Deck 21: Approach to the Mental Health Assessment

Question 1

The nurse is conducting a health maintenance assessment for a patient who lost a spouse 2 months ago. The patient's adult child states, "My mom's behavior has changed since we lost my dad. She seems forgetful and confused at times. It seems to be worse in the morning." Based on this data, which diagnosis does the nurse anticipate?

A) Delirium
B) Dementia
C) Depression
D) Grief

Answer 1

Depression

Question 2

The nurse is providing care to an older adult patient who is experiencing sudden onset of recent memory loss after a surgical procedure. Which diagnosis does the nurse anticipate for this patient?

A) Delirium
B) Dementia
C) Depression
D) Anxiety

Answer 2

Delirium

Question 3

The nurse is providing care to an older adult patient who is diagnosed with delirium. Which finding in the patient's health history is a risk factor for delirium?

A) A history of a brain infarct
B) The recent death of a family member
C) A recent move to a new city
D) The diagnosis of dehydration

Answer 3

The diagnosis of dehydration

Question 4

The nurse is assessing an adolescent patient during a health maintenance visit. Which assessment finding would cause the nurse to suspect the adolescent is participating in the choking game?

A) Stomach pain
B) Red eyes
C) Chronic cough
D) Constipation

Question 5

The nurse is assessing a pediatric patient for anxiety. Which tool is most appropriate for the nurse to use?

A) BASC
B) CBCL
C) CDI
D) PARS

Question 6

The nurse uses the Geriatric Depression Scale (GDS) to assess an older adult patient for depression. Which score range is considered normal?

A) 0-4
B) 5-8
C) 8-11
D) 12-15

Question 7

The nurse is performing a depression screening on an older adult patient. The patient scored 13 on the Geriatric Depression Scale (GDS). Which interpretation of this score by the nurse is accurate?

A) This is a normal finding.
B) This indicates mild depression.
C) This indicates moderate depression.
D) This indicates severe depression.

Question 8

Which is an atypical clinical manifestation associated with depression for an older adult patient?

A) Being obsessed with problems
B) Withdrawing from social interactions
C) Having feelings of guilt
D) Exhibiting aggression

Question 9

The nurse is assessing an older adult patient for risk factors for suicide. Which finding would suggest that this patient is at an increased risk for suicide?

A) Moving to a new city
B) Living with adult children
C) Being married
D) Having a chronic health problem

Question 10

Which older adult patient is at the greatest risk for suicide?

A) A 66-year-old female
B) A 72-year-old male
C) A 78-year-old female
D) An 82-year-old male

Question 11

The nurse is admitting an older adult patient to the emergency department (ED) with a change in mental status with recent and remote memory loss. The family tells the nurse the patient's forgetfulness has gotten progressively worse over the past 6 months. Which diagnosis does the nurse anticipate for this patient?

A) Delirium
B) Dementia
C) Depression
D) Anxiety

Question 12

The nurse is discharging a postpartum patient who vaginally delivered 2 days ago. When teaching the patient about postpartum blues, which statement is most appropriate?

A) "Baby blues is not a normal finding, and you should seek treatment if this occurs."
B) "Baby blues may cause you to want to hurt your baby."
C) "Baby blues are quite common during the first month postpartum."
D) "Baby blues are treated with an antidepressant, which has been prescribed to you."

Question 13

The mental health clinic nurse is assessing an adult patient who reports depression. Which medication noted in the patient's history could be the cause for the current depression?

A) Beta blockers
B) Amphetamines
C) Monoamine oxidase (MAO) inhibitors
D) Levodopa

Question 14

The nurse working at a mental health clinic is reviewing the current medications for a patient who is seeking treatment. Which medication has a psychotic reaction as a side effect?

A) Thyroid hormone
B) MAO inhibitors
C) Steroids
D) Lidocaine

Question 15

The nurse is conducting a health history to determine a patient's risk for mental illness. Which question is most appropriate to determine the risk for posttraumatic stress disorder (PTSD)?

A) "Do you have a family history of depression?"
B) "Have you ever abused drugs or alcohol?"
C) "Did you ever serve in the military?'
D) "Are you married?"

Question 16

The nurse is assessing a patient diagnosed with bipolar disorder at the mental health clinic. The patient is exhibiting symptoms of mania. When reviewing the patient's current medications, which medication could be the cause of the current manic episode?

A) Beta blockers
B) Birth control pills
C) MAO inhibitors
D) Methyldopa

Question 17

The nurse is assessing an older adult patient for depression. Which is a typical clinical manifestation of depression in older adult patients?

A) Loss of motivation
B) Joint pain
C) Fatigue
D) Memory changes

Question 18

The nurse is conducting a mental health assessment for an adolescent patient diagnosed with depression. Which assessment finding would indicate the adolescent is at risk for suicide?

A) Having a part-time job
B) Participating in after-school activities
C) Admitting to drinking alcohol on the weekends
D) Applying for college admission

Question 19

The nurse is assessing a pregnant patient's risk for developing postpartum depression after the birth of her baby. Which finding in the patient's medical history increases this patient's risk for postpartum depression?

A) Having a full-time job
B) Having a planned pregnancy
C) Having a history of infertility
D) Having a history of mood disorders

Question 20

The nurse is assessing an older adult patient for depression. Which is an atypical clinical manifestation that occurs with depression for the older adult patient?

A) Social withdrawal
B) Memory changes
C) Hostility
D) Agitation

Question 21

The nurse is providing care to an older adult patient who is experiencing atypical manifestations of depression. Which clinical manifestations is the patient experiencing? Select all that apply.

A) Constipation
B) Joint pain
C) Fatigue
D) Social withdrawal
E) Loss of motivation

Question 22

The nurse is providing care to a patient who is diagnosed with dementia. Which are possible causes for this diagnosis? Select all that apply.

A) Alcoholism
B) AIDS
C) Acute infection
D) Electrolyte imbalance
E) Loss of a spouse

Question 23

The nurse is assessing a patient who presents with depression. Which medication found during the health history assessment could be the cause for this depression?

A) Tricyclic antidepressants
B) Amphetamines
C) Anticholinergics
D) Oral contraceptives

Question 24

The nurse is assessing a patient diagnosed with anxiety. Which gastrointestinal (GI) manifestation is often associated with this diagnosis?

A) Indigestion
B) Constipation
C) Nausea
D) Emesis

Question 25

The nurse is assessing a patient who is diagnosed with depression. Which clinical manifestation will the nurse assess for when providing care to this patient?

A) Fatigue
B) Restlessness
C) Diaphoresis
D) Pruritus

Question 26

Which classification of medication prescribed to a patient would require the nurse to assess for tardive dyskinesia?

A) Tricyclic antidepressants
B) MAO inhibitors
C) Anticholinergics
D) Antipsychotics

Question 27

The nurse, working in a senior center, performs risk assessments for suicide. Which factors would increase a patient's risk for suicide in the older adult? Select all that apply.

A) Age
B) Lives alone
C) Widower
D) Drug and/or alcohol abuse
E) Limited financial resources

Question 28

The nurse is providing care to a patient who is prescribed tricyclic antidepressants for the treatment of depression. Which side effect will the nurse monitor this patient for?

A) Insomnia
B) Agitation
C) Arrhythmias
D) Dystonia

Question 29

Which assessment finding would indicate that a patient is experiencing neuroleptic malignant syndrome (NMS)?

A) Insomnia
B) Diaphoresis
C) Bradycardia
D) Hypotension

Question 30

The school nurse is told that a student at the school died over the weekend after playing the choking game. Which signs and symptoms would alert you that a child was playing the choking game and may require intervention? Select all that apply.

A) Complaints of dizziness
B) Complaints of headaches
C) Red eyes
D) Dilated pupils
E) Marks on the neck

Question 31

The nurse is conducting a review of systems for a patient with a history of a mood disorder. Which are biographical questions the nurse will include in this process? Select all that apply.

A) "How old are you?"
B) "What is your highest level of education?"
C) "With which cultural background do you associate?"
D) "What is your current marital status?"
E) "Did you have any major health problems when you were a child?"

Question 32

The nurse is conducting a health history for a patient who is exhibiting symptoms of anxiety. Which medication notes during the history could be the cause for this symptom?

A) Ibuprofen
B) Pseudoephedrine
C) St. John's wort
D) Kava kava

Question 33

The nurse is assessing a patient prescribed lithium for side effects associated with this medication. Which question is most appropriate?

A) "Do you have trouble sleeping?"
B) "Are you experiencing constipation?"
C) "Are you experiencing tremors?"
D) "Do you have blurred vision?"

Question 34

You are working in a prenatal clinic, performing risk assessment for postpartum depression. Which factors would increase a patient's risk for postpartum depression? Select all that apply.

A) Low self-esteem
B) Multiple pregnancies
C) Unwanted pregnancy
D) Father depressed
E) History of mood disorders

Question 35

Which psychoactive agent may be the cause for depression?

A) Opioids
B) Levodopa
C) Amphetamines
D) MAO inhibitors

Question 36

The nurse is providing care to a patient recently diagnosed with depression. The patient is also diagnosed with epilepsy. Which antidepressant would the nurse question if prescribed by the healthcare provider?

A) Amitriptyline
B) Buproprion
C) Escitalopram
D) Fluoxetine

Question 37

The nurse is using the Geriatric Depression Scale (GPS) to assess an older adult patient for depression. Which questions will the nurse ask the patient during the assessment process? Select all that apply.

A) "How often do you get bored?"
B) "How old are you?"
C) "Are you married?"
D) "Do you feel full of energy?"
E) "Do you often feel helpless?"