Question 1

A 45-year-old woman is brought to the emergency department with a head injury after her car hit a tree.A few months after recovering from her injuries,the nurse notes during an examination that she is unable to learn new information or recall previously learned information.This is an example of:

Accepted Answer

The development of a memory impairment (inability to learn new information or recall previously learned information)in the absence of other significant cognitive impairments may be due to a pathology such as closed head trauma.

Question 2

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 10 pounds in the past month.Which of these statements or questions is the nurse's best response in this situation?

Accepted Answer

When the person expresses feelings of hopelessness,despair,or grief,it is important to assess for risk of physical harm to himself or herself.Begin this process with more general questions.If the answers are affirmative,then continue with more specific questions.

Question 3

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 and laughs loudly at the content.This behavior is a display of:

Accepted Answer

An inappropriate affect is an affect clearly discordant with the content of the person's speech.The other terms are defined in Table 5-5.

Question 4

The nurse discovers speech problems in a patient during an assessment.The patient has spontaneous speech,but it is mostly absent or is reduced to a few stereotyped words or sounds.This finding reflects which type of aphasia?

Accepted Answer

Global aphasia is the most common and severe form of aphasia.Spontaneous speech is absent or reduced to a few stereotyped words or sounds,and prognosis for language recovery is poor.Broca's and Wernicke's aphasias are described in Table 5-4.Dysphonic aphasia is not a valid condition.

Question 5

A patient states,"I feel so sad all of the time.I can't feel happy even doing things I used to like to do." He also states that he is tired,sleeps poorly,and has no energy.To differentiate between dysthymic disorder and a major depressive disorder,the nurse should ask which question?

Accepted Answer

Major depressive disorder is characterized by one or more major depressive episodes (i.e.,at least 2 weeks of depressed mood or loss of interest accompanied by at least four additional symptoms of depression).Dysthymic disorder is characterized by at least 2 years of depressed mood for more days than not,accompanied by additional depressive symptoms.

Question 6

A patient seems to repeatedly 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." The nurse will note on his chart that he is using or experiencing:

Accepted Answer

Circumlocution is a roundabout expression,substituting a phrase when one cannot think of the name of the object.

Question 7

During an examination,the nurse notes that a patient is exhibiting flight of ideas.Which statement by the patient is an example of flight of ideas?

Accepted Answer

Flight of ideas is demonstrated by an abrupt change,rapid skipping from topic to topic,and practically continuous flow of accelerated speech.Topics usually have recognizable associations or are plays on words.

Question 8

The nurse is planning health teaching for a 65-year-old woman who has had a cerebrovascular accident,or stroke,and is aphasic.Which of these questions is most important to use when assessing mental status in this situation?

Accepted Answer

Additional tests for persons with aphasia include word comprehension (asking the individual to point to articles in the room or parts of the body),reading (asking the person to read available print),and writing (asking the person to make up and write a sentence).

Question 9

A patient repeats,"I feel hot.Hot,cot,rot,tot,got.I'm a spot." The nurse documents this as an illustration of:

Accepted Answer

Clanging is word choice based on sound,not meaning,and includes nonsense rhymes and puns.The other terms are defined in Table 5-6.

Question 10

The nurse is providing instructions to newly hired graduates about the Mini-Mental State Examination.Which statement best describes this examination?

Accepted Answer

The Mini-Mental State Examination is a quick,easy test of 11 questions.It is used for initial and serial evaluations and can demonstrate worsening or improvement of cognition over time and with treatment.It evaluates cognitive functioning,not mood or thought processes.It is a good screening tool to detect dementia and delirium and to differentiate these from psychiatric mental illness.

Question 11

During report,the nurse hears that a patient is experiencing hallucinations.Which is an example of a hallucination?

Accepted Answer

Hallucinations are sensory perceptions for which there are no external stimuli.They may strike any sense: visual,auditory,tactile,olfactory,or gustatory.

Question 12

A patient describes feeling an unreasonable,irrational fear of snakes.It is so persistent that he can no longer comfortably even look at pictures of snakes and has made an effort to identify all the places he might encounter a snake and avoids them.The nurse recognizes that he:

Accepted Answer

A phobia is a strong,persistent,irrational fear of an object or situation;the person feels driven to avoid it.The other terms are defined in Table 5-7.

Question 13

A 20-year-old construction worker has been brought into the emergency department with heat stroke.He has delirium as a result of the fluid and electrolyte imbalance.For the mental status examination,the nurse should first assess the patient's:

Accepted Answer

Delirium is a disturbance of consciousness (i.e.,reduced clarity of awareness of the environment)with reduced ability to focus,sustain,or shift attention.It is not an alteration in mood,affect,or language abilities.

Question 14

During an interview,the nurse notes that the patient gets up several times to wash her hands even though they are not dirty.This is an example of:

Accepted Answer

Repetitive behaviors,such as handwashing,are behaviors that the person feels driven to perform in response to an obsession.The behaviors are aimed at preventing or reducing distress or preventing some dreaded event or situation.

Question 15

The nurse is performing a mental status examination.Which statement is true regarding the assessment of mental status?

Accepted Answer

Mental status functioning is inferred through assessment of an individual's behaviors.It cannot be assessed directly like characteristics of the skin or heart sounds.

Question 16

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 description of this patient's problem?

Accepted Answer

This 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,there is a great urge to speak.Repetition,reading,and writing also are impaired.Echolalia is imitation or repetition of another person's words or phrases.See Table 5-4 for definitions of the other disorders.

Question 17

The nurse is administering a Mini-Cog test to an elderly woman.When asked to draw a clock showing the time of 10:45,the patient drew a clock with the numbers out of order and with the time incorrect.This result indicates which finding?

Accepted Answer

The Mini-Cog is a newer instrument that screens for cognitive impairment,often found with dementia.The result of an abnormal drawing of a clock and time indicates a cognitive impairment.

Question 18

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 would want to be certain to ask her which of these questions?

Accepted Answer

In posttraumatic stress disorder the person has been exposed to a traumatic event.The traumatic event is persistently reexperienced by recurrent and intrusive,distressing recollections of the event,including images,thoughts,or perceptions;recurrent distressing dreams of the event;and acting or feeling as if the traumatic event were recurring.

Question 19

During morning rounds,the nurse asks a patient,"How are you today?" The patient responds,"You today,you today,you today!" and mumbles the words.This speech pattern is an example of:

Accepted Answer

Echolalia occurs when a person imitates or repeats another's words or phrases,often with a mumbling,mocking,or mechanical tone.

Question 20

A 23-year-old patient in the clinic appears anxious.Her speech is rapid,and she is fidgety and in constant motion.Which of these questions or statements would be most appropriate for the nurse to use in this situation to assess attention span?

Accepted Answer

Attention span is evaluated by assessing the individual's ability to concentrate and complete a thought or task without wandering.Giving a series of directions to follow is one method used to assess attention span.

Quiz 5: Mental Status Assessment