Exam 5: Mental Status Assessment

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

The nurse is administering a Mini-Cog test to an older adult 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 an incorrect time. This result indicates which finding?

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 is an example of which speech pattern?

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

The nurse is assessing a patient who is admitted with possible delirium. Which of these are manifestations of delirium? (Select all that apply.)

During a recent interview, a patient diagnosed with schizophrenia shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but then laughs loudly at the content. What is the best description of this behavior?

A 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. When conducting the mental status examination for this patient, what should the nurse assess first?

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?

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?

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

The nurse is providing instructions to newly hired graduates for the mini-mental state examination (MMSE). Which statement best describes this examination?

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?

A patient describes feeling an unreasonable, irrational fear of snakes. His fear is so persistent that he can no longer comfortably look at even pictures of snakes and has made an effort to identify all the places he might encounter a snake and avoids them. What is the best description of this patient's condition?

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?

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?

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?

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