Question 1

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:

Accepted Answer

A)   the presence of phobias.
B)   their general intelligence.
C)   the presence of irrational thinking patterns.
D)   their sensory-perceptive abilities. D

Question 2

During an examination,the nurse notes that a patient is exhibiting flight of ideas.Which statement by the patient is an example of flight of ideas?

Accepted Answer

A)   "My stomach hurts. Hurts, spurts, burts."
B)   "Kiss, wood, reading, ducks, onto, maybe."
C)   "Take this pill? The pill is red. I see red. Red velvet is soft, soft as a baby's bottom."
D)   "I wash my hands, wash them, wash them. I usually go to the sink and wash my hands." C

Question 3

The nurse is providing instructions to newly hired graduates about the Mini-Mental State Examination.Which statement best describes this examination?

Accepted Answer

A)   Scores below 30 indicate cognitive impairment.
B)   It is a good tool to evaluate mood and thought processes.
C)   It is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness.
D)   It is useful for an initial evaluation of mental status. Additional tools are needed to evaluate cognition changes over time. C

Question 4

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,the nurse notes during an examination that she is unable to learn new information or recall previously learned information.This is an example of:

Accepted Answer

A)   mania.
B)   agnosia.
C)   dementia.
D)   amnestic disorder.

Question 5

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

Accepted Answer

A)   "sleeps like a baby."
B)   has no health problems.
C)   "never did too good in school."
D)   Currently is not taking any medication.

Question 6

The nurse is performing the Denver II screening test on a 12-month-old infant during a routine well-child visit.The nurse should tell the infant's parents that the Denver II:

Accepted Answer

A)   tests three areas of development: cognitive, physical, and psychological.
B)   will indicate whether the child has a speech disorder so that treatment can begin.
C)   is a screening instrument designed to detect children who are slow in development.
D)   is a test to determine intellectual ability and may indicate whether there will be problems later in school.

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? The nurse should:

Accepted Answer

A)   plan to 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 subside soon.

Question 8

The nurse is assessing mental status of a child.Which of these statements 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 9

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 assessment of an individual's behaviors.
D)   Mental status can be assessed directly, just like other systems of the body (e.g., cardiac and breath sounds) .

Question 10

A patient seems to repeatedly 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

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:

Accepted Answer

A)   may display some disruption in thought content.
B)   will state, "I am so relieved to be out of intensive care."
C)   will be oriented to place and person but may not be certain of the date.
D)   may show evidence of some clouding of his level of consciousness.

Question 12

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:

Accepted Answer

A)   plan to defer the rest of the mental status examination.
B)   skip the language portion of the examination and go on to assess mood and affect.
C)   do an in-depth speech evaluation and defer the mental status examination to another time.
D)   go ahead and assess for suicidal thoughts because dysarthria is often accompanied by severe depression.

Question 13

A patient has had a cerebrovascular accident,or 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?

Accepted Answer

A)   Global aphasia
B)   Broca's aphasia
C)   Echolalia
D)   Wernicke's aphasia

Question 14

The nurse is planning to assess new memory with a patient.The best way for the nurse to do this would be to:

Accepted Answer

A)   administer the FACT test.
B)   ask him to describe his first job.
C)   give him the Four Unrelated Words Test.
D)   ask him to describe what television show he was watching before coming to the clinic.

Question 15

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 and laughs loudly at the content.This behavior is a display of:

Accepted Answer

A)   confusion.
B)   ambivalence.
C)   depersonalization.
D)   inappropriate affect.

Question 16

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?

Accepted Answer

A)   "I know that my name is John. I couldn't tell you where I am. I think it is 2010, though."
B)   "I know that my name is John, but to tell you the truth, I get kind of confused about the date."
C)   "I know that my name is John; I guess I'm at the hospital in Spokane. No, I don't know the date."
D)   "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-2010."

Question 17

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:

Accepted Answer

A)   Echolalia
B)   Clanging
C)   Word salad
D)   Perseveration

Question 18

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 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, and it must stem from an early traumatic incident involving snakes.

Question 19

A patient drifts off to sleep when she is not being stimulated.The nurse can arouse her easily when calling her name,but she remains drowsy during the conversation.The best description of this patient's level of consciousness would be:

Accepted Answer

A)   lethargic.
B)   obtunded.
C)   stuporous.
D)   semialert.

Question 20

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

Accepted Answer

A)   A patient's family is the best resource for information about the patient's coping skills.
B)   It is usually sufficient to gather mental status information during the health history interview.
C)   It takes an enormous amount of extra time to integrate the mental status examination into the health history interview.
D)   It is usually necessary to perform a complete mental status examination to get a good idea of the patient's level of functioning.

Exam 5: Mental Status Assessment