Question 1

Which of the following examinations will the nurse perform on a client who is not able to perform one or more of the activities of the Mini-Mental State Exam?

Accepted Answer

The Mental Status Examination is a comprehensive assessment that can be used to evaluate a client's cognitive functioning when they are unable to perform the activities of the Mini-Mental State Exam. The other options listed are not appropriate assessments for evaluating cognitive functioning.

Question 2

The nurse reviews the date family and friends provided in the comprehensive assessment of a client's situation. The nurse knows to treat the data as:

Accepted Answer

The data provided by family and friends in the comprehensive assessment are subjective data, meaning they are based on their experiences and perceptions of the client's situation. While they can provide valuable information, it is important for the nurse to also confirm this data with the client and take into consideration their own perspective and input. Therefore, option B is the correct answer. Options A, C, and D are incorrect as they do not accurately reflect the nature of the data provided by family and friends in the assessment.

Question 3

The intake nurse is screening clients for admission to the psychiatric-mental health inpatient unit. For which of the following individuals would the Mini-Mental State Exam be most appropriate?

Accepted Answer

The Mini-Mental State Exam is most appropriate for a client with a history of memory problems as it is a standardized test used to assess cognitive function, including memory, orientation, and attention. It is not appropriate for the significant other accompanying a client seeking outpatient mental health resources or a client seeking community resources. It may also not be appropriate for a client with disabilities affecting motor and sight, related to writing, as they may not be able to complete the exam.

Question 4

The information from a Mental State Examination indicates a client is depressed and has suicidal ideations. Based on this information, which of the following professionals should be included in the plan of care?
Select all that apply.

Accepted Answer

The answer of The information from a Mental State Examination...

Question 5

A nursing student is working to develop assessment skills. The student knows that nurses utilize principles of assessment:

Accepted Answer

Throughout hospitalization, nurses continuously assess patients to monitor their condition and progress, identify changes, and adjust care plans accordingly.

Question 6

A depressed client asks why a physical exam is necessary before being admitted for outpatient treatment. The nurse explains to the client that a physical exam will:

Accepted Answer

A physical exam is necessary to ensure that the client receives all necessary treatment by identifying any underlying physical health issues that may need to be addressed alongside the mental health treatment.

Question 7

Select the priority nursing diagnosis for a client with a Global Assessment of Functioning (GAF) score of 10.

Accepted Answer

A GAF score of 10 indicates severe mental illness with minimal functioning, thus the priority nursing diagnosis would be risk for injury as the client may be unable to care for themselves and may present with increased vulnerability to various forms of injury. Other options may also be applicable, but risk for injury should be the priority.

Question 8

After conducting a Mini-Mental State Assessment on a client, the nurse obtains a score of 30, which indicates a:

Accepted Answer

A score of 30 on the Mini-Mental State Assessment indicates a perfect score and suggests that cognitive functioning has not declined. This is the highest possible score on the assessment, and it indicates good cognitive functioning in areas such as memory, attention, and language ability.

Question 9

A female client disclosed to the nurse that she is in an abusive situation. This information will be used to contribute to:

Accepted Answer

The information about the client's abusive situation relates to her current life stressors, which would contribute to her level of environmental stress (Axis IV) and would also impact her ongoing emotional and psychological well-being (Axis I). It is important for the nurse to document this information in the client's chart and to immediately initiate appropriate safety measures to protect the client from further harm. The nurse should also provide appropriate support and referrals for resources to assist the client in leaving the abusive situation. While confidentiality is important, the safety and well-being of the client is the top priority.

Question 10

How might the nurse make use of the information contained in a client's multiaxial diagnosis? Select all that apply.

Accepted Answer

The answer of How might the nurse make use of...

Question 11

The psychiatric home health nurse is evaluating whether a client's level of functioning has improved since starting the prescribed psychotropic medication. What evidence does the nurse look for?

Accepted Answer

The Global Assessment of Functioning (GAF) score is a standardized tool used to assess a client's level of functioning before and after treatment. A higher GAF score indicates better functioning, so an increase in the GAF score would be evidence that the client's level of functioning has improved since starting the medication. No change in the GAF score may indicate that the medication is not having an effect, and a significant decrease in the GAF score may indicate that the medication is making the client's symptoms worse. If the client has fully recovered and no longer exhibits any significant symptoms, they would not qualify for a GAF score.

Question 12

The nurse is assessing a client with a mood disorder. When analyzing the behaviors manifested by the client, the nurse considers which of the following?

Accepted Answer

The answer of The nurse is assessing a client with...

Question 13

The school nurse, who must be familiar with mental health issues, will find child clinical disorders classified under:

Accepted Answer

Child clinical disorders are classified under Axis I, which includes clinical disorders and other conditions that cause significant impairment in functioning. This includes mental health conditions such as anxiety disorders, mood disorders, and schizophrenia. Axis II is reserved for personality disorders and intellectual disabilities, which may not be as relevant for a school nurse. Axes X and VII do not exist in the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Question 14

During a mental status assessment, the examiner asks the client to repeat these words: motorcar, teacup, and lilies. Five minutes later the client is asked to repeat the words again. The purpose of this exercise is to test the client's:

Accepted Answer

This exercise tests the client's retention and recall of information. The examiner is giving the client a list of words to remember as a way of assessing their memory function. By asking the client to repeat the words again after five minutes, the examiner is testing their ability to retain and recall information over a short period of time.

Question 15

A client is admitted with the following diagnosis: Axis I: 300.01 Panic disorder without agoraphobia Axis II: 301.83 Borderline personality disorder Axis III: No diagnosis
Axis IV: Unemployment
What conclusions can the nurse make relative to the client's Axis III information?

Accepted Answer

Axis III refers to any relevant medical or physiological conditions that may affect the individual's mental health. As there is no diagnosis listed under Axis III, it can be concluded that the client has no diagnosed physiological health problems relevant to mental disorder at the time of admission.

Question 16

A client makes the following statement during a mental status assessment: "I can't use the phones; the CIA has bugged all the wires." Which of the following categories will the nurse use to document the client's response?

Accepted Answer

The client's statement is indicative of a delusion, which falls under the category of content of thought during a mental status assessment. Specifically, this delusion falls under the category of persecutory delusions.

Question 17

Which of the following assessment tools is used to examine a client's mental status at the time of admission?

Accepted Answer

The Mental State Assessment tool is specifically used to examine a client's mental status at the time of admission. The Nurses Observation Scale for Inpatient Evaluations (NOSIE) is more comprehensive and examines various aspects of the client's behavior over time, while personality inventories and personal history assessments are also more comprehensive and focus on the client's background and personality traits.

Question 18

As part of the comprehensive admission assessment, the nurse talks with family and friends who may contribute additional data to a client's psychiatric history. When reviewing the data obtained from these sources, the nurse keeps in mind which of the following perspectives of the data? The information provided:

Accepted Answer

The information obtained from family and friends is subjective and comes from each individual's perspective. It may not necessarily be accurate, but it provides important insight into the client's history and can be valuable in developing an individualized care plan. The nurse should consider each source's relationship to the client, but should not dismiss any information as false without further investigation.

Question 19

A nurse who is admitting a client to the inpatient unit conducts a comprehensive assessment. How does the nurse use the data gathered from the assessment?
Select all that apply.

Accepted Answer

The nurse uses the data gathered from the assessment to make sound clinical judgments, plan appropriate interventions, and support nursing diagnoses. The length of stay is determined based on a variety of factors, including the client's condition and progress, but is not solely determined by the assessment data. Data from secondary sources should not be excluded without careful consideration and validation.

Question 20

After interviewing a client for admission, the nurse gives the client a score of 50 on the Global Assessment of Functioning Scale (GAF). The nurse selected this score based on the client's level of functioning:

Accepted Answer

The Global Assessment of Functioning Scale (GAF) is based on the client's level of functioning within the past week, not the past year, since beginning psychotropic medication, or since being given a psychiatric diagnosis. Therefore, the nurse would select a score based on the client's current level of functioning. A score of 50 indicates serious symptoms or serious impairment in social, occupational, or school functioning, which may require hospitalization or intensive outpatient treatment.

Quiz 2: Psychiatric-Mental Health Nursing Processes, and Clients With Mental Disorders