NCLEX-PN

Levels of Consciousness Assessment : The client's consciousness is evaluated and classified into six levels: ●​ Alert ●​ Confused ●​ Lethargic ●​ Obtunded ●​ Stuporous ●​ Comatose Assessing Cognition: Cognitive evaluation encompasses orientation to time, place, and person; grounding in reality; memory assessment (remote, intermediate, and short-term); insight into illness; speech rate and quality; and abstract thinking. The Mini-Mental State test (sometimes called the " Folstein test "), is a standardized tool that evaluates cognition through orientation, basic calculations, object recognition, language, and response to commands. The test allows a maximum score of 30 points , which is determined based on the client's accurate responses and their ability to follow the examiner's instructions. Scores from 0 to 17 suggest severe cognitive impairment, 18 to 23 are somewhat mild, and 24 to 30 have no cognitive impairment. A.​ GABA (General Appearance, Behavior, Attitude) ●​ General Appearance : age/gender, appearance vs. stated age, body habitus, clothing, hygiene, grooming, physical abnormalities, tattoos, piercings. ●​ Behavior : posture, eye contact, mannerisms, tics, activity level, psychomotor retardation/activation, akathisia, automatisms, catatonia, choreoathetoid, compulsions, dystonias, tremors. ●​ Attitude : cooperative/uncooperative, seductive, flattering, charming, eager to please, entitled, controlling, hostile, guarded, critical, antagonistic, childish. B.​ Mood : The client reported an emotional tone in quotations. C.​ Affect : Physical expression of immediate feeling state. ●​ Type : euthymic, hyperthymic, elevated, euphoric, dysphoric, irritable, anxious. ●​ Quality/range : Intense > full > constricted > blunted > flat. ●​ Motility : Labile > supple/stable > sluggish. ●​ Appropriateness to content : appropriate or not Speech Rate: pressured > rapid > regular > slowed. ●​ Rhythm : prosody, cadence, latency, spontaneity Articulation: dysarthria, stuttering Accent/dialect, tone, volume/modulation. D. Speech ●​ Rate : pressured > rapid > regular > slowed. ●​ Rhythm : prosody, cadence, latency, spontaneity.

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