Chapter 6: Mental Status Assessment

Question 1

When examining a patient, the nurse can assess mental status by:

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.

Question 2

The nurse is assessing mental status in children. Which of the following statements is true?

a. All aspects of mental status in children are interrelated.
b. Children are highly labile and unstable until the age of 2 years.
c. Until the age of 7 years, children’s mental status is largely a function of their parents’ mental status.
d. Children’s mental status is impossible to assess until they develop the ability to concentrate.

Answer 2

a.

Question 3

The nurse is assessing a 75-year-old male patient. At the beginning of 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 3

c.

Question 4

When assessing older adults, the nurse knows that one of the first things that should be assessed before drawing conclusions 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 4

d.

Question 5

Which of the following statements about the mental status examination is true?

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 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 of the following statements reflects the nurse’s best course of action?

a. The nurse should plan to perform a complete mental status examination.
b. It would be most appropriate to refer him to a psychometrician.
c. The nurse should plan to integrate the mental status examination into history taking and physical examination.
d. The nurse should reassure his wife that memory loss after a physical shock is normal and the problem will correct itself soon.

Answer 6

a.

Question 7

When interviewing a patient, it is important for the nurse to obtain some basic history. Which of the following statements should be explored more fully during an interview? The patient states that he:

a. “sleeps like a baby.”
b. has no health problems.
c. “never did too good in school.”
d. is currently not taking any medication.

Answer 7

c.

Question 8

A patient is admitted 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 in this situation is to:

a. 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 in-depth 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 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 her other clothes. Her hair is dyed pink with black streaks. She has several piercings in her nares and ears and is wearing an earring on her eyebrow and heavy black makeup. The nurse concludes:

a. she probably does not have any problems at all.
b. she is just trying to shock people and her appearance should be ignored.
c. she has manic syndrome because of her abnormal way of dressing and grooming.
d. more information should be gathered to decide whether her way of dressing 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 cognitive function tests, the nurse would expect that he:

a. might display some disruption in thought content.
b. might state, “I am so relieved to be out of intensive care.”
c. might be oriented to place and person but not be certain of the date.
d. might show evidence of some clouding of consciousness.

Answer 10

c.

Question 11

To assess affect, the nurse should ask the patient:

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 dress yourself?”

Answer 11

a.

Question 12

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

a. administer the FACT Test.
b. ask him to describe his first job to you.
c. give him the Four Unrelated Words Test.
d. ask him to describe the last TV show he watched before coming to the clinic.

Answer 12

c.

Question 13

A 45-year-old woman is at the clinic for a mental status assessment. When giving her the Four Unrelated Words Test, the nurse would be concerned if the patient:

a. could not give four unrelated words within 5 minutes.
b. could not give four unrelated words within 30 seconds.
c. could not recall four unrelated words after a 30-minute delay.
d. could not recall four unrelated words after a 60-minute delay.

Answer 13

c.

Question 14

Which of the following questions would best assess a person’s judgement?

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 saying ‘People in glass houses shouldn’t throw stones’ mean to you?”
d. “What would you do if you found a stamped, addressed envelope on the sidewalk?”

Answer 14

b.

Question 15

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

a. A man who jokes about death
b. A woman who, during a past episode of major depression, attempted suicide
c. An adolescent who has just broken up with her boyfriend and states that she wants to kill herself
d. An older adult who tells the nurse that he is going to “join his wife in heaven” tomorrow and plans to shoot himself

Answer 15

d.

Question 16

The nurse is performing a mental status assessment on a 5-year-old girl. Her parents are in the middle of a bitter divorce and are worried about the effect it is having on their daughter. Which of the following might lead the nurse to be concerned about the girl’s 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 the girl 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 would plan to use the Pediatric Symptoms Checklist with a child who is:

a. 8 years old.
b. 16 years old.
c. 5 years old, just before starting kindergarten.
d. having difficulty with gross motor skills.

Answer 17

a.

Question 18

The nurse is assessing orientation in a 79-year-old patient. Which of the following 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 this year is 2009, 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 Victoria. No, I don’t know the date.”
d. “I know that my name is John. I am at the hospital in Victoria. I couldn’t tell you what date it is, but I know that it is February of a new year—2009.”

Answer 18

d.

Question 19

The nurse has decided to administer the Set Test to Mr. C., age 70 years. To administer this test the nurse needs to:

a. ask him to name 10 each of fruits, animals, colours, and towns. The nurse will tell him that he or she will be available to help if he gets stuck.
b. ask him to name 10 items based on the categories in the acronym FACT. The nurse will tell him that he can do this without any hurry.
c. ask him to name 10 items based on the categories in the acronym FACT. If he has difficulty doing this, the nurse may prompt his memory.
d. ask him to name 10 items based on the categories in the acronym FACT. The nurse will tell him that this test is timed and he has only 2 minutes to complete it.

Answer 19

b.

Question 20

A patient drifts off to sleep when there is no stimulation. The nurse can arouse her easily by 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. semi-alert.

Answer 20

a.

Question 21

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 way for the nurse to communicate with this patient?

a. Use speech because he will understand even if the nurse cannot understand him.
b. Abandon all attempts to communicate with him. His aphasia is irreversible.
c. Give him a pencil and paper because reading and writing abilities will not be impaired.
d. Support his efforts to communicate and use pantomime and gestures to communicate when possible.

Answer 21

d.

Question 22

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

a. blocking.
b. neologism.
c. circumlocution.
d. circumstantiality.

Answer 22

c.

Question 23

Which of the following statements 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 23

c.

Question 24

A patient describes an unreasonable, irrational fear of snakes. The feeling is so persistent that he can no longer even look at pictures of snakes without feeling uncomfortable. He has tried to identify all the places where he might encounter snakes and avoids them. The nurse recognizes that:

a. he has a snake phobia.
b. he is a hypochondriac. Snakes are usually harmless.
c. he has an obsession. In this case, it is about snakes.
d. he has a delusion that snakes are harmful. It must stem from an early traumatic incident involving snakes.

Answer 24

a.

Question 25

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 laughs loudly when looking at it. This behaviour is a display of:

a. confusion.
b. ambivalence.
c. depersonalization.
d. inappropriate affect.

Answer 25

d.

Question 26

Which of the following would illustrate 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 at the door.
c. A child sees a man standing inside the closet. When the lights are turned on, it is just a dry cleaning bag.
d. A man thinks that a dog is lying curled up on his bed, but when he gets closer, he sees that it is a blanket.

Answer 26

a.

Question 27

A 20-year-old construction worker has suffered a heat stroke and has been brought into the emergency department. He has delirium as a result of fluid and electrolyte imbalance. The nurse will assess his:

a. affect and mood.
b. memory and affect.
c. thought processes and memory.
d. level of consciousness and cognitive abilities.

Answer 27

d.

Question 28

A woman has come to the clinic to seek help for a substance abuse problem. She admits to using cocaine just before coming to the clinic. Which of the following describes what the nurse may find when examining this woman?

a. Dilated pupils, pacing, psychomotor agitation
b. Dilated pupils, unsteady gait, aggressiveness
c. Pupil constriction, lethargy, apathy, dysphoria
d. Constricted pupils, euphoria, decreased temperature

Answer 28

a.

Question 29

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

a. “Has there been any change in your weight?”
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 29

c.

Question 30

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 must be sure to ask her:

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 30

d.

Question 31

Which of the following statements about mental status assessment is true?

a. Mental status assessment diagnoses specific psychiatric disorders.
b. Mental disorders occur in response to everyday life stressors.
c. Mental functioning is inferred through assessment of an individual’s behaviours.
d. Mental status can be assessed directly, just like the characteristics of any other body system (e.g., cardiac and breath sounds).

Answer 31

c.

Question 32

A 23-year-old patient is in the clinic and appears anxious. Her speech is rapid. She is fidgety and in constant motion. Which of the following 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 behaviour 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 rose-coloured glasses’.”
d. “Please pick up the pencil in your left hand, move it to your right hand, and place it on the table.”

Answer 32

d.

Question 33

The nurse is planning health education for a 65-year-old woman who has had a cerebrovascular accident (stroke) and is aphasic. Which of the following is most important to use when assessing mental status in this situation?

a. “Please count back from 100 by sevens.”
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 33

c.

Question 34

A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self-mutilation and has a history of prior suicide attempts. She describes difficulty sleeping at night and has lost 4.5 kg (10 lb) in the past month. Which of the following is the nurse’s best response in this situation?

a. “Do you own any lethal 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 feeling resolves within a few weeks.”

Answer 34

c.

Question 35

Which of the following statements best describes the MiniMental State 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 changes in cognition over time.

Answer 35

c.

Question 36

A 45-year-old woman suffered a head injury in a car accident. A few months after recovering from her injuries, 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 36

d.

Question 37

Which of the following is the most common and severe form of aphasia in which spontaneous speech is absent or is reduced to a few stereotypical words or sounds?

a. Global aphasia
b. Broca’s aphasia
c. Dysphonic aphasia
d. Wernicke’s aphasia

Answer 37

a.

Question 38

A patient keeps saying, “I feel hot. Hot, cot, rot, tot, got. I’m a spot.” This is an illustration of:

a. blocking.
b. clanging.
c. echolalia.
d. neologism.

Answer 38

b.

Question 39

During an interview, the nurse notes that the patient gets up several times to wash her hands even though they are clean. This is an example of:

a. social phobia.
b. compulsive disorder.
c. generalized anxiety disorder.
d. Post-traumatic stress disorder.

Answer 39

b.

Question 40

The nurse has completed a Set Test on a 70-year-old woman who has exhibited some dramatic behaviour changes, according to her family. Her score on the Set Test is 14. How will the nurse interpret this result?

a. It indicates delirium.
b. It indicates dementia.
c. It may indicate dementia, but further testing is needed.
d. It is within normal limits.

Answer 40

b.

Question 41

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

a. Echolalia
b. Clanging
c. Word salad
d. Perseveration

Answer 41

a.