Ch. 5 (Mental Status Assessment)

Question 1

When should a nurse perform a mental status assessment?

Answer 1

• comprehensive assessment
• focused exam if client is experiencing issues (e.g. confusion, memory loss, anxiety)

Question 2

How is a mental health status assessment performed?

Answer 2

through
* inspection
* special tests (MMSE, MOCA, Mini-Cog)

Question 3

What are the nurse’s responsibilities when performing a mental health status assessment?

Answer 3

• assess
• interpret
• report
• document findings

Question 4

What is described as a significant behavioral or psychological pattern that is associated with distress or disability (impaired functioning) and has a significant risk of pain, disability, death, or loss of freedom?

Answer 4

mental disorder

Question 5

What is described as a person’s emotional and cognitive functioning?

Answer 5

mental status

Question 6

What are the two different categories of mental disorders?

Answer 6

• organic disorder
• psychiatric mental illness

Question 7

There are two different categories relative to mental disorders.

What type of mental disorder is caused by brain disease of a known specific organic (eg. alzheimers)?

Answer 7

organic disorder

Question 8

There are two different categories relative to mental disorders.

What type of mental disorder is caused by an unknown cause (eg. depression)?

Answer 8

psychiatric mental illness

Question 9

What some developmental considerations of older adults?

Answer 9

• processing & response time is slower
• recent memory falters

Question 10

True or False?:

Sensory perception can affect a person’s mental status.

Answer 10

true

(someone who is deaf/hard of hearing cannot respond properly)

Question 11

What four categories fall under mental status?

Answer 11

• appearance (posture, positioning, body movements, appropriate dressing/grooming)
• behavior (lvl. of consciousness, facial expressions, speech, mood/affect)
• cognition (orientation, attention span, recent/remote memory, new learning)
• thought process (perceptions, logical, liniear, future oriented, hallucinations/delusions, suicidal/homicidal thoughts)

also known as A, B, C, T

Question 12

What type of exam tests cognitive function through eleven questions and takes five to ten minutes?

Answer 12

mini mental state exam

Question 13

When testing anxiety, you should ask what question?

Answer 13

if you could describe your anxiety without the word anxious, how would you describe it?

Question 14

When assessing a patient’s remote memory, what do you have to make sure you know?

Answer 14

the remote memory is verifiable

Question 15

What type of exam tests cognitive impairment through a three-item recall and clock-drawing test?

Answer 15

mini-cog

Question 16

What is the most common screen given to test for anxiety disorders?

Answer 16

generalized anxiety disorder scale (GAD-7)

Question 17

What is the most common screen given to test depression disorders?

Answer 17

patient health questionaire-2/9 (PHQ-2 or PHQ-9)

Question 18

What does the seven mean in GAD-7?

Answer 18

seven questions

(number in title usually represents how many questions in screen)

Question 19

If a patient comes in with a total score of 15 on their GAD-7, what would that mean?

Answer 19

severe anxiety

Question 20

A GAD-7 screen is given to a patient.

What score would prompt a further evaluation in a patient without a known anxiety disorder?

Answer 20

an 8 or higher

Question 21

If a patient comes in with a total score of 5 on their GAD-7, what would that mean?

Answer 21

mild anxiety

Question 22

If a patient comes in with a total score of 10 on their GAD-7, what would that mean?

Answer 22

moderate anxiety

Question 23

If a patient comes in with a score between the ranges 5-9 on their PHQ-9, what would that mean?

Answer 23

minimal symptoms

Question 24

If a patient comes in with a score between the ranges 10-14 on their PHQ-9, what would that mean?

Answer 24

minor depression

Question 25

If a patient comes in with a score between the ranges 15-19 on their PHQ-9, what would that mean?

Answer 25

major depression

Question 26

If a patient comes in with a score between the ranges over 20 on their PHQ-9, what would that mean?

Answer 26

major/severe depression

Question 27

A patient comes in an acute confusional state, disoriented with disordered thinking and perceptions. What is their assumed diagnosis?

Answer 27

delirium