30 Questions
What is the primary purpose of Gordon's Functional Health Patterns?
To identify the three types of health patterns in a person
What is an example of a functional pattern in a person?
Coping with stressful situations
What is the role of the nurse when identifying dysfunctional patterns in a client?
To focus on the client's strengths and plan teaching accordingly
What is an example of a potentially dysfunctional pattern in a person?
Being a pre-diabetic
What is the goal of assessing a client's functional health patterns?
To understand the client's strengths and weaknesses
What is the difference between dysfunctional and potentially dysfunctional patterns?
Dysfunctional patterns are present health issues, while potentially dysfunctional patterns are risk conditions for future health problems
What is the primary focus of sensory awareness in the context of mental status examination?
External stimuli in the environment and their interrelationships
What aspect of thought processes refers to the logic, coherence, and relevance of a person's thoughts?
Thought processes themselves
What is the primary function of judgment in the context of mental status examination?
To compare and evaluate alternatives when deciding on a course of action
What is the key feature that distinguishes insight from judgment?
The recognition of symptoms or disturbed behaviors as normal or abnormal
What is the primary focus of the level of consciousness in the context of mental status examination?
The patient's awareness of their environment and internal stimuli
What is the relationship between thought content and insight in the context of mental status examination?
Thought content refers to what a person thinks about, while insight refers to the awareness of the abnormality of those thoughts
What is the term for the emotional expression that is consistent with the mood?
Congruence
Which type of thought process involves verbalizations that shift from one unrelated topic to another?
Associative looseness
What is the term for the creation of nonsensical sounding words that only have meaning to the individual?
Neologisms
What type of thinking is literal and lacks the ability to think abstractly?
Concrete thinking
What is the term for the outward emotional expression that is incompatible with the situation?
Inappropriate
Which type of thought process involves speaking in puns or rhymes; using words that sound alike but have different meanings?
Clang associations
What is the purpose of assessing a client's mental status?
To develop a plan of care
What is included in the assessment of violence risk?
Thoughts of harming others, lethality of the plan, and means to carry out the plan
What is the purpose of asking about high-risk behaviors in a psychosocial assessment?
To identify the client's self-injurious behaviors
What is included in the abuse assessment?
History of physical harm, threats, and forced sexual contact
What is a critical component of the mental status assessment?
Evaluating the client's mental functioning in all areas
Why is it important to assess a client's suicidal thoughts?
To evaluate the client's risk of harming themselves
Who introduced the task of measuring attentional disturbances in 1899?
Kraepelin
What is the primary reason the subtraction version is the most commonly administered version?
It is perceived as more difficult than serial additions
What is the purpose of the Memory NEW LEARNING ABILITY task?
To determine if a patient can recall new information
How many items were included in the 1942 version of the task?
14 items
What is the primary focus of the Higher Cognitive Functions Information and Vocabulary task?
Evaluating a patient's understanding of complex ideas
How long should a patient be given to recall the words in the Memory NEW LEARNING ABILITY task?
3-5 minutes
Study Notes
Functional Health Patterns
- Gordon's Functional Health Patterns help identify three types of health patterns in a person: functional, dysfunctional, and potentially dysfunctional patterns
- Functional patterns are strengths and powers of a client to overcome dysfunctional and potential dysfunctional patterns
- Examples of functional patterns include how a person copes with stressful situations in daily life
Dysfunctional Patterns
- Dysfunctional patterns are concerns where the nurse identifies a problem in normal health patterns
- Examples of dysfunctional patterns include high blood pressure
- The nurse identifies the coping strengths of the client and plans teaching based on the strengths rather than nursing interventions
Potentially Dysfunctional Patterns
- Potentially dysfunctional patterns are risk conditions of a client that can develop in the future
- Examples of potentially dysfunctional patterns include a pre-diabetic client at risk of developing diabetes
Mental Status Examination
- Level of Consciousness: awareness of the environment and internal stimuli
- Thought Processes:
- Logic, coherence, and relevance of the patient's thought
- Content: what the patient thinks about, including level of insight and judgment
- Judgment: process of comparing and evaluating alternatives when deciding on a course of action
Emotions and Affect
- Congruence with mood: outward emotional expression is consistent with mood
- Constricted or blunted: minimal outward emotional expression
- Flat: absence of outward emotional expression
- Appropriate: outward emotional expression is expected in a certain situation
- Inappropriate: outward emotional expression is incompatible with the situation
Thought Processes: Form of Thought
- Flight of ideas: verbalizations are continuous and rapid
- Associative looseness: verbalizations shift from one unrelated topic to another
- Circumstantiality: verbalizations are lengthy and tedious
- Tangentiality: verbalizations are lengthy and tedious, and never reach an intended point
- Clang associations: speaking in puns or rhymes
- Concrete thinking: thinking is literal and elemental
- Neologisms: making up nonsensical sounding words
Psychosocial Assessment
- Questions to ask to assess violence risk:
- Thoughts of hurting oneself or others
- Previous suicide attempts or plans
- Means to carry out a plan
- Intent to carry out a plan
- Lethality of the plan
- Questions to ask to assess abuse:
- History of physical harm or threats from others
- Forced sexual contact
- History of abuse
Mental Status Assessment
- Gathering correct information about the client's mental status is essential for developing an appropriate plan of care
- Components of mental status assessment:
- Level of Consciousness
- Thought Processes
- Judgment
- Emotions and Affect
- Thought Content
- Insight and Judgment
Physical Examination
- Mental Status Assessment is a description of all areas of the client's mental functioning
Assess your understanding of mental status examination concepts, including awareness of the environment, thought processes, and content. Test your knowledge of the logic, coherence, and relevance of patient thought patterns and their insight and judgment.
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