Mental Status
ABCT stands for what?
Appearance, behavior, cognition, and thought process.
When we have more time to assess a client's potential dependency or abuse of alcohol, what assessment can we use?
AUDIT, or the AUDIT-C (which is a condensed version of the AUDIT). AUDIT is 10 questions total.
EASI stands for what, and screens for what?
BAMS is an acronym for what assessment?
The general survey
This heart sound is heard right before S1
S4
GAD-7 assesses for what?
Generalized Anxiety Disorder.
The CIWA assessment screens for what?
Alcohol withdrawal.
True or false: the Danger Assessment tells the client they are at risk for homicide.
False: it is used to help the client realize how often they are being abused. On the 20 question questionnaire, and the more "yeses" the client has, the more dangerous their situation is.
FICA is a tool to assess for which holistic part of the patient?
Spirituality.
This lung sound is mixed, and expected to be heard over beside the sternum, and scapulas.
Bronchovesicular.
PHQ-9 assesses for what?
Depression. You start out with 2 questions, if they show potential signs of depression in those first 2 questions, perform all 9 questions.
The following questions make up which assessment? Have you ever felt the need to cut down on your drinking?
Have others annoyed you by criticizing your drinking?
Have you ever felt guilty about drinking?
Have you ever felt the need to drink in the morning to steady your nerves or get rid of a hangover? (Eye opener?
What is CAGE?
Asking if a client's partner harms, insults, threatens, or screams at them is known as which screening tool?
HITS
ABCDEF assesses for what?
The vascular disease will have decreased pedal pulses, delayed capillary refill, and dried, well-proximitized wounds.
Arterial disease
ASQ assesses for what?
Suicidal Ideation.
What is the SMAST-G
Short Michigan Alcohol Screening Test-Geriatric Version
A nurse is asked by the provider to determine the age of a bruise. Is this in the scope of a nurse's practice?
No. We can document the size, shape, pattern, and color.
What are all of the ways we assess cranial nerve V (trigeminal)?
Clenching the jaw, assessing jaw strength, corneal reflex, and sensation on the forehead, cheek, and chin.
These breath sounds are abnormal, in the tracheal area, and known to be a musical sound.
What is stridor?
What is the difference between the MMSE (Mini Mental State Examination), MoCA (Montreal Cognitive Assessment), and the Mini-cog?
MMSE: Assesses baseline and ongoing decline (progression)
MoCA: detects mild cognitive impairments
Mini-cog: rapid screening that assesses baseline and progression
When a client scores an 8 or more on a CIWA scale, what medications are we supposed to give them?
Versed or Lorazepam (short-acting benzodiazepines).
Which populations are at higher risks of IPV?
Those who have many societal stressors (live in poverty, minority, and immigrants), those without citizenship, lack of culturally appropriate care, those who are unaware of their resources, and those who are of sexual and gender minorities.
A pressure ulcer that is shallow and has an open wound is what stage?
Stage 2
How can you tell a client has chronic venous insufficiency?
Browned discoloration of the shins, sense of fullness in the leg at the end of the day, elevation alleviates leg pain, good pulses, good capillary refills, moist wounds that have an irregular edge, varicose veins.