assessment prepu ch 6

An auditory hallucination is considered an alteration in which component of the mental health assessment? a.perceptions b. thought processes c. affect d. insight

a

A nurse is collecting both subjective and objective data in assessment of a client's mental health. Which of the following are examples of subjective data? Select all that apply. a. Use of recreational drugs b. Onset of memory lapses c. History of hospitalization for a mental health problem d. Glasgow Coma Scale score e. Tone, clarity, and pace of speech f. History of Alzheimer's disease in a family member

a, b, c, f

When depression goes undiagnosed, what consequences occur eight times more frequently than in the general population? a. Bankruptcy b. Polyhedonia c. Death d. Comorbidity

c

The nurse completes the mental health assessment before continuing with a head-to-toe assessment. Why did the nurse use this approach?

Validates the information the client provides during the rest of the assessment

A 19-year-old college student, Todd, comes to the clinic with his mother, who is concerned that there is something seriously wrong with him. She states that for the past 6 months, her son's behaviour has become peculiar, and that he has flunked out of college. Todd denies any recent illness or injuries. His past medical history is remarkable only for a broken foot. His parents are healthy. He has a paternal uncle who had similar symptoms in college. The client admits to smoking cigarettes and drinking alcohol. He also admits to marijuana use but not in the last week. He denies use of any other substances and feelings of depression or anxiety. The nurse does a complete physical examination, which is essentially normal. When the nurse questions the client about how he is feeling, he says that he is worried that his software for creating a better browser has been stolen. He says that he has seen a black van in his neighbourhood at night, and he is sure that it is full of computer programmers stealing his work through special gamma waves. The nurse asks why Todd believes they are trying to steal his programs. He replies that the programmers have been telepathing their intents directly into his head. He says he hears these conversations at night, so he knows this is happening. What psychotic disorder is most consistent with Todd's history and physical examination findings? a. Schizophrenia b. Psychotic disorder due to a medical illness c. Substance-induced psychotic disorder d. Generalized anxiety disorder

a

A 22-year-old man is brought to the office by his father. The client was diagnosed with schizophrenia 6 months ago and has been taking medication since. The father states that his son's dose isn't high enough and needs to be increased. He states that his son has been hearing things that don't exist. The nurse asks the young man what is going on. He says that his father is just jealous because his sister only talks to him. His father turns to him and says, "Son, you know your sister died 2 years ago!" His son replies "Well, she still talks to me in my head all the time!" Which best describes this client's abnormality of perception? a. Hallucination b. Illusion c. Fugue state d. Perseveration

a

A 27-year-old woman comes to the office with her mother, who tells the nurse that her daughter has had schizophrenia for the last 8 years and is starting to decompensate despite medication. The client states that she has been taking her antipsychotic and is doing fine. Her mother retorts that her daughter has become quite paranoid and gives an example. She says that her daughter goes and gets the mail every day and then microwaves the letters. The client agrees that she does this but only because she sees the mailman flipping through the envelopes. She says that she knows he's putting anthrax on the letters. Her mother turns to her and says, "He's only sorting the mail!" Which best describes the client's abnormality of perception? a. Illusion b. Aphasia c. Fugue state d. Hallucination

a

A nurse reviews the documentation of the nurse on the previous shift and finds that the client was obtunded. The nurse anticipates that the client will respond to stimulation in what manner? a. Opens eyes to a loud voice and answers with confusion b. Opens eyes, answers the question, and falls back to sleep c. Awakens only to a vigorous shake or painful stimuli d. Does not respond even to painful stimuli

a

During assessment, the nurse asks a patient to explain what the following means: "A penny saved is a penny earned." The nurse is assessing which of the following? a. Abstract reasoning b. Affect c. Concentration d. Attention

a

The nurse notes that a client hesitates when responding to questions. With which part of the mental health assessment is this client having difficulty? a. attention b. orientation c. insight d. mood

a

When assessing the client's ability to make sound judgments, what question should the nurse ask? a. "How do you plan to pay rent if you lose your job?" b. "Do you eat breakfast?" c. "Can you keep track of your finances on an ongoing basis?" d. "How many dimes are in one dollar?"

a

When observing a patient diagnosed with mania, the nurse observes his mood to be elated. Another term for this type of mood includes which of the following? a. Euthymic b. Dysphoric c. Euphoric d. Labile

a

An experienced nurse is training a novice nurse on how to perform mental health assessments. The novice nurse asks the colleague exactly what "mental health" means. The experienced nurse responds by citing the 2010 definition of the World Health Organization (WHO), which states that mental health requires which of the following components? *Select all that apply.* a. Ability to make a contribution to one's community b. A state of well-being c. Ability to work productively d. Ability to cope with the normal stresses of life e. Ability to earn a high school diploma or equivalent f. An IQ that is 100 or greater

a, b, c, d,

A nurse has been asked to complete a mental status examination of a psychiatric-mental health client. Which of the following is included in this assessment? a. Evaluation of medication compliance b. Evaluation of insight and judgment c. A review of systems d. Questions regarding past behaviors

b

As part of assessing the client's level of consciousness, the nurse asks questions related to person, place, and time. Which of these statements is true? a. Orientation to person is usually lost first and orientation to place is usually lost last. b. Orientation to time is usually lost first and orientation to person is usually lost last. c. Orientation to person is usually lost first and orientation to time is usually lost last. d. Orientation to time is usually lost first and orientation to place is usually lost last.

b

The nurse has been asked to assess a 54-year-old client's memory. Which of the following techniques would allow the nurse to evaluate recent memory? a. Ask the client to recall event from childhood. b. Ask the client to recall events that have occurred over the past few weeks. c. Provide the client with three words and ask the client to recall the words several minutes later. d. Provide the client with three words and ask the client to recall the words several months later.

b

Which Glasgow Coma Score indicates the client is in a deep coma? a. 14 b. 3 c. 8 d. 15

b

While conducting an assessment the nurse suspects that a client is making up things in response to specific questions. What behavior is this client demonstrating? a. flight of ideas b. confabulation c. derailment d. perseveration

b

A nurse is evaluating a client who may have Alzheimer's disease. Which of the following are warning signs of Alzheimer's disease? *Select all that apply.* a. Gaining 5 pounds or more within a 2-week period b. Asking the same question over and over again c. Neglecting to bathe d. Losing one's ability to pay bills e. Sleeping longer than 12 hours in a 24-hour period f. Getting lost in familiar surroundings

b, c, d, f

Which of the following are cues that a person may have dementia? Select all that apply. a. Serving as a "good historian" b. Disorientation c. Finding the right words d. Looking to a family member to answer questions directed to the client e. Repeatedly failing to follow instructions

b, d, e

72-year-old man comes to the clinic with his daughter for a follow-up visit after a recent hospitalization. He had been admitted to the local hospital for speech problems and weakness in his right arm and leg. On admission his MRI showed a small stroke. The client was in rehabilitation for 1 month following his initial presentation. He is now walking with a walker and has good use of his arm. His daughter complains, however, that everyone is still having trouble communicating with him. The nurse asks the client how he thinks he is doing. Although it is hard to make out his words, the nurse believes the client's answer is "well . . . fine . . . doing . . . okay." His prior medical history involved high blood pressure and coronary artery disease. He is a widower and retired handyman. He has three children who are healthy. He denies tobacco, alcohol, or drug use. He has no other current symptoms. On examination he is in no acute distress but does seem embarrassed when it takes him so long to answer. Blood pressure is 150/90; other vital signs are normal. Other than his weak right arm and leg, physical examination findings are unremarkable. What disorder of speech does he have? a. Wernicke's aphasia b. Dysarthria c. Broca's aphasia d. Stutter

c

A 23-year-old ticket agent is brought in by her husband because he is concerned about her recent behavior. He states that for the last 2 weeks she has been completely out of control. She hasn't showered in days, stays awake most of the night cleaning their apartment, and has run up more than $5,000 on their credit cards. While he is talking the client interrupts him frequently, declares this is all untrue, and says she has never been so happy and fulfilled in her whole life. She speaks very quickly, changing the subject often. After a longer than normal interview, the nurse learns that the client has had no recent illnesses or injuries. Her past medical history is unremarkable. Both her parents are healthy, but the husband has heard rumours about an aunt with similar symptoms. The client and her husband have no children. She smokes one pack of cigarettes a day (although she has been chain smoking in the last 2 weeks), drinks four to six times a week, and smokes marijuana occasionally. She is very loud and outspoken. Physical examination findings are unremarkable. Which mood disorder does she most likely have? a. Dysthymic disorder b. Major depressive episode c. Manic episode d. Schizophrenia

c

A client reports ingesting alcohol most nights of the week, smoking marijuana on weekends, and using cocaine with friends when playing poker. Which tool should the nurse use to learn more information about this client's substance use? a. CAGE b. AUDIT c. SBIRT d. HOPE

c

A nurse begins the mental status exam of an older adult. Before assessing the client's thought processes and perceptions, the nurse should first obtain the results of what other assessments? a. Ability to follow commands and move extremities b. Vital signs and nutritional status c. Vision and hearing d. Speech and facial expressions

c

A nurse has just assessed a client using the St. Louis University Mental Status (SLUMS) exam. From his health record, the nurse sees that the client graduated from high school. Which of the following scores would indicate mild cognitive impairment in this client? a. 29 b. 17 c. 25 d. 35

c

A older adult client is brought to the clinic by the client's daughter who voices concerns about changes in her parent's mental status. What behavior would the nurse look for to formulate a plan of care for dementia in this client? a. Uses appropriate and comprehensible words b. Repeatedly and apparently unintentionally follows instructions c. Defers to family members to answer questions directed to the client d. Appears oriented

c

A patient with a nursing diagnosis of disturbed sensory perception would be expected to exhibit what characteristics? a.Agitation, depression, extreme anxiety b. Poor concentration, blunted affect, violence c. Poor concentration, irritability, agitation, change in behavior d. Visual or auditory hallucinations, agitation, normal concentration

c

The CAGE assessment is used by the nurse to determine if further assessment is needed. The nurse may assess that it is highly likely the client has a problem and would seek additional assessments if the client a. answered "no" to three of the four CAGE questions. b. answered "no" to all of the four CAGE questions. c. answered "yes" to three of the four CAGE questions. d. answered "yes" to one of the four CAGE questions.

c

The client is brought to the clinic by his son, who states, "My father just doesn't seem to be able to function as well as he used to." When assessing this client the nurse is aware that she will be a what? a.Diagnostician b. Surrogate decision maker c. Patient advocate d. Family liaison

c

The nurse suspects that a client may have an alcohol problem. Which of the following assessments should the nurse use to confirm this suspicion? a. CAM b. GCS c. CAGE questionnaire d. SLUMS exam

c

Which clients are most at risk for depressive symptoms? (Select all that apply.) a. Married patients b. Males c. Chronically ill patients d. Divorced patients e. Females

c, d, e

A 29-year-old woman comes to the office. During history taking, the nurse notices that the client is speaking very quickly and jumping from topic to topic so rapidly that it is difficult to follow her. The nurse can find some connections between ideas, but it is difficult. Which word best describes this thought process? a. Incoherence b. Derailment c. Circumstantiality d. Flight of ideas

d

If a nurse suspects that a client is depressed, asking the client about any suicidal thoughts: a. will stimulate thoughts of suicide b. will stimulate clients to act on suicidal ideation c. is important, but not an early priority d. is important and will not stimulate the thought of suicide

d

The client's daughter asks the nurse why the nurse is asking her mother depression-related questions. The nurse explains that even though the client has symptoms of dementia, the Geriatric a. Depression Scale is being used because b. depression and dementia are one in the same disorder. c.it is the most accurate tool to determine the stage of dementia. finding out why she is depressed will help determine the cause of her dementia. d. depression often mimics signs and symptoms of dementia.

d

The nurse asks the client to draw the face of a clock with numbers and hands and to make it read 3 o'clock. What is tested by the completion of this task? a. New learning ability b. Visual spatial ability c. Time orientation d. Constructional ability

d

The nurse documents findings from the client's Mini-Mental State Examination. The following information will be documented as a result of this test. a. Mood, feelings, expressions, and perceptions. b. Energy level, satisfaction, and social participation. c. Appropriateness of dress, grooming, and eye contact. d. Orientation, memory, and cognitive function.

d

The nurse is admitting a patient to the mental health unit with a diagnosis of attempted suicide. Which is the best question for the nurse to ask first? a. Do you hear voices that tell you what to do? b. On a sense of 0 to 10, with 10 being most intense, how suicidal do you feel now? c. Do you have a sense of hope for the future? d. Do you have any thoughts of wanting to harm or kill yourself?

d

The nurse is completing a mental health assessment. When the nurse asks the patient to interpret a proverb, the nurse is assessing which of the following? a. Concentration b. Memory c. Insight d. Abstract reasoning

d

The nurse prepares to conduct a mental health assessment with an older client. What should the nurse do first before beginning this assessment? a. Read the medical record b. Review current medications c. Measure height and weight d. Assess vision and hearing

d

The nurse suspects that a client is experiencing normal age-related changes in mental functioning. What assessment finding caused the nurse to come to this conclusion? a. No idea where a wallet may be located b. Not engaging in conversation c. Inability to remember the date d. Forgot the word to describe indigestion

d

The patient has difficulty when the nurse asks him to say "No ifs, ands, or buts." The nurse understands that this may indicate a form of a. mania b. disorientation c. dysarthria d. aphasia

d

Which assessment notation describes a client's level of consciousness? a. "Client demonstrated difficulty with recalling events occurring this morning." b. "Client answered questions both logically and coherently." c. "Client was inattentive to the questions being asked." d. "Client was alert and cooperative during the assessment."

d

Which statement represents a clanging speech pattern? a. "The yard is covered in gukkers." b. "See that nurse, it's cold in here, my mother likes pink flowers." c. "I love flowers, I love beer, I love January, I love loving." d. "Peas are good. Trees are wood. I'd leave if I could."

d