with Complete Solutions
Level of consciousness - Correct Answer Alert- responsive
Lethargic- able to open eyes and respond but is drowsy
Stupor - requires painful stimuli to elicit brief response
Coma - no response (abnormal posturing: decorticate/ decerebrate rigidity)
Physical Apperance - Correct Answer Personal hygiene
Grooming
Clothing choice (appropriate for environment)
Behavior - Correct Answer Voluntary movements
Involuntary movements
Eye contact
Mood - Correct Answer Emotion being felt
Affect - Correct Answer Objective expression of mood
Ex: flat or lack of facial expression
Cognitive and Intellect - Correct Answer Orientation to time, person, place
Memory- recent and remote
Immediate= repeat series of numbers
Recent= recall recent events
Remote= state verifiable fact from past
Level of knowledge
Ability to calculate
Assess ability to think abstractly
Objective assessment of perception of illness
, Assess logical judgment based on a hypothetical question
Assess rate and volume of speech
MMSE - Correct Answer Orientation to time/place
Attention span
Ability to calculate
Registration/recalling of objects
Language including naming of objects, following commands, ability to write
HEADSS - Correct Answer Home
Education/employment
Peer group activities
Drugs
Sexuality
Suicide depression
Glasgow Coma Scale - Correct Answer Eye
Verbal
Motor Response
15= perfect
<7= coma
Diagnostic and Statistical Manual of Mental Disorders 5th Edition - Correct Answer Help identify
diagnoses and diagnostic criteria to guide assessment
Identify nursing diagnosis
Plan, implement, evaluate care
Therapeutic Nursing interventions - Correct Answer Counseling
Milieu therapy
Promotion of self-care activities
Psychobiological interventions