Deck 6: Mental Status Assessment

Question 1

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:
1)he has a snake phobia.
2)he is a hypochondriac.Snakes are usually harmless.
3)He has an obsession.In this case,it is with snakes.
4)He has a delusion that snakes are harmful.It must stem from an early traumatic incident involving snakes.

Answer 1

1
A phobia is a strong,persistent,irrational fear of an object or situation;the person feels driven to avoid it.

Question 2

Which of the following questions would best assess a person's judgment?
1)"Do you feel that you are being watched,followed,or controlled?"
2)"Tell me about what you plan to do once you are discharged from the hospital."
3)"What does the statement,'People in glass houses shouldn't throw stones,' mean to you?"
4)"What would you do if you found a stamped,addressed envelope lying on the sidewalk?"

Answer 2

2
A person exercises judgment when he or she can compare and evaluate the alternatives in a situation and reach an appropriate course of action.Rather than testing the person's response to a hypothetical situation (as illustrated in option 4),the nurse should be more interested in the person's judgment about daily or long-term goals,the likelihood of acting in response to delusions or hallucinations and the capacity for violent or suicidal behavior.

Question 3

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?
1)"I know that my name is John.I couldn't tell you where I am.I think it is 2007,though."
2)"I know that my name is John,but to tell you the truth,I get kind of confused about the date."
3)"I know that my name is John;I guess I'm at the hospital in Spokane.No,I don't know the date."
4)"I know that my name is John.I am at the hospital in Spokane.I couldn't tell you what date it is,but I know that it is February of a new year-2007."

Answer 3

4
Many aging persons experience social isolation,loss of structure without a job,a change in residence,or some short-term memory loss.These factors affect orientation and the person may not provide the precise date or complete name of the agency.You may consider aging persons oriented if they know generally where they are and the present period.That is,consider them oriented to time if the year and month are correctly stated.Orientation to place is accepted with the correct identification of the type of setting (e.g. ,the hospital)and the name of the town.

Question 4

Which of the following statements is true regarding the mental status examination?
1)A patient's family is the best resource for information about the patient's coping skills.
2)It is usually sufficient to gather mental status information during the health history interview.
3)It takes an enormous amount of extra time to integrate the mental status examination into the health history interview.
4)It is usually necessary to perform a complete mental status examination to get a good idea of the patient's level of functioning.

Question 5

The nurse has decided to administer the Set Test to Mr.C. ,70.To administer this test the nurse needs to:
1)ask him to name 10 fruits,animals,colors,and towns.The nurse will tell him that he or she will be available to help if he gets stuck.
2)ask him to name 10 items based on the categories in the acronym FACT.The nurse will tell him that there is no hurry to do this.
3)ask him to name 10 items based on the categories in the acronym FACT.If he has difficulty,the nurse may prompt his memory.
4)ask him to name 10 items based on the categories in the acronym FACT.Tell him this test is timed and he can only have 2 minutes to take it.

Question 6

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 statement reflects the nurse's best course of action?
1)The nurse should plan to perform a complete mental status examination.
2)It would be most appropriate to refer him to a psychometrician.
3)The nurse should plan to integrate the mental status examination into the history and physical examination.
4)The nurse should reassure his wife that memory loss after a physical shock is normal and will subside soon.

Question 7

When examining a patient,the nurse can assess mental status by:
1)examining the patient's electroencephalogram.
2)observing the patient as he or she performs an IQ test.
3)observing the patient and inferring health or dysfunction.
4)examining the patient's response to a specific set of questions.

Question 8

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?
1)"Have you had any weight changes?"
2)"Are you having any thoughts of suicide?"
3)"How long have you been feeling this way?"
4)"Are you having feelings of worthlessness?"

Question 9

The nurse is planning to assess new memory with a patient.The best way to do this would be to:
1)administer the FACT Test.
2)ask him to describe his first job to you.
3)give him the Four Unrelated Words Test.
4)ask him to describe what TV show he was watching before coming to the clinic.

Question 10

A patient is admitted to the unit after an automobile accident.The nurse begins the mental status examination and finds that the patient's speech is dysarthric and that she is lethargic.The nurse's best approach regarding this examination is to:
1)plan to defer the rest of the mental status examination.
2)skip the language portion of the examination and go on to assess mood and affect.
3)do an in-depth speech evaluation and defer the mental status examination to another time.
4)go ahead and assess for suicidal thoughts because dysarthria is often accompanied by severe depression.

Question 11

A woman has come to the clinic to seek help with a substance abuse problem.She admits to using cocaine just before arrival.Which of the following describes what the nurse would expect to find when examining this woman?
1)Dilated pupils,pacing,psychomotor agitation
2)Dilated pupils,unsteady gait,aggressiveness
3)Pupil constriction,lethargy,apathy,dysphoria
4)Constricted pupils,euphoria,decreased temperature

Question 12

To assess affect,the nurse should ask the patient:
1)"How do you feel today?"
2)"Would you please repeat the following words?"
3)"Have these medications had any effect on your pain?"
4)"Has this pain affected your ability to get dressed by yourself?"

Question 13

Which of the following individuals would the nurse consider at highest risk for a suicide attempt?
1)A man who jokes about death
2)A woman who,during a past episode of major depression,attempted suicide
3)An adolescent who has just broken up with her boyfriend and states that she would like to kill herself
4)An elderly man who tells the nurse that he is going to "join his wife in heaven" tomorrow and plans to use a gun

Question 14

Which of the following statements is true regarding the assessment of mental status?
1)Mental status assessment diagnoses specific psychiatric disorders.
2)Mental disorders occur in response to everyday life stressors.
3)Mental status functioning is inferred through assessment of an individual's behaviors.
4)Mental status can be assessed directly,just like other systems of the body (e.g. ,cardiac and breath sounds).

Question 15

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:
1)"How are things going with the trial?"
2)"How are things going with your job?"
3)"Tell me about your recent engagement!"
4)"Are you having any disturbing dreams?"

Question 16

In an interview with a patient,it will be important for the nurse to ascertain some basic history information.Which of the following statements should be explored more fully during an interview? The patient states that he:
1)"sleeps like a baby."
2)has no health problems.
3)"never did too good in school."
4)is currently not taking any medication.

Question 17

Which of the following examples would be a hallucination?
1)A man believes that his dead wife is talking to him.
2)A woman hears the doorbell ring and goes to answer it,but no one is there.
3)A child sees a man standing in his closet.When the lights are turned on it is only a dry cleaning bag.
4)A man believes that the dog has curled up on the bed,but when he gets closer he sees that it is a blanket.

Question 18

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:
1)she could not invent four unrelated words within 5 minutes.
2)she could not invent four unrelated words within 30 seconds.
3)she could not recall four unrelated words after a 30-minute delay.
4)she could not recall four unrelated words after a 60-minute delay.

Question 19

When assessing aging adults,the nurse knows that one of the first things that should be assessed before making judgments about their mental status is:
1)the presence of phobias.
2)their general intelligence.
3)the presence of irrational thinking patterns.
4)their sensory-perceptive abilities.

Question 20

A patient has been in the intensive 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 status examination on him.During the tests of cognitive function the nurse would expect that he:
1)may display some disruption in thought content.
2)will state,"I am so relieved to be out of intensive care."
3)will be oriented to place and person but may not be certain of the date.
4)may show evidence of some clouding of his level of consciousness.

Question 21

A patient repeats,"I feel hot.Hot,cot,rot,tot,got.I'm a spot." This is an illustration of:
1)blocking.
2)clanging.
3)echolalia.
4)neologism.

Question 22

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,she is unable to learn new information or recall previously learned information.This is an example of:
1)mania.
2)agnosia.
3)dementia.
4)amnestic disorder.

Question 23

Which of the following are manifestations of delirium? Select all that apply.
1)Develops over a short period of time
2)The person is experiencing apraxia.
3)Memory impairment or deficits
4)Occurs as a result of a medical condition,such as systemic infection
5)The person is experiencing agnosia.

Question 24

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:
1)social phobia.
2)compulsive disorder.
3)generalized anxiety disorder.
4)posttraumatic stress disorder.

Question 25

Which type of aphasia is the most common and severe form-spontaneous speech is absent or it is reduced to a few stereotyped words or sounds?
1)Global aphasia
2)Broca's aphasia
3)Dysphonic aphasia
4)Wernicke's aphasia

Question 26

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 the following is most important to use when assessing mental status in this situation?
1)"Please count back from 100 by seven."
2)"I will name three items and ask you to repeat them in a few minutes."
3)"Please point to articles in the room and parts of the body as I name them."
4)"What would you do if you found a stamped,addressed envelope on the sidewalk?"

Question 27

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 the following is the nurse's best response in this situation?
1)"Do you have a weapon?"
2)"How do other people treat you?"
3)"Are you feeling so hopeless that you feel like hurting yourself now?"
4)"Oftentimes people feel hopeless,but the feelings resolve within a few weeks."

Question 28

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:
1)Echolalia
2)Clanging
3)Word salad
4)Perseveration

Question 29

Which of the following statements best describes the Mini-Mental State Examination?
1)Scores below 30 indicate cognitive impairment.
2)It is a good tool to evaluate mood and thought processes.
3)It is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness.
4)It is useful for an initial evaluation of mental status.Additional tools are needed to evaluate cognition changes over time.