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
... [Show More] consciousness? CORRECT ANSWER 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 ANSWER 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 ANSWER Stuporous
The client is unconscious and does not respond to painful stimuli. What is the level of consciousness? CORRECT ANSWER Comatose
How to test a client's immediate memory CORRECT ANSWER Ask the client to repeat a series of numbers or a list of objects
How to test a client's recent memory CORRECT ANSWER 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 ANSWER 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 ANSWER Ask the client to count backward from 100 in sevens
How to assess a client's ability to think abstractly CORRECT ANSWER Ask the client to interpret something complex such as, "A bird in the hand is worth two in the bush."
Glasgow coma scale CORRECT ANSWER 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 ANSWER 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 ANSWER A. Counting backward by sevens is an appropriate technique to assess a client's cognitive abil [Show Less]