Question 1

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?

Accepted Answer

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.

Question 2

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:

Accepted Answer

Age-related changes in sensory perception can affect mental status.For example,vision loss (as detailed in Chapter 14)may result in apathy,social isolation,and depression.Hearing changes are common in older adults,which produces frustration,suspicion,and social isolation and makes the person appear confused.

Question 3

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?

Accepted Answer

Many aging persons experience social isolation,loss of structure without a job,a change in residence,or some short-term memory loss.These factors affect orientation,and the person may not provide the precise date or complete name of the agency.You may consider aging persons oriented if they generally know where they are and the present period.They should be considered oriented to time if the year and month are correctly stated.Orientation to place is accepted with the correct identification of the type of setting (e.g.,hospital)and the name of the town.

Question 4

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 ____.

Accepted Answer

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 persons under 60 years is an accurate three- or four-word recall after a 5-,10-,and 30-minute delay.

Question 5

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 nurse's best approach regarding this examination is to:

Accepted Answer

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.

Question 6

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

Accepted Answer

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.

Question 7

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:

Accepted Answer

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.

Question 8

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

Accepted Answer

A person exercises judgment when he or she can compare and evaluate the alternatives in a situation and reach an appropriate course of action.Rather than testing the person's response to a hypothetical situation (as illustrated in the option with the envelope),the nurse should be more interested in the person's judgment about daily or long-term goals,the likelihood of acting in response to delusions or hallucinations,and the capacity for violent or suicidal behavior.

Question 9

The nurse is assessing the mental status of a child.Which statement about children and mental status is true?

Accepted Answer

Separating and tracing the development of only one aspect of mental status is difficult.All aspects are interdependent.For example,consciousness is rudimentary at birth because the cerebral cortex is not yet developed.The infant cannot distinguish the self from the mother's body.The other statements are not true.

Question 10

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

Accepted Answer

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.

Question 11

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 infant's parents that the Denver II:

Accepted Answer

The Denver II is a screening instrument designed to detect developmental delays in infants and preschoolers.It tests four functions: gross motor,language,fine motor-adaptive,and personal-social.The Denver II is not an intelligence test; it does not predict current or future intellectual ability.It is not diagnostic; it does not suggest treatment regimens.

Question 12

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

Accepted Answer

In every mental status examination,the following factors from the health history that could affect the findings should be noted: any known illnesses or health problems,such as alcoholism or chronic renal disease; current medications,the side effects of which may cause confusion or depression; the usual educational and behavioral level,noting this level as the patient's normal baseline and not expecting a level of performance on the mental status examination to exceed it; and responses to personal history questions,indicating current stress,social interaction patterns,and sleep habits.

Question 13

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

Accepted Answer

Judge mood and affect by body language and facial expression and by directly asking,"How do you feel today?" or "How do you usually feel?" The mood should be appropriate to the person's place and condition and should appropriately change with the topics.

Question 14

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

Accepted Answer

When the person expresses feelings of sadness,hopelessness,despair,or grief,assessing any possible risk of 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.

Question 15

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:

Accepted Answer

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.

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 girl's mental status?

Accepted Answer

The mental status assessment of infants and children covers behavioral,cognitive,and psychosocial development and examines how the child is coping with his or her environment.Essentially,the nurse should follow the same Association for Behavioral and Cognitive Therapies (ABCT)guidelines as those for the adult,with special consideration for developmental milestones.The best examination technique arises from a thorough knowledge of the developmental milestones (described in Chapter 2).Abnormalities are often problems of omission (e.g.,the child does not achieve a milestone as expected).

Question 17

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?

Accepted Answer

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.(See Table 5-4 for the definitions of the other disorders.)

Question 18

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 patient's level of consciousness would be:

Accepted Answer

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.(See Table 5-3 for the definitions of the other terms.)

Question 19

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

Accepted Answer

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.

Question 20

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:

Accepted Answer

Grooming and hygiene should be noted-the person is clean and well groomed,hair is neat and clean,women have moderate or no makeup,and men are shaved or their beards or moustaches are well groomed.Care should be taken when interpreting clothing that is disheveled,bizarre,or in poor repair because these sometimes reflect the person's economic status or a deliberate fashion trend.

Quiz 5: Mental Status Assessment