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

The nurse is performing the Denver II screening test on a 12-month-old infant during a routine well-child visit. What should the nurse tell the infant's parents about the Denver II screening test?

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. The Denver II does not asses cognitive, physical, and psychological domains; is not an intelligence test and it does not predict current or future intellectual ability; and does not diagnose speech disorders or suggest treatment regimens.

Question 3

When assessing aging adults, what is one of the first things the nurse should assess before making judgments about the aging person's mental status?

Accepted Answer

Presence of phobias, general intelligence, and presence of irrational thinking patterns are not one of the first things a nurse should assess before making a judgment about an aging person's mental status. 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 produce frustration, suspicion, and social isolation and make the person appear confused.

Question 4

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?

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

Question 5

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?

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 6

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

Accepted Answer

It is difficult to separate and trace the development of just one aspect of mental status. 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. Options B, C, and D are all false statements. It is difficult to separate and trace the development of just one aspect of mental status. 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.

Question 7

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

Accepted Answer

Mood and affect should be judged by observing 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. Options B, C, and D do not assess affect.

Question 8

The nurse is planning to assess new memory with a patient. Which is the best way for the nurse to do this?

Accepted Answer

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.

Question 9

The nurse is assessing a 75-year-old man. What should the nurse expect when performing the mental status portion of the assessment?

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 10

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. 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.

Question 11

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. 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.

Question 12

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?

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. 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.

Question 13

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. 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.

Question 14

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?

Accepted Answer

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.

Question 15

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 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.

Question 16

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 people 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 people 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 17

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 18

The nurse is conducting a patient interview. Which statement made by the patient should the nurse more fully explore to assess the mental status 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. A patient stating that he/she sleeps like a baby, has no health problems, or is currently not taking any medications are not r/t the patient's mental status.

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. What is the best description of this patient's level of consciousness?

Accepted Answer

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.

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. Which is an appropriate conclusion for the nurse draw?

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