Question 1

A 45-year-old woman is at the clinic for a mental health assessment.When giving her the Four Unrelated Words Test,the nurse would be concerned if the patient:

Accepted Answer

The Four Unrelated Words Test tests a person's ability to lay down new memories.It is a highly sensitive and valid memory test.It requires more effort than does the recall of personal or historical 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 the person to repeat the four words.The normal response for persons under 60 years is an accurate three- or four-word recall after 5-,10-,and 30-minute delays.

Question 2

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 her other clothes.Her hair is dyed pink with black streaks.She has several piercings in her nares and ears and is wearing an earring on her eyebrow and heavy black makeup.The nurse concludes that:

Accepted Answer

Grooming and hygiene should be noted-whether the person is clean and well groomed,whether the hair is neat and clean,whether the women have on moderate or no makeup,and whether the men are clean-shaven,or their beards or moustaches are well groomed.Use care in interpreting clothing that is dishevelled,bizarre,or in poor repair because these may be the result of the person's economic status or a deliberate fashion trend.

Question 3

A patient has been in the critical 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 health examination.During the cognitive function tests,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 tactfully ask,"Some people have trouble keeping track of dates while in hospital.Do you know today's date?" Many hospitalized people normally have trouble with the exact date but are fully oriented on the remaining items.

Question 4

The nurse would plan to use the Nipissing District Developmental Screen with a child who is:

Accepted Answer

The Nipissing District Developmental Screen is a screening tool designed to help parents and caregivers monitor children`s development from birth to 6 years.

Question 5

The nurse is assessing a 75-year-old male patient.At the beginning of 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.There is no decrease in general knowledge and little or no loss in vocabulary.Response time is slower,as it takes a bit longer for the brain to process information and react to it.

Question 6

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

Accepted Answer

Ask questions that have answers that can be corroborated.This screens for the occasional person who confabulates or makes up answers to fill in the gaps of memory loss.New learning-the Four Unrelated Words Test-tests the person's ability to lay down new memories.It is a highly sensitive and valid memory test.

Question 7

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 of the following statements reflects the nurse's best course of action?

Accepted Answer

It is necessary to perform a full mental health examination when any abnormality in affect or behaviour is discovered and when family members are concerned about a person's behavioural changes (e.g. ,memory loss,inappropriate social interaction).

Question 8

The nurse has decided to administer the Set Test to Mr.C. ,age 70 years.To administer this test the nurse needs to:

Accepted Answer

The Set Test was developed specifically to be used in an aging population.The test is easy to administer and takes less than 5 minutes.Ask the person to name 10 items in each of four categories or sets: fruits,animals,colours,and towns (FACT).Do not coach,prompt,or hurry the person.

Question 9

Which of the following questions would best assess a person's judgement?

Accepted Answer

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

Question 10

Which of the following statements about the mental health examination is true?

Accepted Answer

A full mental health examination is a systematic assessment of emotional and cognitive functioning.It is rarely necessary to take all of the steps described in Box 6-1,Mental Status Examination,and is sufficient to complete the mental health historyduring the health history interview.

Question 11

The nurse is assessing mental health in children.Which of the following statements is true?

Accepted Answer

It is difficult to separate and trace the development of just one aspect of a person's mental health.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 12

When interviewing a patient,it is important for the nurse to obtain some basic history.Which of the following statements should be explored more fully during an interview? The patient states that he:

Accepted Answer

In every mental health examination,make a note of the factors from the general health history that could be relevant: 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 behavioural levels (record that factor as the normal baseline,and do not expect performance on the mental health examination to exceed it);and responses to personal history questions about current stress,social interaction patterns,and sleep habits.

Question 13

When examining a patient,the nurse can assess mental health by:

Accepted Answer

To provide comprehensive mental health nursing assessment,you will integrate close observations and routine social interactions into the collection of information about the patient's circumstances.You will combine (a)observation,(b)interview,(c)examination,(d)physical assessment,and (e)collaboration with others.

Question 14

A patient drifts off to sleep when there is no stimulation.The nurse can arouse her easily by calling her name,but she remains drowsy during the conversation.The best description of this patient's level of consciousness would be:

Accepted Answer

In the lethargic (or somnolent)state,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 responds appropriately 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.

Question 15

When assessing older adults,the nurse knows that one of the first things that should be assessed before drawing conclusions about their mental health is:

Accepted Answer

Age-related changes in sensory perception can affect mental health.For example,vision loss (as discussed in Chapter 15 may result in apathy,social isolation,and depression.Hearing changes are common in older adults,producing frustration,suspicion,and social isolation,and making the person appear confused.

Question 16

The nurse is assessing orientation in a 79-year-old patient.Which of the following responses would lead the nurse to conclude that this patient is oriented?

Accepted Answer

Many older adults experience social isolation,loss of structure without a job or due to a change in residence,or some short-term memory loss.These factors affect orientation,so the person may not be able to state the precise date or the complete name of the agency.You can consider older adults to be oriented if they know generally where they are and the present time.That is,consider them oriented to time if they state the correct year and month.Orientation to place is considered to be present if they correctly identify the type of setting (e.g. ,the hospital)and the name of the town.

Question 17

The nurse is performing a mental health assessment on a 5-year-old girl.Her parents are in the middle of a bitter divorce and are worried about the effect it is having on their daughter.Which of the following might lead the nurse to be concerned about the girl's mental health?

Accepted Answer

The mental health assessment of an infant or child covers behavioural,cognitive,and psychosocial development and examines how the child is coping with his or her environment.Essentially,follow the same A-B-C-T guidelines (i.e. ,appearance,behaviour,cognition,and thought processes)as with adults,with special consideration for developmental milestones.Abnormalities are often problems of omission (e.g. ,the child does not achieve a milestone as expected).

Question 18

Which of the following 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,it is important to assess any possible risk of physical harm to himself or herself.Begin with more general questions about suicide.If you get affirmative answers,continue with more specific questions.A detailed plan for committing suicide in the next 24 to 48 hours using a lethal method indicates high risk.

Question 19

A patient is admitted after an automobile accident.The nurse begins the mental health examination and finds that the patient's speech is dysarthric and that she is lethargic.The nurse's best approach in this situation is to:

Accepted Answer

In the mental health 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 for the steps to follow.That is,if consciousness is clouded,then the person cannot be expected to have full attention and to cooperate with new learning.If language is impaired,subsequent assessment of new learning or abstract reasoning (anything that requires language functioning)can lead to erroneous conclusions.

Question 20

To assess affect,the nurse should ask the patient:

Accepted Answer

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

Quiz 6: Mental Health Assessment