Question 1

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

Accepted Answer

A) Blocking 
B) Clanging 
C) Echolalia 
D) Neologism

Question 2

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:

Accepted Answer

A) Will have no decrease in any of his abilities, including response time. 
B) Will have difficulty on tests of remote memory because this ability typically decreases with age. 
C) May take a little longer to respond, but his general knowledge and abilities should not have declined. 
D) Will exhibit had a decrease in his response time because of the loss of language and a decrease in general knowledge.

Question 3

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

Accepted Answer

A) "Do you feel that you are being watched, followed, or controlled?" 
B) "Tell me what you plan to do once you are discharged from the hospital." 
C) "What does the statement, 'People in glass houses shouldn't throw stones,' mean to you?" 
D) "What would you do if you found a stamped, addressed envelope lying on the sidewalk?"

Question 4

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.The nurse recognizes that he:

Accepted Answer

A) Has a snake phobia. 
B) Is a hypochondriac; snakes are usually harmless. 
C) Has an obsession with snakes. 
D) Has a delusion that snakes are harmful, which must stem from an early traumatic incident involving snakes.

Question 5

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.The nurse's best approach regarding this examination is to:

Accepted Answer

A) Plan to defer the rest of the mental status examination. 
B) Skip the language portion of the examination, and proceed onto assessing mood and affect. 
C) Conduct an in-depth speech evaluation, and defer the mental status examination to another time. 
D) Proceed with the examination, and assess the patient for suicidal thoughts because dysarthria is often accompanied by severe depression.

Question 6

The nurse is assessing the mental status of a child.Which statement about children and mental status is true?

Accepted Answer

A) All aspects of mental status in children are interdependent. 
B) Children are highly labile and unstable until the age of 2 years. 
C) Children's mental status is largely a function of their parents' level of functioning until the age of 7 years. 
D) A child's mental status is impossible to assess until the child develops the ability to concentrate.

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 statement reflects the nurse's best course of action?

Accepted Answer

A) Perform a complete mental status examination. 
B) Refer him to a psychometrician. 
C) Plan to integrate the mental status examination into the history and physical examination. 
D) Reassure his wife that memory loss after a physical shock is normal and will soon subside.

Question 8

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 stereotypical words or sounds.This finding reflects which type of aphasia?

Accepted Answer

A) Global 
B) Broca's 
C) Dysphonic 
D) Wernicke's

Question 9

A patient has been diagnosed with schizophrenia.During a recent interview,he 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.This behavior is a display of:

Accepted Answer

A) Confusion 
B) Ambivalence 
C) Depersonalization 
D) Inappropriate affect

Question 10

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." The nurse will note on his chart that he is using or experiencing:

Accepted Answer

A) Blocking 
B) Neologism 
C) Circumlocution 
D) Circumstantiality

Question 11

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

Accepted Answer

A) Man who jokes about death 
B) Woman who, during a past episode of major depression, attempted suicide 
C) Adolescent who just broke up with her boyfriend and states that she would like to kill herself 
D) Older adult man who tells the nurse that he is going to "join his wife in heaven" tomorrow and plans to use a gun

Question 12

The nurse is conducting a patient interview.Which statement made by the patient should the nurse more fully explore during the interview?

Accepted Answer

A) "I sleep like a baby." 
B) "I have no health problems." 
C) "I never did too good in school." 
D) "I am not currently taking any medications."

Question 13

A 30-year-old female patient is describing feelings of hopelessness and depression.She has attempted self-mutilation and has a history of 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?

Accepted Answer

A) "Do you have a weapon?" 
B) "How do other people treat you?" 
C) "Are you feeling so hopeless that you feel like hurting yourself now?" 
D) "People often feel hopeless, but the feelings resolve within a few weeks."

Question 14

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 will want to ask her which one of these questions?

Accepted Answer

A) "How are things going with the trial?" 
B) "How are things going with your job?" 
C) "Tell me about your recent engagement!" 
D) "Are you having any disturbing dreams?"

Question 15

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?

Accepted Answer

A) "How do you usually feel? Is this normal behavior for you?" 
B) "I am going to say four words. In a few minutes, I will ask you to recall them." 
C) "Describe the meaning of the phrase, 'Looking through rose-colored glasses.'" 
D) "Pick up the pencil in your left hand, move it to your right hand, and place it on the table."

Question 16

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

Accepted Answer

A) Man believes that his dead wife is talking to him. 
B) Woman hears the doorbell ring and goes to answer it, but no one is there. 
C) Child sees a man standing in his closet. When the lights are turned on, it is only a dry cleaning bag. 
D) Man believes that the dog has curled up on the bed, but when he gets closer he sees that it is a blanket.

Question 17

The nurse is planning health teaching for a 65-year-old woman who has had a cerebrovascular accident (stroke)and has aphasia.Which of these questions is most important to use when assessing mental status in this patient?

Accepted Answer

A) "Please count backward from 100 by seven." 
B) "I will name three items and ask you to repeat them in a few minutes." 
C) "Please point to articles in the room and parts of the body as I name them." 
D) "What would you do if you found a stamped, addressed envelope on the sidewalk?"

Question 18

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

Accepted Answer

A) Mental status assessment diagnoses specific psychiatric disorders. 
B) Mental disorders occur in response to everyday life stressors. 
C) Mental status functioning is inferred through the assessment of an individual's behaviors. 
D) Mental status can be directly assessed, similar to other systems of the body (e.g., heart sounds, breath sounds).

Question 19

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

Accepted Answer

A) Develops over a short period. 
B) Person is experiencing apraxia. 
C) Person is exhibiting memory impairment or deficits. 
D) Occurs as a result of a medical condition, such as systemic infection. 
E) Person is experiencing agnosia.

Exam 5: Mental Status Assessment