand turned laterally. Facing the person, place the calipers on the condyles of the humerus. Read the distance between the condyles.
ANS: 1Body mass index, calculated by using height and weight measurements, is a practical marker of optimal weight for height and an indicator of obesity.
The waist-to-hip ratio assesses body fat distribution as an indicator of health risk. A waist-to-hip ratio of 1.0 or greater in men or 0.8 or greater in women is indicative of android (upper body obesity) and increasing risk for obesity-related disease and early death.
Determination of skinfold thickness or body mass index may be useful in evaluating childhood and teenage overnutrition.
Height measures may not be accurate in individuals confined to a bed or wheelchair or those over 60 years of age (because of osteoporotic changes).
The hemoglobin determination is used to detect iron-deficiency anemia. Hematocrit, a measure of cell volume, is also an indicator of iron status.
Totalcholesterol is measured to evaluate fat metabolism and to assess the risk ofcardiovascular disease. Serum triglycerides are used to screen forhyperlipidemia and to determine the risk of coronary artery disease.
Loss of immunocompetence is strongly correlated with malnutrition in stressed and starving patients. The most commonly used tests of immune function are total lymphocyte count and skin testing, also called delayed cutaneous hypersensitivity.
ANS: 3The validities of creatinine-height index and nitrogen balance studies are dependent on the accuracy of the 24-hour urine collection.
Biocultural variations occur with some laboratory tests, such as hemoglobin/hematocrit, serum cholesterol, and serum transferrin.
Imbalancednutrition, less than body requirements, would result from inadequate foodintake.
Kwashiorkor (protein malnutrition) is due to diets that may be high in calories but contain little or no protein (e.g., low-protein liquid diets, fad diets, and long-term use of dextrose-containing intravenous fluids). Serum albumin <3.5 g/dl.
Normal physiological changes in aging adults that affect nutritional status include slowed gastrointestinal motility, decreased gastrointestinal absorption, diminished olfactory and taste sensitivity, decreased saliva production, decreased visual acuity, and poor dentition.
Important nutritional features of the older years are a decrease in energy requirements as a result of loss of lean body mass, the most metabolically active tissue, and an increase in fat mass.
Unless disease is suspected, evaluation of hemoglobin and hematocrit levels and urinalysis for glucose and protein levels are adequate in adolescents. In infancy, laboratory tests are performed only if nutritional problems are suspected or illnesses affect nutritional status. Many laboratory values are monitored during pregnancy and older adulthood.
Fooddiaries require the individual to write down everything consumed for a certaintime period. Because of the erratic eating patterns of this individual,assessing dietary intake over a few days would produce more accurateinformation regarding eating patterns. Direct observation is best used withyoung children or older adults.
Adequate immunity can be assessed by a positive reaction to multiple skin test antigens. Antigens are injected and the response is noted at 24 and 48 hours. Anergy occurs with malnutrition, hepatic failure, infection, and immunosuppressive drugs.
Dual-energy x-ray absorptiometry measures bone mineral density and fat and lean body mass.
Serum transferrin, with a half-life of 8 to 10 days, may be a more sensitive indicator of visceral protein status than albumin. Serum albumin has a relatively long half-life of 17 to 20 days.
Low serum albumin levels may be caused by reasons other than protein-calorie malnutrition, such as an altered hydration status and decreased liver function.
ANS: 3Marasmus, protein-calorie malnutrition, is due to an inadequate intake of protein and calories or prolonged starvation.
"Magenta tongue” is a sign of riboflavin deficiency. In contrast, a pale tongue is probably attributable to iron deficiency. Vitamin D and calcium deficiency causes osteomalacia in adults, and vitamin C deficiency causes scorbutic gums.
ANS: 2, 3
Metabolic syndrome is diagnosed when three or more of the following risk factors are present: (1) fasting plasma glucose level ?110 mg/dl; (2) blood pressure ?130/85 mm Hg; (3) waist circumference ?40 inches for men and 35 inches for women; (4) high-density lipoprotein cholesterol <40 in men and <50 in women; and (5) triglyceride levels ?150 mg/dl
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