Jarvis ch 6 - mental status assessment Flashcards
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 intelligence quotient (IQ) test
c. Observing the patient and inferring health or dysfunction
d. Examining the patient’s response to a specific set of questions
ANS: C
Mental status cannot be directly scrutinized like the characteristics of skin or heart sounds. Its functioning is inferred through an
assessment of an individual’s behaviors, such as consciousness, language, mood and affect, and other aspects. Mental status cannot
be directly scrutinized through tests such as an electroencephalogram, intelligence quotient (IQ) test, or responses to questions.
Instead, the functioning of mental status is inferred through an assessment of an individual’s behaviors, such as consciousness,
language, mood and affect, and other aspects.
The nurse is assessing a 75-year-old man. What should the nurse expect when performing the mental status portion of the
assessment?
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 a decrease in his response time because of the loss of language and a
decrease in general knowledge.
ANS: C
The aging process leaves the parameters of mental status mostly intact. General knowledge does not decrease, and little or no loss
in vocabulary occurs. Response time is slower than in a youth. It takes a little longer for the brain to process information and to
react to it. Recent memory, which requires some processing, is somewhat decreased with aging, but remote memory is not affected
The nurse is preparing to conduct 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. 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 patient’s level of functioning, performing a complete
mental status examination is usually necessary.
ANS: B
The full mental status examination is a systematic check of emotional and cognitive functioning. The steps described, however,
rarely need to be taken in their entirety. Usually, one can assess mental status through the context of the health history interview. A
patient’s family is not the best resource for information about the patient’s coping skills. The nurse can gain ample data to assess
mental health and coping skills during the health history with the mental health examination integrated into it
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?
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
ANS: A
Performing a complete mental status examination is necessary when any abnormality in affect or behavior is discovered or when
family members are concerned about a person’s behavioral changes (e.g., memory loss, inappropriate social interaction) or after
trauma, such as a head injury.
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. How should the nurse proceed?
a. 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
ANS: A
In the mental status examination, the sequence of steps forms a hierarchy in which the most basic functions (consciousness,
language) are assessed first. The first steps must be accurately assessed to ensure validity of the steps that follow. For example, if
consciousness is clouded, then the person cannot be expected to have full attention and to cooperate with new learning. If language
is impaired, then a subsequent assessment of new learning or abstract reasoning (anything that requires language functioning) can
give erroneous conclusions. Dysarthric speech and lethargy are signs of altered consciousness and answers to questions on the
mental status examination may be invalid. The nurse should not proceed with any further part of the mental status examination at
this time.
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. What should the nurse expect during this patient’s tests of cognitive
function?
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
ANS: C
The nurse can discern the orientation of cognitive function through the course of the interview or can directly and tactfully ask,
“Some people have trouble keeping up with the dates while in the hospital. Do you know today’s date?” Many hospitalized people
have trouble with the exact date but are fully oriented on the remaining items.
The nurse is planning to assess new memory with a patient. Which is the best way for the nurse to do this?
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.
ANS: C
To assess new memory, the nurse should ask questions that can be corroborated, which screens for the occasional person who
confabulates or makes up answers to fill in the gaps of memory loss. The Four Unrelated Words Test tests the person’s ability to
lay down new memories and is a highly sensitive and valid memory test. The FACT test, describing his first job, or describing the
television show he was watching before coming to the clinic, does not test new memory.
A 45-year-old woman is at the clinic for a mental status assessment. Which describes the expecting findings on the Four Unrelated
Words Test?
a. Invents four unrelated words within 5 minutes
b. Invents four unrelated words within 30 seconds
c. Recalls four unrelated words after a 30-minute delay
d. Recalls four unrelated words after a 60-minute delay
ANS: C
The Four Unrelated Words Test tests the person’s ability to lay down new memories. It is a highly sensitive and valid memory test.
It requires more effort than the recall of personal or historic events. To the person say, “I am going to say four words. I want you to
remember them. In a few minutes I will ask you to recall them.” After 5 minutes, ask for the four words. The normal response for
people under 60 years is an accurate three- or four-word recall after a 5-, 10-, and 30-minute delay.
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
ANS: D
When the person expresses feelings of sadness, hopelessness, despair, or grief, assessing any possible risk for physical harm to him
or herself is important. The interview should begin with more general questions. If the nurse hears affirmative answers, then he or
she should continue with more specific questions. A precise suicide plan to take place in the next 24 to 48 hours with use of a lethal
method constitutes high risk.
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. What is the best description of this patient’s level of consciousness?
a. Lethargic
b. Obtunded
c. Stuporous
d. Semi-coma
ANS: A
The term lethargic best describes a patient who drifts off to sleep when not being stimulated, can easily be aroused by calling his or
her name, but remains drowsy during conversation. Lethargic (or somnolent) is when the person is not fully alert, drifts off to sleep
when not stimulated, and can be aroused when called by name in a normal voice but looks drowsy. He or she appropriately
responds to questions or commands, but thinking seems slow and fuzzy. He or she is inattentive and loses the train of thought.
Spontaneous movements are decreased. Obtunded is a transitional state between lethargy and stupor. Stuporous and semi-coma
have the same meaning which is unconscious and responding only to persistent or vigorous shaking or pain
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 patient’s problem?
a. Echolalia
b. Global aphasia
c. Broca’s aphasia
d. Wernicke’s aphasia
ANS: D
This type of communication illustrates Wernicke’s or receptive aphasia. The person can hear sounds and words but cannot relate
them to previous experiences. Speech is fluent, effortless, and well-articulated, but it has many paraphasias (word substitutions that
are malformed or wrong) and neologisms (made-up words) and often lacks substantive words. Speech can be totally
incomprehensible. Often, a great urge to speak is present. Repetition, reading, and writing also are impaired. Echolalia is an
imitation or the repetition of another person’s words or phrases. With global aphasia, spontaneous speech is absent or reduced to a
few stereotyped words or sounds and comprehension is absent or reduced to only a person’s own name and a few select words.
With Broca’s aphasia the person can understand language but cannot express himself using words or language.
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.” How should the nurse record this on his
chart?
a. Blocking
b. Neologism
c. Circumlocution
d. Circumstantiality
ANS: C
Circumlocution is a roundabout expression, substituting a phrase when one cannot think of the name of the object. The statement in
the question is not an example of blocking, neologism, or circumstantiality. Blocking is when a person experiences sudden
interruption in train of thought and unable to complete sentences which seems r/t strong emotion. Neologism involves coining a
new word which is inventing or making up words that have no real meaning except for the person. Circumstantiality is when a
person talks excessively with unnecessary detail and delays reaching the point. Their sentences have a meaningful connection but
are irrelevant. The statement in the question is an example of circumlocution which is a roundabout expression, substituting a
phrase when one cannot think of the name of the object.
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 individual’s
behaviors.
d. Mental status can be directly assessed, similar to other systems of the body (e.g.,
heart sounds, breath sounds).
ANS: C
Mental status functioning is inferred through the assessment of an individual’s behaviors. It cannot be directly assessed like the
characteristics of the skin or heart sounds
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 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. “People often feel hopeless, but the feelings resolve within a few weeks.”
ANS: C
When the person expresses feelings of hopelessness, despair, or grief, assessing the risk for physical harm to him or herself is
important. This process begins with more general questions. If the answers are affirmative, then the assessment continues with
more specific questions.
During the health history interview, the patient informs the nurse that she has not been able to keep a consistent job for the past 2 years, that she was evicted from her apartment, and that her fiancée just left her. She states, “I don’t know what to do. I wish I could go to sleep and never wake up.” The nurse recognizes that the patient is:
a. Undergoing abuse
b. Facing mental wellness
c. Demonstrating mental violence
d. Experiencing mental disorder
ANS: D
Mental disorder is the medical term for mental illness and is defined and diagnosed in Canada according to criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) by the American Psychiatric Association. Mental disorders are depicted as constellations of co-occurring symptoms that may involve alterations in thought, experience, and emotion that are serious enough to cause distress and impair functioning, cause difficulties in sustaining interpersonal relationships and performing jobs, and sometimes lead to self-destructive behaviour and suicide
