Chapter 05: Mental Status Assessment
Jarvis: Physical Examination and Health Assessment, 8th 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
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.
A child’s mental status is impossible to assess until the child develops the ability to
concentrate.
d.
Children’s mental status is largely a function of their parents’ level of functioning
until the age of 7 years.
3. The nurse is assessing a 75-year-old man. What should the nurse expect when performing the
mental status portion of the assessment?
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 a decrease in his response time because of the loss of language and a
decrease in general knowledge.
4. When assessing aging adults, what is one of the first things the nurse should assess before
making judgments about the aging person’s mental status?
a.
Presence of phobias
b.
General intelligence
c.
Sensory-perceptive abilities
d.
Presence of irrational thinking patterns
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.
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.
7. The nurse is conducting a patient interview. Which statement made by the patient should the
nurse more fully explore to assess the mental status 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.”
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. How
should the nurse proceed?
a.
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.
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. Which is an appropriate
conclusion for the nurse draw?
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.
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. What should the nurse expect during this patient’s tests of cognitive function?
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.
11. During a mental status examination, the nurse wants to assess a patient’s affect. Which
question the nurse should ask?
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?”
12. The nurse is planning to assess new memory with a patient. Which is the best way for the
nurse to do this?
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.
13. A 45-year-old woman is at the clinic for a mental status assessment. Which describes the
expecting findings on the Four Unrelated Words Test?
a.
Invents four unrelated words within 5 minutes
b.
Invents four unrelated words within 30 seconds
c.
Recalls four unrelated words after a 30-minute delay
d.
Recalls four unrelated words after a 60-minute delay
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?”
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
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?
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.”
17. The nurse is performing the Denver II screening test on a 12-month-old infant during a routine
well-child visit. What should the nurse tell the infant’s parents about the Denver II screening
test?
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
18. 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. What is the best
description of this patient’s level of consciousness?
a.
Lethargic
b.
Obtunded
c.
Stuporous
d.
Semi-coma
19. 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.
Echolalia
b.
Global aphasia
c.
Broca’s aphasia
d.
Wernicke’s aphasia
20. 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.” How should the nurse record this on his chart?
a.
Blocking
b.
Neologism
c.
Circumlocution
d.
Circumstantiality
21. 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.
“I wash my hands, wash them, wash them. I usually go to the sink and wash my
hands.”
d.
“Take this pill? The pill is red. I see red. Red velvet is soft, soft as a baby’s
bottom.”
22. 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. What is the best
description of this patient’s condition?
a.
A snake phobia
b.
A hypochondriac
c.
An obsession with snakes
d.
A delusion that snakes are harmful stemming from an early traumatic incident
involving snakes
23. During a recent interview, a patient diagnosed with schizophrenia 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. What is the best description of this behavior?
a.
Confusion
b.
Ambivalence
c.
Depersonalization
d.
Inappropriate affect
24. During change of shift report, 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.
25. 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. When conducting the
mental status examination for this patient, what should the nurse assess first?
a.
Affect and mood
b.
Memory and affect
c.
Cognitive abilities
d.
Level of consciousness
26. 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 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?”
27. 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).
28. 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?
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.”
29. 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 the mental status of this patient?
a.
“Please count backward from 100 by 7.”
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?”
30. 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.”
31. 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 a useful tool for an initial evaluation of mental status. Additional
tools are needed to evaluate cognition changes over time.
32. 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
33. A patient repeats, “I feel hot. Hot, cot, rot, tot, got. I’m a spot.” What term should the nurse
use to document this?
a.
Blocking
b.
Clanging
c.
Echolalia
d.
Neologism
34. 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 what behavior?
a.
Social phobia
b.
Compulsive disorder
c.
Generalized anxiety disorder
d.
Posttraumatic stress disorder
35. 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.
Amnesia
b.
Delirium
c.
Cognitive impairment
d.
Attention-deficit disorder
36. 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 is an example of which
speech pattern?
a.
Echolalia
b.
Clanging
c.
Word salad
d.
Perseveration
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.
Person experiences agnosia.
b.
Person demonstrates apraxia.
c.
Develops over a short period
d.
Person exhibits memory impairment or deficits.
e.
Occurs as a result of a medical condition, such as systemic infection