Exam 5: Mental Status Assessment

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?

A 45-year-old woman is at the clinic for a mental status assessment.In giving her the Four Unrelated Words Test,the nurse would be concerned if she could not _____ four unrelated words _____.

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?

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

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:

During a mental status assessment,which question by the nurse would best assess a person's judgment?

During an examination,the nurse can assess mental status by which activity?

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.The nurse concludes:

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

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?

The nurse is planning to assess a child using the Behavioral Checklist.This tool is most appropriate for a(n):

The nurse is performing a mental status assessment on a 5-year-old girl.Her parents are undergoing a bitter divorce and are worried about the effect it is having on their daughter.Which action or statement might lead the nurse to be concerned about the girl's mental status?

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:

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?

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

Which of these individuals would the nurse consider at highest risk for a suicide attempt?

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?

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?

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

The nurse is assessing a 75-year-old man.As the nurse begins the mental status portion of the assessment,the nurse expects that this patient: