Weber Chp 6 - Mental Status

The nurse is assessing a client using the Glasgow Coma Scale following an acute hypoglycemic episode and obtains a score of 14. The nurse interprets this as indicating which of the following?

Alert and oriented

A client demonstrates nervousness and fear with a worsening loss of memory. Which nursing diagnosis should the nurse select to help guide this client's care?

Anxiety related to awareness of increasing memory loss

While conducting a mental status history, the nurse notes that the client is articulate, makes spontaneous comments, and speaks at a normal rate. For which section of the history is this information important?

speech & language

Which Glasgow Coma Score indicates the client is in a deep coma?

3

When a nurse asks a client "Do you have any thoughts of wanting to harm or kill yourself?" for what is the nurse assessing?

Suicide risk

The nurse is assessing the client's ability to make sound judgments. Which question would be best for the nurse to ask?

"If you lost your job, how would you plan to pay your rent or mortgage?"

A client is concerned that their spouse is planning to commit suicide. What information should the nurse provide to address the spouse's safety?

"Substance abuse is a risk factor."

An older client is demonstrating mental status changes. Which question would the nurse ask when conducting a mini-mental state examination of this client?

"What is today's date?"

Which question asked by the nurse assesses judgment of the client?

"What will you do if you feel the need to use cocaine again?"

A nurse is working with a client who appears to have some form of cognitive impairment. He has a high fever, and the nurse suspects delirium. Which assessment tool should the nurse use?

CAM (confusion assessment method)

A nurse performs the Quick Inventory of Depressive Symptomatology (Self-Report) to determine if the client is at risk for depression. The client scores 4. What is the best action of the nurse?

Continue to monitor the client.

Which clients are most at risk for depressive symptoms? (Select all that apply.)

Divorced clients females chronically ill patients

The nurse is admitting a client 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 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.

During a health history, a client reports drinking bloody Mary's several mornings a week before going to work. In which part of the CAGE questionnaire should the nurse document this information?

Eye-openers

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

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

The nurse suspects a client has undiagnosed Alzheimer disease but changes the care plan after talking with a family member. What information caused the nurse to alter the client's plan of care?

Ingests a 6-pack of beer every evening

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.

A client tells the nurse not to bother with an assessment because "my condition is 'hopeless'." This response should cause the nurse to perform which type of assessment?

Patient Health Questionnaire (PHQ)

During a comprehensive assessment, the nurse identifies signs of possible dementia. What is the best action of the nurse?

Perform the SLUMS examination to assess cognitive function. (Saint Louis University Mental Status)

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

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 behavior 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 neighborhood 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

Schizophrenia

The client states, "I don't know why God as abandoned me; I am a good person." The nurse suspects the client is at risk for:

Suicide

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

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.

The nurse notes that a client hesitates when responding to questions. With which part of the mental health assessment is this client having difficulty?

attention

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

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.

The client has a Glasgow Coma Score of 7. The nurse understands this client is considered to be what?

in coma

A client opens the eyes and answers questions however falls back asleep within seconds. How should the nurse document this assessment finding?

lethargy

The client exhibits auditory hallucinations while the nurse is performing a mental health assessment. The nurse should document this as an alteration in which component of the mental health assessment?

perception