NUR103: Ch. 5, 6, & 7

A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination. What should the nurse expect during this patient’s tests of cognitive function?

• May display some disruption in thought content.

• Will state, “I am so relieved to be out of intensive care.”

• Will be oriented to place and person, but the patient may not be certain of the date.

• May show evidence of some clouding of his level of consciousness.

During a mental status examination, the nurse wants to assess a patient’s affect. Which question the nurse should ask?

• “How do you feel today?”

• “Would you please repeat the following words?”

• “Have these medications had any effect on your pain?”

• “Has this pain affected your ability to get dressed by yourself?”

A 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. When conducting the mental status examination for this patient, what should the nurse assess first?

• Affect and mood

• Memory and affect

• Cognitive abilities

• Level of consciousness

The nurse is planning to assess new memory with a patient. Which is the best way for the nurse to do this?

• Administer the FACT test.

• Ask him to describe his first job.

• Give him the Four Unrelated Words Test.

• Ask him to describe what television show he was watching before coming to the clinic.

During a session on substance abuse, the nurse is reviewing statistics with the class. For people aged 12 years and older, which illicit substance was most commonly used?

• Heroin

• Marijuana

• Crack cocaine

• Hallucinogens

The nurse is reviewing aspects of substance abuse in preparation for a seminar. Which of these statements illustrates the concept of tolerance to an illicit substance?

• A physiologic dependence on a substance.

• A person requires an increased amount of the substance to produce the same effect.

• A person requires daily use of the substance to function and is unable to stop using it.

• A person experiences a syndrome of physiologic symptoms if the substance is not used.

The nurse is admitting a patient with an addiction to alcohol to a treatment center. Which screening tool should the nurse use to assess for symptoms of alcohol withdrawal?

• TWEAK

• AUDIT

• SMAST-G

• CIWA-Ar

When reviewing the use of alcohol by older adults, the nurse notes that older adults have several characteristics that can increase the risk for alcohol use. Which would increase the bioavailability of alcohol in the blood for longer periods in the older adult? (Select all that apply.)

• Increased muscle mass

• Decreased blood pressure

• Increased cardiac output

• Decreased liver metabolism

• Decreased kidney functioning

What should the nurse include when documenting IPV and older adult abuse?

• Photographic documentation of the injuries

• Summary of the abused patient’s statements

• General description of injuries in the progress notes

• Verbatim documentation of every statement made by the victim

As a mandatory reporter of older adult abuse, which must be present before a nurse should notify the authorities?

• Statements from victim

• Statements from witnesses

• Proof of abuse and/or neglect

• Suspicion of older adult abuse and/or neglect