N260-Chapter 6

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N260-Chapter 6
2012-10-11 03:07:47
260 chap6 nurs260

Chapter 6 Assessing Mental Status & Psychosocial Developmental Level
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  1. Assess the clients mental status using the Mini-Mental State Examination Tool.
    a brief 30-point questionnaire test that is used to screen for cognitive impairment. It is commonly used in medicine to screen for dementia. It is also used to estimate the severity of cognitive impairment and to follow the course of cognitive changes in an individual over time, thus making it an effective way to document an individual's response to treatment. Any score greater than or equal to 25 points (out of 30) is effectively normal (intact). Below this, scores can indicate severe (9 points), moderate (10-20 points) or mild (21-24 points) cognitive impairment

    • MiniMental State Tests:
    • Orientation- time and place
    • Registration- repeating prompts
    • Attention and calculation- ex spelling backwards
    • Recall
    • Language- ex naming an object
  2. Identify and describe five levels of consciousness.
    • Alert- Client is alert and oriented to what is happening at the time of the interview
    • and physical assessment. Client is alert to person, place, day, and time, and responds to your questions and interacts
    • appropriately.
    • Lethargic (somnolent)- Client opens eyes, answers questions, and falls back asleep.
    • Obtunded- Client opens eyes to loud voice, responds slowly with confusion, seems unaware of environment
    • Stupor or semicoma- Client awakens to vigorous shake or painful stimuli but returns to unresponsive sleep.
    • Coma- Client remains unresponsive to all stimuli; eyes stay closed. Client with lesions of the corticospinal tract draws
    • hands up to chest when stimulated
    • Acute confusional state (delirium)
  3. Explain how and when to use the Glasgow Coma Scale with a client.
    The Glasgow Coma Scale is useful for rating ones response to stimuli. Use the Glasgow Coma Scale (GCS) for clients who are at high risk for rapid deterioration of the nervous system.

    GCS score of less than 14 indicates some impairment in the level of consciousness. The client who scores 10 or lower needs emergency attention. The client with a score of 7 or lower is generally considered to be in a coma. A score of 3, the lowest possible score, indicates deep coma.
  4. Describe Eriksons developmental tasks for the Young Adult, Middle-Aged Adult and Older Adult.
    • Young adult: Intimacy versus isolation (Affiliation and love)
    • Middle-aged adult: Generativity versus stagnation (Production and care)
    • Older adult: Integrity versus despair (Renunciation and wisdom)