Chapter 5

Question 1

During an examination, the nurse can assess mental status by which activity?

A) Examining the patient’s electroencephalogram
B) Observing the patient as he or she performs an IQ test
C) Observing the patient and inferring health or dysfunction
D) Examining the patient’s response to a specific set of questions

Answer 1

C) Observing the patient and inferring health or dysfunction

Question 2

The nurse is assessing a 75 ­year ­old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient:

A) will have no decrease in any of his abilities, including response time.
B) will have difficulty on tests of remote memory because this typically decreases with age.
C) may take a little longer to respond, but his general knowledge and abilities should not have declined.
D) will have had a decrease in his response time because of language loss and a decrease in general knowledge.

Answer 2

C) may take a little longer to respond, but his general knowledge and abilities should not have declined.

Question 3

When assessing aging adults, the nurse knows that one of the first things that should be assessed before making judgments about their mental status is:

A) the presence of phobias.
B) their general intelligence.
C) the presence of irrational thinking patterns.
D) their sensory ­perceptive abilities.

Answer 3

D

Question 4

5. The nurse is preparing to do a mental status examination. Which statement is true regarding the mental status examination?

A) A patient’s family is the best resource for information about the patient’s coping skills.
B) It is usually sufficient to gather mental status information during the health history interview.
C) It takes an enormous amount of extra time to integrate the mental status examination into the health history interview.
D) It is usually necessary to perform a complete mental status examination to get a good idea of the patient’s level of functioning.

Answer 4

B

Question 5

6. A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse’s best course of action? The nurse should:

A) plan to perform a complete mental status examination.
B) refer him to a psychometrician.
C) plan to integrate the mental status examination into the history and physical examination.
D) reassure his wife that memory loss after a physical shock is normal and will subside soon.

Answer 5

A

Question 6

The nurse is conducting a patient interview. Which statement made by the patient should the nurse explore more fully during the interview? The patient states that he:

A) “sleeps like a baby.”
B) has no health problems.
C) “never did too good in school.”
D) Currently is not taking any medication.

Answer 6

C

Question 7

8. A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient’s speech is dysarthric and that she is lethargic. The nurse’s best approach regarding this examination is to:
   A) plan to defer the rest of the mental status examination.
   B) skip the language portion of the examination and go on to assess mood and affect.
   C) do an in­depth speech evaluation and defer the mental status examination to another time.
   D) go ahead and assess for suicidal thoughts because dysarthria is often accompanied by severe depression.

Answer 7

A

Question 8

A 19­year­old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes.Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. The
nurse concludes:

A) she probably doesn’t have any problems at all.
B) she is just trying to shock people and her dress should be ignored.
C) she has manic syndrome because of her abnormal dress and grooming.
D) that more information should be gathered to decide whether her dress is appropriate.

Answer 8

D

Question 9

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 on him. During the tests of cognitive function the nurse would expect that he:
A) may display some disruption in thought content.
B) will state, “I am so relieved to be out of intensive care.”
C) will be oriented to place and person but may not be certain of the date.
D) may show evidence of some clouding of his level of consciousness.

Answer 9

C

Question 10

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

A) “How do you feel today?”
B) “Would you please repeat the following words?”
C) “Have these medications had any effect on your pain?”
D) “Has this pain affected your ability to get dressed by yourself?”

Answer 10

A

Question 11

The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to:

A) administer the FACT test.
B) ask him to describe his first job.
C) give him the Four Unrelated Words Test.
D) ask him to describe what television show he was watching before coming to the

clinic.

Answer 11

C

Question 12

A 45­year­old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she could not _____ four unrelated words _____.

A) invent; within 5 minutes
B) invent; within 30 seconds
C) recall; after a 30­minute delay
D) recall; after a 60­minute delay

Answer 12

C

Question 13

14. During a mental status assessment, which question by the nurse would best assess a person’s judgment?

A) “Do you feel that you are being watched, followed, or controlled?”
B) “Tell me about what you plan to do once you are discharged from the hospital.”
C) “What does the statement, ‘People in glass houses shouldn’t throw stones,’ mean to you?”
D) “What would you do if you found a stamped, addressed envelope lying on the sidewalk?”

Answer 13

B

Question 14

Which of these individuals would the nurse consider at highest risk for a suicide attempt?

A) Man who jokes about death
B) Woman who, during a past episode of major depression, attempted suicide
C) Adolescent who has just broken up with her boyfriend and states that she would like to kill herself
D) Elderly man who tells the nurse that he is going to “join his wife in heaven” tomorrow and plans to use a gun

Answer 14

D

Question 15

The nurse is assessing orientation in a 79­year­old patient. Which of these responses would lead the nurse to conclude that this patient is oriented?

A) “I know that my name is John. I couldn’t tell you where I am. I think it is 2010, though.”
B) “I know that my name is John, but to tell you the truth, I get kind of confused about the date.”
C) “I know that my name is John; I guess I’m at the hospital in Spokane. No, I don’t know the date.”
D) “I know that my name is John. I am at the hospital in Spokane. I couldn’t tell you what date it is, but I know that it is February of a new year—2010.”

Answer 15

D

Question 16

A patient drifts off to sleep when she is not being stimulated. The nurse can arouse her easily when calling her name, but she remains drowsy during the conversation. The best description of this patient’s level of consciousness would be:

A) lethargic.
B) obtunded.
C) stuporous.
D) semialert.

Answer 16

A

Question 17

A patient has had a cerebrovascular accident, or stroke. He is trying very hard to communicate. He seems driven to speak and says, “I buy obie get spirding and take my train.” What is the best description of this patient’s problem?

A) Global aphasia
B) Broca’s aphasia
C) Echolalia
D) Wernicke’s aphasia

Answer 17

D

Question 18

22. A patient seems to repeatedly have difficulty coming up with a word. He says, “I was on my way to work, and when I got there, the thing that you step into that goes up in the air was so full that I decided to take the stairs.” The nurse will note on his chart that he is using or experiencing:

A) blocking.
B) neologism.
C) circumlocution.
D) circumstantiality.

Answer 18

C

Question 19

23. During an examination, the nurse notes that a patient is exhibiting flight of ideas. Which statement by the patient is an example of flight of ideas?

A) “My stomach hurts. Hurts, spurts, burts.”
B) “Kiss, wood, reading, ducks, onto, maybe.”
C) “Take this pill? The pill is red. I see red. Red velvet is soft, soft as a baby’s bottom.”
D) “I wash my hands, wash them, wash them. I usually go to the sink and wash my hands.”

Answer 19

C

Question 20

persistent that he can no longer comfortably even look at pictures of snakes and has made an effort to identify all the places he might encounter a snake and avoids them. The nurse recognizes that he:

A) has a snake phobia.
B) is a hypochondriac; snakes are usually harmless.
C) has an obsession with snakes.
D) has a delusion that snakes are harmful, and it must stem from an early traumatic incident involving snakes.

Answer 20

A

Question 21

A patient has been diagnosed with schizophrenia. During a recent interview, he shows the nurse a picture of a man holding a decapitated head. He describes this picture as
horrifying and laughs loudly at the content. This behavior is a display of:

A) confusion.
B) ambivalence.
C) depersonalization.
D) inappropriate affect.

Answer 21

D

Question 22

During report, the nurse hears that a patient is experiencing hallucinations.Which is an example of a hallucination?

A) A man believes that his dead wife is talking to him.
B) A woman hears the doorbell ring and goes to answer it, but no one is there.
C) A child sees a man standing in his closet. When the lights are turned on, it is only a dry cleaning bag.
D) A man believes that the dog has curled up on the bed, but when he gets closer he sees that it is a blanket.

Answer 22

A

Question 23

A 20­year­old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of the fluid and electrolyte imbalance. For the mental status examination, the nurse should first assess the patient’s:

A) affect and mood.
B) memory and affect.
C) language abilities.
D) level of consciousness and cognitive abilities.

Answer 23

D

Question 24

A patient states, “I feel so sad all of the time. I can’t feel happy even doing things I used to like to do.” He also states that he is tired, sleeps poorly, and has no energy. To differentiate between dysthymic disorder and a major depressive disorder, the nurse should ask which question?

A) “Have you had any weight changes?”
B) “Are you having any thoughts of suicide?”
C) “How long have you been feeling this way?”
D) “Are you having feelings of worthlessness?”

Answer 24

C

Question 25

A 26­ year­old woman was robbed and beaten a month ago. She is returning to the clinic today for a follow­up assessment. The nurse would want to be certain to ask her which of these questions?

A) “How are things going with the trial?”
B) “How are things going with your job?”
C) “Tell me about your recent engagement!”
D) “Are you having any disturbing dreams?”

Answer 25

D

Question 26

30. The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status?

A) Mental status assessment diagnoses specific psychiatric disorders.
B) Mental disorders occur in response to everyday life stressors.
C) Mental status functioning is inferred through assessment of an individual’s behaviors.
D) Mental status can be assessed directly, just like other systems of the body (e.g.,

cardiac and breath sounds).

Answer 26

C

Question 27

A 23­year­old patient in the clinic appears anxious. Her speech is rapid, and she is fidgety and in constant motion. Which of these questions or statements would be most appropriate for the nurse to use in this situation to assess attention span?

A) “How do you usually feel? Is this normal behavior for you?”
B) “I am going to say four words. In a few minutes, I will ask you to recall them.”
C)“Please describe the meaning of the phrase, ‘Looking through rose­colored glasses.’”
D) “Please pick up the pencil in your left hand, move it to your right hand, and place it on the table.”

Answer 27

D

Question 28

The nurse is planning health teaching for a 65­year­old woman who has had a cerebrovascular accident, or stroke, and is aphasic. Which of these questions is most important to use when assessing mental status in this situation?

A) “Please count back from 100 by seven.”
B) “I will name three items and ask you to repeat them in a few minutes.”
C) “Please point to articles in the room and parts of the body as I name them.”
D) “What would you do if you found a stamped, addressed envelope on the sidewalk?”

Answer 28

C

Question 29

A 30­year­old female patient is describing feelings of hopelessness and depression. She has attempted self­mutilation and has a history of prior suicide attempts.
She describes difficulty sleeping at night and has lost 10 pounds in the past month. Which of these statements or questions is the nurse’s best response in this situation?

A) “Do you have a weapon?”
B) “How do other people treat you?”
C) “Are you feeling so hopeless that you feel like hurting yourself now?”
D) “Oftentimes people feel hopeless, but the feelings resolve within a few weeks.”

Answer 29

C

Question 30

The nurse is providing instructions to newly hired graduates about the Mini- Mental State Examination. Which statement best describes this examination?

A) Scores below 30 indicate cognitive impairment.
B) It is a good tool to evaluate mood and thought processes.
C) It is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness.
D) It is useful for an initial evaluation of mental status. Additional tools are needed to evaluate cognition changes over time.

Answer 30

C

Question 31

A 45­year­old woman is brought to the emergency department with a head injury after her car hit a tree. A few months after recovering from her injuries, the nurse
notes during an examination that she is unable to learn new information or recall previously learned information. This is an example of:

A) mania.
B) agnosia.
C) dementia.
D) amnestic disorder.

Answer 31

D

Question 32

36. The nurse discovers speech problems in a patient during an assessment. The patient has spontaneous speech, but it is mostly absent or is reduced to a few stereotyped words or sounds. This finding reflects which type of aphasia?

A) Global
B) Broca’s
C) Dysphonic
D) Wernicke’s

Answer 32

A

Question 33

A patient repeats, “I feel hot. Hot, cot, rot, tot, got. I’m a spot.” The nurse documents this as an illustration of:

A) blocking.
B) clanging.
C) echolalia.
D) neologism.

Answer 33

B

Question 34

During an interview, the nurse notes that the patient gets up several times to wash her hands even though they are not dirty. This is an example of:

A) social phobia.
B) compulsive disorder.
C) generalized anxiety disorder.
D) posttraumatic stress disorder.

Answer 34

B

Question 35

The nurse is administering a Mini­Cog test to an elderly woman. When asked to draw a clock showing the time of 10:45, the patient drew a clock with the numbers out of
order and with the time incorrect. This result indicates which finding?

A) Cognitive impairment
B) Amnesia
C) Delirium
D) Attention deficit disorder

Answer 35

A

Question 36

During morning rounds, the nurse asks a patient, “How are you today?” The patient responds, “You today, you today, you today!” and mumbles the words. This speech pattern is an example of:

A) Echolalia
B) Clanging
C) Word salad
D) Perseveration

Answer 36

A