Prep U CH 6
Which assessment notation describes a client's level of consciousness
"Client was alert and cooperative during the assessment."
Which of the following assessment questions is most likely to allow the nurse to assess a client's judgment
"How do you plan to meet your responsibilities at work?"
When assessing the client's ability to make sound judgments, what question should the nurse ask
"How do you plan to pay rent if you lose your job?"
After using the SLUMS tool to test a client's mental status, the nurse calculates a score of 12. The nurse should make
A referral to the primary health care provider for further evaluation.
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
Abstract reasoning
When the nurse asks the client to explain similarities and differences between objects, what cognitive ability is being tested
Abstract reasoning
The nurse is concerned that a client is at risk for developing Alzheimer disease. Which assessment finding caused the nurse to have this concern? Select all that apply
Age 70 Smokes cigarettes Treatment for hypertension Gained 10 kg over the last year
The nurse suspects that a client may have an alcohol problem. Which of the following assessments should the nurse use to confirm this suspicion
CAGE questionnaire
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
Confabulation
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
Constructional ability
When depression goes undiagnosed, what consequences occur eight times more frequently than in the general population
Death Failure to diagnose depression can have fatal consequences—suicide rates among patients with major depression are eight times higher than in the general population.
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 Depression Scale is being used because
Depression often mimics signs and symptoms of dementia
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
Evaluation of insight and judgement
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
Forgot the word to describe indigestion
During the health-history interview, which of the following components of cognitive function can the nurse quickly assess
Memory and attention
The nurse assesses the client to have a Glasgow Coma score of 15. The nurse anticipates what degree of impairment
None A Glasgow Coma Score of 15 would indicate no impairments. All other scores indicate some degree of impairment up to and including deep coma.
The patient states, "I don't know why God as abandoned me; I am a good person." The nurse suspects the patient is at risk for:
Suicide Other terms to know: The patient who does not experience a sense of hope for the future may be at risk for suicide. Confabulation refers to making up answer to cover for not knowing. Psychosis occurs when the patient has difficulty distinguishing reality from internal perceptions. Delusions are false beliefs the person holds despite lack of supportive evidence
When a nurse asks a patient "Do you have any thoughts of wanting to harm or kill yourself?" for what is the nurse assessing
Suicide risk
A patient experiencing a manic episode may begin to sing or dance
True
If a nurse suspects that a client is depressed, asking the client about any suicidal thoughts
is important and will not stimulate the thought of suicide
As part of the mental status examination, a nurse assesses the cognitive abilities of a client. Which question should the nurse ask to assess the judgment ability in the client
"What do you do if you have pain?"
An older patient is demonstrating mental status changes. Which question would the nurse ask when conducting a mini-mental state examination of this patient
"What is today's date?"
Which question asked by the nurse assesses judgment of the patient
"What will you do if you feel the need to use cocaine again?"
Which Glasgow Coma Score indicates the client is in a deep coma
3
The client has been admitted for depression. What should the nurse include in the admission mental status assessment? Select all that apply
A recent loss New physiological impairment History of a stroke The mental status assessment should include questions related to loss; and change in physiological status, including history of a stroke. Headache and fluid intake would not be part of the mental status assessment but may play a role in the client's mental status.
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 state of well-being Ability to cope with the normal stresses of life Ability to work productively Ability to make a contribution to one's community
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
Answered yes to three of the four CAGE questions
A 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
Broca's aphasia
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
Defers to family members to answer questions directed to the client Some cues that a client may have dementia include seeming disoriented, being a "poor historian," deferring to a family member to answer questions directed to the client, repeatedly and apparently unintentionally failing to follow instructions, having difficulty finding the right words or using inappropriate or incomprehensible words, and having difficulty following conversations.
Which clients are most at risk for depressive symptoms? (Select all that apply.)
Divorced patients -Females -Chronically ill patients
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
Do you have any thoughts of wanting to harm or kill yourself?
The nurse is administering the Depression Questionnaire to a client. Which of the following symptoms listed on the questionnaire would most indicate depression
Eating much less than usual and only with personal effort
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
Euphoric
The nurse assesses a client using the Glasgow Coma Scale. Which of the following indicators will be used to determine the score
Eye opening, and appropriateness of verbal and motor responses.
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
Flight of ideas
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
Hallucination
A nurse performs an admission assessment and notices that a client's speech is slow and the client has difficulty answering some of the questions. How can the nurse differentiate the cause of the client's slow speech
Have the patient read a few sentences out loud.
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
Illusion
The client has a Glasgow Coma Score of 7. The nurse understands this client is considered to be what
In coma
The client states her husband died a few months ago and she has not been the same since. Which nursing diagnosis is most appropriate
Ineffective coping Ineffective coping would be most appropriate. Not Anticipatory grieving because this occurs prior to change.
A client opens the eyes and answers questions however falls back asleep within seconds. How should the nurse document this assessment finding?
Lethargy Opening the eyes, answering questions, and falling back asleep describes lethargy. Being completely unresponsive to all stimuli with the eyes closed describes a coma. Being awakened with vigorous or painful stimuli describes stupor. Opening the eyes to loud voices, responding slowly with confusion, and being unaware of the environment describes obtunded.
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
Manic episode
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
Opens eyes to a loud voice and answers with confusion --The obtunded client opens the eyes to a loud voice and answers with confusion. If the client opens eyes, answers the question, and falls back to sleep, the client is said to be lethargic. If the client awakens to a vigorous shake or painful stimuli, he is in the stupor stage. If the client is unresponsive even to painful stimuli, the client is in a coma.
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
Orientation to time is usually lost first and orientation to person is usually lost last
The nurse documents findings from the client's Mini-Mental State Examination. The following information will be documented as a result of this test
Orientation, memory, and cognitive function
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
Patient Advocate
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
Patient advocate
The nurse is admitting a client to the unit for surgery the next morning. The nurse notes that the client speaks at an accelerated pace and jumps from topic to topic, none of which progresses to sensible conversation. What would the nurse document about this patient
Patient demonstrates flight of ideas
A patient with a nursing diagnosis of disturbed sensory perception would be expected to exhibit what characteristics
Poor concentration, irritability, agitation, change in behavior
The nurse begins the health history with a focus on the client's mental status. Why does the nurse ask for the client's age
Provides a reference point for psychosocial developmental level
When assessing level of consciousness, what should a nurse do if a client does not respond appropriately to a verbal stimulus
Repeat the command louder and in a lower tone of voice
After assessing a patient, the nurse noted the following: he was tearful, he tried to kill himself before coming into the hospital, he had no immediate plan for another suicide attempt, he was unable to concentrate, and he reported having trouble sleeping and having little or no appetite. The nurse also noted that the patient's appearance was unkempt, that he spoke in a low monotone, and that he was unable to establish and maintain eye contact. Based on this information, which nursing diagnoses would be the most appropriate
Risk for Suicide
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
Schizophrenia
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 75-year-old homemaker brings her 76-year-old husband to the clinic. She states that 4 months ago he had a stroke; ever since she has been frustrated with his problems with communication. They were at a restaurant after church one Sunday when he suddenly became quiet. When she realized something was wrong, he was taken to the hospital by ambulance. He spent 2 weeks in the hospital with right-sided weakness and difficulty speaking. After hospitalization he was in a rehab center where he regained the ability to walk and most of the use of his right hand. He also began to speak more, but she says that much of the time "he doesn't make any sense." She gives an example that when she reminded him the car needed to be serviced he told her "I will change the Kool-Aid out of the sink myself with the ludrip." She says that these sayings are becoming frustrating. She wants the nurse to tell her what is wrong and what can be done about it. What type of aphasia does the client have
Wernicke's aphasia
The nurse notes that an older client speaks rapidly and uses words that make no sense or communicate any clear meaning. When documenting this finding, the nurse should use which term to describe this client's speech
Wernicke's aphasia
A patient with a nursing diagnosis of disturbed sensory perception would be expected to exhibit what characteristics
agitation, change in behavior
A client known to a health clinic arrives wearing soiled clothing with matted hair and streaks of dirt on the face and hands. What should this client's appearance suggest to the nurse
depression Grooming and personal hygiene may deteriorate in depression.
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 Depression Scale is being used because
depression often mimics signs and symptoms of dementia.
An auditory hallucination is considered an alteration in which component of the mental health assessment
perceptions Perception is the sensory awareness of objects in the environment and their interrelationships (external stimuli). Perception also refers to internal stimuli such as dreams or hallucinations. Thought processes involve the logic, coherence, and relevance of a client's thought as it leads to selected goals or how people think.