Chapter 5 - Mental Status Assessment

Question 1

During an examination, the nurse can assess mental status by which activity?
a. examining the Pt’s electroencephalogram
b. observing the Pt as he/she performs and intelligence quotient (IQ) test
c. observing the Pt and inferring health or dysfunction
d. examining the Pt’s response to a specific set of questions

Answer 1

C

Question 2

The nurse is assessing the mental status of a child. Which statement about children and mental status is true?
a. All aspects of mental status in children are interdependent.
b. Children are highly labile and unstable until the age of 2 years.
c. Childrens mental status is largely a function of their parents level of functioning until the age of 7 years.
d. A childs mental status is impossible to assess until the child develops the ability to concentrate.

Answer 2

a

Question 3

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 ability typically decreases with age.
c. May take a little longer to respond, but his general knowledge and abilities should not have declined
d. Will exhibit had a decrease in his response time because of the loss of language and a decrease in general knowledge.

Answer 3

c

Question 4

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. Presence of phobias
b. General intelligence
c. Presence of irrational thinking patterns
d. Sensory-perceptive abilities

Answer 4

d

Question 5

The nurse is preparing to conduct a mental status examination. Which statement is true regarding the mental status examination?
a. A patients family is the best resource for information about the patients coping skills.
b. Gathering mental status information during the health history interview is usually sufficient.
c. Integrating the mental status examination into the health history interview takes an enormous amount of extra time.
d. To get a good idea of the patients level of functioning, performing a complete mental status examination is usually necessary.

Answer 5

b

Question 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 nurses best course of action?
a. 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 soon subside.

Answer 6

a

Question 7

The nurse is conducting a patient interview. Which statement made by the patient should the nurse more fully explore during the interview?
a. I sleep like a baby.
b. I have no health problems.
c. I never did too good in school.
d. I am not currently taking any medications.

Answer 7

c

Question 8

A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient has dysarthric speech and is lethargic. The nurses 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 proceed onto assessing mood and affect.
c. Conduct an in-depth speech evaluation, and defer the mental status examination to another time.
d. Proceed with the examination, and assess the patient for suicidal thoughts because dysarthria is often accompanied by severe depression.

Answer 8

a

Question 9

A 19-year-old 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 that:
a. She probably does not have any problems.
b. She is only trying to shock people and that her dress should be ignored.
c. She has a manic syndrome because of her abnormal dress and grooming.
d. More information should be gathered to decide whether her dress is appropriate.

Answer 9

d

Question 10

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. 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 the patient may not be certain of the date.
d. May show evidence of some clouding of his level of consciousness.

Answer 10

c

Question 11

During a mental status examination, the nurse wants to assess a patients 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 11

a

Question 12

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 12

c

Question 13

A 45-year-old 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 30-minute delay
d. Recall; after a 60-minute delay

Answer 13

c

Question 14

During a mental status assessment, which question by the nurse would best assess a persons judgment?
a. Do you feel that you are being watched, followed, or controlled?
b. Tell me what you plan to do once you are discharged from the hospital.
c. What does the statement, People in glass houses shouldnt throw stones, mean to you?
d. What would you do if you found a stamped, addressed envelope lying on the sidewalk?

Answer 14

b

Question 15

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 just broke up with her boyfriend and states that she would like to kill herself
d. Older adult man who tells the nurse that he is going to join his wife in heaven tomorrow and plans to use a gun

Answer 15

d

Question 16

The nurse is performing a mental status assessment on a 5-year-old girl. Her parents are undergoing a bitter divorce and are worried about the effect it is having on their daughter. Which action or statement might lead the nurse to be concerned about the girls mental status?
a. She clings to her mother whenever the nurse is in the room.
b. She appears angry and will not make eye contact with the nurse.
c. Her mother states that she has begun to ride a tricycle around their yard.
d. Her mother states that her daughter prefers to play with toddlers instead of kids her own age while in daycare.

Answer 16

d

Question 17

The nurse is assessing orientation in a 79-year-old patient. Which of these responses would lead the nurse to conclude that this patient is oriented?
a. I know my name is John. I couldnt tell you where I am. I think it is 2010, though.
b. I know my name is John, but to tell you the truth, I get kind of confused about the date.
c. I know my name is John; I guess Im at the hospital in Spokane. No, I dont know the date.
d. I know my name is John. I am at the hospital in Spokane. I couldnt tell you what date it is, but I know that it is February of a new year2010.

Answer 17

d

Question 18

The nurse is performing the Denver II screening test on a 12-month-old infant during a routine well-child visit. The nurse should tell the infants parents that the Denver II:
a. Tests three areas of development: cognitive, physical, and psychological
b. Will indicate whether the child has a speech disorder so that treatment can begin.
c. Is a screening instrument designed to detect children who are slow in development.
d. Is a test to determine intellectual ability and may indicate whether problems will develop later in school.

Answer 18

c

Question 19

A patient drifts off to sleep when she is not being stimulated. The nurse can easily arouse her by calling her name, but the patient remains drowsy during the conversation. The best description of this patients level of consciousness would be:
a. Lethargic
b. Obtunded
c. Stuporous
d. Semialert

Answer 19

a

Question 20

A patient has had a cerebrovascular accident (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 patients problem?
a. Global aphasia
b. Brocas aphasia
c. Echolalia
d. Wernickes aphasia

Answer 20

d

Question 21

A patient repeatedly seems to 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 21

c

Question 22

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 babys bottom.
d. I wash my hands, wash them, wash them. I usually go to the sink and wash my hands.

Answer 22

c

Question 23

A patient describes feeling an unreasonable, irrational fear of snakes. His fear is so persistent that he can no longer comfortably look at even 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, which must stem from an early traumatic incident involving snakes.

Answer 23

a

Question 24

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 but then laughs loudly at the content. This behavior is a display of:
a. Confusion
b. Ambivalence
c. Depersonalization
d. Inappropriate affect

Answer 24

d

Question 25

During reporting, the nurse hears that a patient is experiencing hallucinations. Which is an example of a hallucination?
a. Man believes that his dead wife is talking to him.
b. Woman hears the doorbell ring and goes to answer it, but no one is there.
c. Child sees a man standing in his closet. When the lights are turned on, it is only a dry cleaning bag.
d. Man believes that the dog has curled up on the bed, but when he gets closer he sees that it is a blanket.

Answer 25

a

Question 26

A 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. For the mental status examination, the nurse should first assess the patients:
a. Affect and mood
b. Memory and affect
c. Language abilities
d. Level of consciousness and cognitive abilities

Answer 26

d

Question 27

A patient states, I feel so sad all of the time. I cant 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 a 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 27

c

Question 28

A 26-year-old woman was robbed and beaten a month ago. She is returning to the clinic today for a follow- up assessment. The nurse will want to ask her which one 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 28

d

Question 29

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 the assessment of an individuals behaviors.
d. Mental status can be directly assessed, similar to other systems of the body (e.g., heart sounds, breath sounds).

Answer 29

c

Question 30

A 23-year-old 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. Describe the meaning of the phrase, Looking through rose-colored glasses.
d. Pick up the pencil in your left hand, move it to your right hand, and place it on the table.

Answer 30

d

Question 31

The nurse is planning health teaching for a 65-year-old woman who has had a cerebrovascular accident (stroke) and has aphasia. Which of these questions is most important to use when assessing mental status in this patient?
a. Please count backward 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 31

c

Question 32

A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self- mutilation and has a history of 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 nurses 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. People often feel hopeless, but the feelings resolve within a few weeks.

Answer 32

c

Question 33

The nurse is providing instructions to newly hired graduates for the minimental state examination (MMSE). Which statement best describes this examination?
a. Scores below 30 indicate cognitive impairment.
b. The MMSE is a good tool to evaluate mood and thought processes.
c. This examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness.
d. The MMSE is useful tool for an initial evaluation of mental status. Additional tools are needed to evaluate cognition changes over time.

Answer 33

c

Question 34

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 stereotypical words or sounds. This finding reflects which type of aphasia?
a. Global
b. Brocas
c. Dysphonic
d. Wernickes

Answer 34

a

Question 35

A patient repeats, I feel hot. Hot, cot, rot, tot, got. Im a spot. The nurse documents this as an illustration of:
a. Blocking
b. Clanging
c. Echolalia
d. Neologism

Answer 35

b

Question 36

The nurse is administering a Mini-Cog test to an older adult 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 an incorrect time. This result indicates which finding?
a. Cognitive impairment
b. Amnesia
c. Delirium
d. Attention-deficit disorder

Answer 36

a

Question 37

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 37

a

Question 38

The nurse is assessing a patient who is admitted with possible delirium. Which of these are manifestations of delirium? Select all that apply.
a. Develops over a short period.
b. Person is experiencing apraxia.
c. Person is exhibiting memory impairment or deficits.
d. Occurs as a result of a medical condition, such as systemic infection.
e. Person is experiencing agnosia.

Answer 38

a, c, d