Chapter 5 JARVIS

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?

Global

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

Older adult man who tells the nurse that he is going to join his wife in heaven tomorrow and plans to use a gun

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

All aspects of mental status in children are interdependent.

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 nurses best response in this situation?

Are you feeling so hopeless that you feel like hurting yourself now?

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?

Are you having any disturbing dreams?

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:

Circumlocution

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

Clanging

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?

Cognitive impairment

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:

Compulsive disorder

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

Develops over a short period. Person is exhibiting memory impairment or deficits. Occurs as a result of a medical condition, such as systemic infection.

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:

Echolalia

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

Gathering mental status information during the health history- check consciousness

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

Give him the Four Unrelated Words Test.

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:

Has a snake phobia.

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 girls mental status?

Her mother states that her daughter prefers to play with toddlers instead of kids her own age while in daycare.

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

How do you feel today?

A patient states, I feel so sad all of the time. I cant 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?

How long have you been feeling this way?

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?

I know my name is John. I am at the hospital in Spokane. I couldnt tell you what date it is, but I know that it is February of a new year2010.

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

I never did too good in school.

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:

Inappropriate affect

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 infants parents that the Denver II:

Is a screening instrument designed to detect children who are slow in development.

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 patients level of consciousness would be:

Lethargic

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 patients:

Level of consciousness and cognitive abilities

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

Man believes that his dead wife is talking to him.

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:

May take a little longer to respond, but his general knowledge and abilities should not have declined.

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

Mental status functioning is inferred through the assessment of an individuals behaviors.

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:

More information should be gathered to decide whether her dress is appropriate.

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 nurses best course of action?

Perform a complete mental status examination.

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?

Pick up the pencil in your left hand, move it to your right hand, and place it on the table.

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 nurses best approach regarding this examination is to:

Plan to defer the rest of the mental status examination.

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?

Please point to articles in the room and parts of the body as I name them.

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 ____.

Recall; after a 30-minute delay

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:

Sensory-perceptive abilities

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?

Take this pill? The pill is red. I see red. Red velvet is soft, soft as a babys bottom.

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

Tell me what you plan to do once you are discharged from the hospital.

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

This examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness.

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 patients problem?

Wernickes aphasia

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:

Will be oriented to place and person, but the patient may not be certain of the date.

During an examination, the nurse can assess mental status by which test first?

conciousness