Physical Examination And Health Assessment 7th Edition by Carolyn Jarvis -Test Bank

Physical Examination And Health Assessment 7th Edition by Carolyn Jarvis -Test Bank

 

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Chapter 05: Mental Status Assessment

Jarvis: Physical Examination & Health Assessment, 7th Edition

 

MULTIPLE CHOICE

 

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

a.	Examining the patient’s electroencephalogram
b.	Observing the patient as he or she performs an intelligence quotient (IQ) test
c.	Observing the patient and inferring health or dysfunction
d.	Examining the patient’s response to a specific set of questions

 

 

ANS:  C

Mental status cannot be directly scrutinized like the characteristics of skin or heart sounds. Its functioning is inferred through an assessment of an individual’s behaviors, such as consciousness, language, mood and affect, and other aspects.

 

PTS:   1                    DIF:    Cognitive Level: Understanding (Comprehension)

REF:   p. 67               MSC:  Client Needs: Psychosocial Integrity

 

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

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.

 

 

ANS:  A

Separating and tracing the development of only one aspect of mental status is difficult. All aspects are interdependent. For example, consciousness is rudimentary at birth because the cerebral cortex is not yet developed. The infant cannot distinguish the self from the mother’s body. The other statements are not true.

 

PTS:   1                    DIF:    Cognitive Level: Understanding (Comprehension)

REF:   p. 68               MSC:  Client Needs: Psychosocial Integrity

 

3. 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:

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.

 

 

ANS:  C

The aging process leaves the parameters of mental status mostly intact. General knowledge does not decrease, and little or no loss in vocabulary occurs. Response time is slower than in a youth. It takes a little longer for the brain to process information and to react to it. Recent memory, which requires some processing, is somewhat decreased with aging, but remote memory is not affected.

 

PTS:   1                    DIF:    Cognitive Level: Analyzing (Analysis)

REF:   p. 68               MSC:  Client Needs: Psychosocial Integrity

 

4. 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:

a.	Presence of phobias
b.	General intelligence
c.	Presence of irrational thinking patterns
d.	Sensory-perceptive abilities

 

 

ANS:  D

Age-related changes in sensory perception can affect mental status. For example, vision loss (as detailed in Chapter 14) may result in apathy, social isolation, and depression. Hearing changes are common in older adults, which produces frustration, suspicion, and social isolation and makes the person appear confused.

 

PTS:   1                    DIF:    Cognitive Level: Analyzing (Analysis)

REF:   p. 68               MSC:  Client Needs: Psychosocial Integrity

 

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

a.	A patient’s family is the best resource for information about the patient’s coping skills.
b.	Gathering mental status information during the health history interview is usually sufficient.
c.	Integrating the mental status examination into the health history interview takes an enormous amount of extra time.
d.	To get a good idea of the patient’s level of functioning, performing a complete mental status examination is usually necessary.

 

 

ANS:  B

The full mental status examination is a systematic check of emotional and cognitive functioning. The steps described, however, rarely need to be taken in their entirety. Usually, one can assess mental status through the context of the health history interview.

 

PTS:   1                    DIF:    Cognitive Level: Applying (Application)

REF:   p. 68               MSC:  Client Needs: Psychosocial Integrity

 

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?

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.

 

 

ANS:  A

Performing a complete mental status examination is necessary when any abnormality in affect or behavior is discovered or when family members are concerned about a person’s behavioral changes (e.g., memory loss, inappropriate social interaction) or after trauma, such as a head injury.

 

PTS:   1                    DIF:    Cognitive Level: Applying (Application)

REF:   p. 69               MSC:  Client Needs: Psychosocial Integrity

 

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

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.”

 

 

ANS:  C

In every mental status examination, the following factors from the health history that could affect the findings should be noted: any known illnesses or health problems, such as alcoholism or chronic renal disease; current medications, the side effects of which may cause confusion or depression; the usual educational and behavioral level, noting this level as the patient’s normal baseline and not expecting a level of performance on the mental status examination to exceed it; and responses to personal history questions, indicating current stress, social interaction patterns, and sleep habits.

 

PTS:   1                    DIF:    Cognitive Level: Analyzing (Analysis)

REF:   p. 69               MSC:  Client Needs: Psychosocial Integrity

 

8. 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:

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.

 

 

ANS:  A

In the mental status examination, the sequence of steps forms a hierarchy in which the most basic functions (consciousness, language) are assessed first. The first steps must be accurately assessed to ensure validity of the steps that follow. For example, if consciousness is clouded, then the person cannot be expected to have full attention and to cooperate with new learning. If language is impaired, then a subsequent assessment of new learning or abstract reasoning (anything that requires language functioning) can give erroneous conclusions.

 

PTS:   1                    DIF:    Cognitive Level: Analyzing (Analysis)

REF:   p. 69               MSC:  Client Needs: Psychosocial Integrity

 

9. 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 that:

a.	She probably does not have any problems.
b.	She is only trying to shock people and that her dress should be ignored.
c.	She has a manic syndrome because of her abnormal dress and grooming.
d.	More information should be gathered to decide whether her dress is appropriate.

 

 

ANS:  D

Grooming and hygiene should be noted—the person is clean and well groomed, hair is neat and clean, women have moderate or no makeup, and men are shaved or their beards or moustaches are well groomed. Care should be taken when interpreting clothing that is disheveled, bizarre, or in poor repair because these sometimes reflect the person’s economic status or a deliberate fashion trend.

 

PTS:   1                    DIF:    Cognitive Level: Applying (Application)

REF:   p. 70               MSC:  Client Needs: Psychosocial Integrity

 

10. 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. During the tests of cognitive function, the nurse would expect that he:

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 the patient may not be certain of the date.
d.	May show evidence of some clouding of his level of consciousness.

 

 

ANS:  C

The nurse can discern the orientation of cognitive function through the course of the interview or can directly and tactfully ask, “Some people have trouble keeping up with the dates while in the hospital. Do you know today’s date?” Many hospitalized people have trouble with the exact date but are fully oriented on the remaining items.

 

PTS:   1                    DIF:    Cognitive Level: Analyzing (Analysis)

REF:   pp. 70-71        MSC:  Client Needs: Psychosocial Integrity

 

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

a.	“How do you feel today?”
b.	“Would you please repeat the following words?”
c.	“Have these medications had any effect on your pain?”
d.	“Has this pain affected your ability to get dressed by yourself?”

 

 

ANS:  A

Judge mood and affect by body language and facial expression and by directly asking, “How do you feel today?” or “How do you usually feel?” The mood should be appropriate to the person’s place and condition and should appropriately change with the topics.

 

PTS:   1                    DIF:    Cognitive Level: Applying (Application)

REF:   p. 70               MSC:  Client Needs: Psychosocial Integrity

 

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

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.

 

 

ANS:  C

Ask questions that can be corroborated, which screens for the occasional person who confabulates or makes up answers to fill in the gaps of memory loss. The Four Unrelated Words Test tests the person’s ability to lay down new memories and is a highly sensitive and valid memory test.

 

PTS:   1                    DIF:    Cognitive Level: Applying (Application)

REF:   p. 71               MSC:  Client Needs: Psychosocial Integrity

 

13. 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.	Invent; within 5 minutes
b.	Invent; within 30 seconds
c.	Recall; after a 30-minute delay
d.	Recall; after a 60-minute delay

 

 

ANS:  C

The Four Unrelated Words Test tests the person’s ability to lay down new memories. It is a highly sensitive and valid memory test. It requires more effort than the recall of personal or historic events. To the person say, “I am going to say four words. I want you to remember them. In a few minutes I will ask you to recall them.” After 5 minutes, ask for the four words. The normal response for persons under 60 years is an accurate three- or four-word recall after a 5-, 10-, and 30-minute delay.

 

PTS:   1                    DIF:    Cognitive Level: Analyzing (Analysis)

REF:   p. 71               MSC:  Client Needs: Psychosocial Integrity

 

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

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?”

 

 

ANS:  B

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 the option with the envelope), 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.

 

PTS:   1                    DIF:    Cognitive Level: Applying (Application)

REF:   p. 74               MSC:  Client Needs: Psychosocial Integrity

 

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

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

 

 

ANS:  D

When the person expresses feelings of sadness, hopelessness, despair, or grief, assessing any possible risk of physical harm to him or herself is important. The interview should begin with more general questions. If the nurse hears affirmative answers, then he or she should continue with more specific questions. A precise suicide plan to take place in the next 24 to 48 hours with use of a lethal method constitutes high risk.

 

PTS:   1                    DIF:    Cognitive Level: Applying (Application)

REF:   p. 74               MSC:  Client Needs: Psychosocial Integrity

 

16. 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?

a.	She clings to her mother whenever the nurse is in the room.
b.	She appears angry and will not make eye contact with the nurse.
c.	Her mother states that she has begun to ride a tricycle around their yard.
d.	Her mother states that her daughter prefers to play with toddlers instead of kids her own age while in daycare.

 

 

ANS:  D

The mental status assessment of infants and children covers behavioral, cognitive, and psychosocial development and examines how the child is coping with his or her environment. Essentially, the nurse should follow the same Association for Behavioral and Cognitive Therapies (ABCT) guidelines as those for the adult, with special consideration for developmental milestones. The best examination technique arises from a thorough knowledge of the developmental milestones (described in Chapter 2). Abnormalities are often problems of omission (e.g., the child does not achieve a milestone as expected).

 

PTS:   1                    DIF:    Cognitive Level: Applying (Application)

REF:   p. 75               MSC:  Client Needs: Psychosocial Integrity

 

17. 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?

a.	“I know my name is John. I couldn’t tell you where I am. I think it is 2010, though.”
b.	“I know my name is John, but to tell you the truth, I get kind of confused about the date.”
c.	“I know my name is John; I guess I’m at the hospital in Spokane. No, I don’t know the date.”
d.	“I know 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.”

 

 

ANS:  D

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 generally know where they are and the present period. They should be considered 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., hospital) and the name of the town.

 

PTS:   1                    DIF:    Cognitive Level: Applying (Application)

REF:   p. 76               MSC:  Client Needs: Psychosocial Integrity

 

18. 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:

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 problems will develop later in school.

 

 

ANS:  C

The Denver II is a screening instrument designed to detect developmental delays in infants and preschoolers. It tests four functions: gross motor, language, fine motor-adaptive, and personal-social. The Denver II is not an intelligence test; it does not predict current or future intellectual ability. It is not diagnostic; it does not suggest treatment regimens.

 

PTS:   1                    DIF:    Cognitive Level: Applying (Application)

REF:   p. 75               MSC:  Client Needs: Psychosocial Integrity

 

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

a.	Lethargic
b.	Obtunded
c.	Stuporous
d.	Semialert

 

 

ANS:  A

Lethargic (or somnolent) is when the person is not fully alert, drifts off to sleep when not stimulated, and can be aroused when called by name in a normal voice but looks drowsy. He or she appropriately responds to questions or commands, but thinking seems slow and fuzzy. He or she is inattentive and loses the train of thought. Spontaneous movements are decreased. (See Table 5-3 for the definitions of the other terms.)

 

PTS:   1                    DIF:    Cognitive Level: Understanding (Comprehension)

REF:   p. 79               MSC:  Client Needs: Psychosocial Integrity

 

20. A patient has had a cerebrovascular accident (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?

a.	Global aphasia
b.	Broca’s aphasia
c.	Echolalia
d.	Wernicke’s aphasia

 

 

ANS:  D

This type of communication illustrates Wernicke’s or receptive aphasia. The person can hear sounds and words but cannot relate them to previous experiences. Speech is fluent, effortless, and well articulated, but it has many paraphasias (word substitutions that are malformed or wrong) and neologisms (made-up words) and often lacks substantive words. Speech can be totally incomprehensible. Often, a great urge to speak is present. Repetition, reading, and writing also are impaired. Echolalia is an imitation or the repetition of another person’s words or phrases. (See Table 5-4 for the definitions of the other disorders.)

 

PTS:   1                    DIF:    Cognitive Level: Applying (Application)

REF:   p. 80               MSC:  Client Needs: Psychosocial Integrity

 

21. 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:

a.	Blocking
b.	Neologism
c.	Circumlocution
d.	Circumstantiality

 

 

ANS:  C

Circumlocution is a roundabout expression, substituting a phrase when one cannot think of the name of the object.

 

PTS:   1                    DIF:    Cognitive Level: Understanding (Comprehension)

REF:   p. 84               MSC:  Client Needs: Psychosocial Integrity

 

22. 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?

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.”

 

 

ANS:  C

Flight of ideas is demonstrated by an abrupt change, rapid skipping from topic to topic, and practically continuous flow of accelerated speech. Topics usually have recognizable associations or are plays on words.

 

PTS:   1                    DIF:    Cognitive Level: Understanding (Comprehension)

REF:   p. 84               MSC:  Client Needs: Psychosocial Integrity

 

23. 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:

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.

 

 

ANS:  A

A phobia is a strong, persistent, irrational fear of an object or situation; the person feels driven to avoid it. (See Table 5-7 for the definitions of the other terms.)

 

PTS:   1                    DIF:    Cognitive Level: Applying (Application)

REF:   p. 85               MSC:  Client Needs: Psychosocial Integrity

 

24. 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:

a.	Confusion
b.	Ambivalence
c.	Depersonalization
d.	Inappropriate affect

 

 

ANS:  D

An inappropriate affect is an affect clearly discordant with the content of the person’s speech. (See Table 5-5 for the definitions of the other terms.)

 

PTS:   1                    DIF:    Cognitive Level: Analyzing (Analysis)

REF:   p. 81               MSC:  Client Needs: Psychosocial Integrity

 

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

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.

 

 

ANS:  A

Hallucinations are sensory perceptions for which no external stimuli exist. They may strike any sense: visual, auditory, tactile, olfactory, or gustatory.

 

PTS:   1                    DIF:    Cognitive Level: Remembering (Knowledge)

REF:   p. 85               MSC:  Client Needs: Psychosocial Integrity

 

26. A 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. For the mental status examination, the nurse should first assess the patient’s:

a.	Affect and mood
b.	Memory and affect
c.	Language abilities
d.	Level of consciousness and cognitive abilities

 

 

ANS:  D

Delirium is a disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention. Delirium is not an alteration in mood, affect, or language abilities.

 

PTS:   1                    DIF:    Cognitive Level: Understanding (Comprehension)

REF:   p. 69               MSC:  Client Needs: Psychosocial Integrity

 

27. 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 a dysthymic disorder and a major depressive disorder, the nurse should ask which question?

a.	“Have you had any weight changes?”
b.	“Are you having any thoughts of suicide?”
c.	“How long have you been feeling this way?”
d.	“Are you having feelings of worthlessness?”

 

 

ANS:  C

Major depressive disorder is characterized by one or more major depressive episodes, that is, at least 2 weeks of depressed mood or loss of interest accompanied by at least four additional symptoms of depression. Dysthymic disorder is characterized by at least 2 years of depressed mood for more days than not, accompanied by additional depressive symptoms.

 

PTS:   1                    DIF:    Cognitive Level: Analyzing (Analysis)

REF:   p. 73               MSC:  Client Needs: Psychosocial Integrity

 

28. 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?

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?”

 

 

ANS:  D

In posttraumatic stress disorder, the person has been exposed to a traumatic event. The traumatic event is persistently reexperienced by recurrent and intrusive, distressing recollections of the event, including images, thoughts, or perceptions; recurrent distressing dreams of the event; and acting or feeling as if the traumatic event were recurring.

 

PTS:   1                    DIF:    Cognitive Level: Applying (Application)

REF:   p. 82               MSC:  Client Needs: Psychosocial Integrity

 

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

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).

 

 

ANS:  C

Mental status functioning is inferred through the assessment of an individual’s behaviors. It cannot be directly assessed like the characteristics of the skin or heart sounds.

 

PTS:   1                    DIF:    Cognitive Level: Understanding (Comprehension)

REF:   p. 67               MSC:  Client Needs: Psychosocial Integrity

 

30. 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.	“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.”

 

 

ANS:  D

Attention span is evaluated by assessing the individual’s ability to concentrate and complete a thought or task without wandering. Giving a series of directions to follow is one method used to assess attention span.

 

PTS:   1                    DIF:    Cognitive Level: Applying (Application)

REF:   p. 71               MSC:  Client Needs: Psychosocial Integrity

 

31. 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?

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?”

 

 

ANS:  C

Additional tests for persons with aphasia include word comprehension (asking the individual to point to articles in the room or parts of the body), reading (asking the person to read available print), and writing (asking the person to make up and write a sentence).

 

PTS:   1                    DIF:    Cognitive Level: Applying (Application)

REF:   p. 71               MSC:  Client Needs: Psychosocial Integrity

 

32. 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?

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.”

 

 

ANS:  C

When the person expresses feelings of hopelessness, despair, or grief, assessing the risk of physical harm to him or herself is important. This process begins with more general questions. If the answers are affirmative, then the assessment continues with more specific questions.

 

PTS:   1                    DIF:    Cognitive Level: Applying (Application)

REF:   p. 74               MSC:  Client Needs: Psychosocial Integrity

 

33. The nurse is providing instructions to newly hired graduates for the mini–mental state examination (MMSE). Which statement best describes this examination?

a.	Scores below 30 indicate cognitive impairment.
b.	The MMSE is a good tool to evaluate mood and thought processes.
c.	This examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness.
d.	The MMSE is useful tool for an initial evaluation of mental status. Additional tools are needed to evaluate cognition changes over time.

 

 

ANS:  C

The MMSE is a quick, easy test of 11 questions and is used for initial and serial evaluations and can demonstrate a worsening or an improvement of cognition over time and with treatment. It evaluates cognitive functioning, not mood or thought processes. MMSE is a good screening tool to detect dementia and delirium and to differentiate these from psychiatric mental illness.

 

PTS:   1                    DIF:    Cognitive Level: Understanding (Comprehension)

REF:   p. 75               MSC:  Client Needs: Psychosocial Integrity

 

34. 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?

a.	Global
b.	Broca’s
c.	Dysphonic
d.	Wernicke’s

 

 

ANS:  A

Global aphasia is the most common and severe form of aphasia. Spontaneous speech is absent or reduced to a few stereotyped words or sounds, and prognosis for language recovery is poor. (Broca’s aphasia and Wernicke’s aphasia are described in Table 5-4.) Dysphonic aphasia is not a valid condition.

 

PTS:   1                    DIF:    Cognitive Level: Understanding (Comprehension)

REF:   p. 80               MSC:  Client Needs: Psychosocial Integrity

 

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

a.	Blocking
b.	Clanging
c.	Echolalia
d.	Neologism

 

 

ANS:  B

Clanging is word choice based on sound, not meaning, and includes nonsense rhymes and puns. (See Table 5-6 for the definitions of the other terms.)

 

PTS:   1                    DIF:    Cognitive Level: Understanding (Comprehension)

REF:   p. 80               MSC:  Client Needs: Psychosocial Integrity

 

36. During an interview, the nurse notes that the patient gets up several times to wash her hands even though they are not dirty. This behavior is an example of:

a.	Social phobia
b.	Compulsive disorder
c.	Generalized anxiety disorder
d.	Posttraumatic stress disorder

 

 

ANS:  B

Repetitive behaviors, such as handwashing, are behaviors that the person feels driven to perform in response to an obsession. The behaviors are aimed at preventing or reducing distress or preventing some dreaded event or situation.

 

PTS:   1                    DIF:    Cognitive Level: Understanding (Comprehension)

REF:   p. 84               MSC:  Client Needs: Psychosocial Integrity

 

37. The nurse is administering a Mini-Cog test to an older adult 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 an incorrect time. This result indicates which finding?

a.	Cognitive impairment
b.	Amnesia
c.	Delirium
d.	Attention-deficit disorder

 

 

ANS:  A

The Mini-Cog is a newer instrument that screens for cognitive impairment, often found with dementia. The result of an abnormal drawing of a clock and time indicates a cognitive impairment.

 

PTS:   1                    DIF:    Cognitive Level: Analyzing (Analysis)

REF:   p. 85               MSC:  Client Needs: Psychosocial Integrity

 

38. 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:

a.	Echolalia
b.	Clanging
c.	Word salad
d.	Perseveration

 

 

ANS:  A

Echolalia occurs when a person imitates or repeats another’s words or phrases, often with a mumbling, mocking, or a mechanical tone.

 

PTS:   1                    DIF:    Cognitive Level: Applying (Application)

REF:   p. 76               MSC:  Client Needs: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

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

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.

 

 

ANS:  A, C, D

Delirium is a disturbance of consciousness that develops over a short period and may be attributable to a medical condition. Memory deficits may also occur. Apraxia and agnosia occur with dementia.

 

PTS:   1                    DIF:    Cognitive Level: Applying (Application)

REF:   p. 83               MSC:  Client Needs: Psychosocial Integrity