Chapter 19 prepu

A nursing instructor is discussing mental health assessments with students. In what situations would the instructor tell the students an acute mental health assessment is necessary? A situation that involves danger of harm to self or others A situation in which the admitted client is diagnosed with schizophrenia Any time a client is severely depressed When a client is assessed as delirious

A situation that involves danger of harm to self or others

When the nurse asks the client to explain similarities and differences between objects, what cognitive ability is being tested? Judgment. Concentration. Memory to learn new information. Abstract reasoning.

Abstract reasoning.

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? Impaired memory related to dementia Risk for powerlessness related to prolonged disability Impaired verbal communication related to hearing loss Anxiety related to awareness of increasing memory loss

Anxiety related to awareness of increasing memory loss

A client states reports feeling like a burden to the family and totally worthless. Which response would be appropriate for the nurse to make to this client? "Where does your family live?" "I'm sure that you aren't worthless." "Have you thought of killing yourself?" "Everyone feels that way every now and then."

"Have you thought of killing yourself?"

Which question is appropriate for a nurse to ask a client to assess the client's recent memory? "When is your birthday?" "What did you eat for breakfast today?" "How are an orange and an apple different?" "Why are you at the health care clinic today?"

"What did you eat for breakfast today?"

As part of the mental status examination, the nurse assesses the cognitive abilities of the client. Which questions should the nurse ask to assess the judgment ability in the client? "What do you do if you have pain?" "When did you get your first job?" "When were you last hospitalized?" "How is an apple different from an orange?"

"What do you do if you have pain?"

The nurse is preparing to assess a client's remote memory. Which question would be most appropriate for the nurse to use? "Can you tell me what you have eaten in the last 24 hours?" "When did you get your first job?" "What did you do last evening?" "How are an apple and orange the same?"

"When did you get your first job?"

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

3

The nurse asks a client to explain the saying, "people in glass houses shouldn't throw stones." Which of the following is the nurse assessing? Remote memory Abstract reasoning Judgment Concentration

Abstract reasoning

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

Abstract reasoning

The nurse notes that an older adult client is wearing multiple layers of clothing on a warm fall day. What would be the nurse's priority assessment at this time? Asking whether the client often feels cold Assessing the client's developmental level Reviewing the client's culture for possible influence Observing the client's overall hygiene

Asking whether the client often feels cold

The nurse is admitting a client with substance abuse. What screening tool would be best to use if this client is in denial about his substance abuse? CAGE questionnaire Mini-mental status examination Mini-Cog exam SAD PERSONAS

CAGE questionnaire

Assessment of a client who has suffered a recent stroke reveals that he is unresponsive to all stimuli and his eyes remain closed. The nurse documents the client's level of consciousness as which of the following? Obtunded Stupor Coma Lethargy

Coma

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 Repeatedly and apparently unintentionally follows instructions Uses appropriate and comprehensible words Appears oriented

Defers to family members to answer questions directed to the client

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? Do you hear voices that tell you what to do? On a sense of 0 to 10, with 10 being most intense, how suicidal do you feel now? Do you have a sense of hope for the future?

Do you have any thoughts of wanting to harm or kill yourself?

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

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. Ability to recall recent and remote memories, and to use abstract reasoning. Assessment of the 12 cranial nerves. Naming of objects, recall of three words, and ability to redraw a design.

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? Derailment Flight of ideas Circumstantiality Incoherence

Flight of ideas

The nurse has made a nursing diagnosis of self-esteem disturbance. Which assessment data supports the nursing diagnosis? Guilt and negative comments about self Feeling ill-at ease during social situations Expressions of hopelessness, loneliness Poor concentration, hallucinations

Guilt and negative comments about self

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 Anticipatory grieving Fear Mental status change

Ineffective coping

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

Lethargy

A 32-year-old white woman comes to the clinic complaining of overwhelming sadness. She says for the past 2 months she has had crying episodes, difficulty sleeping, and problems with overeating. She says she used to go out with friends from work but now she just wants to go home and be alone. She also thinks that her work productivity has been dropping because she just is too tired to care or concentrate. She denies any feelings of guilt or suicidal ideation. She states that she has never felt this way in the past. She denies any recent illness or injuries. Past medical history consists of an appendectomy when she was a teenager; otherwise, she has been healthy. She is single and works as a clerk in a medical office. She denies tobacco, alcohol, or illegal drug use. Her mother has high blood pressure, and her father has a history of mental illness. Examination reveals a woman who appears her stated age and seems sad. Her facial expression does not change during conversation, and she makes little eye contact. She speaks so softly that the nurse cannot always understand her. Her thought processes and content seem unremarkable. What type of mood disorder is most consistent with these findings? Dysthymic disorder Manic (bipolar) disorder Major depressive episode Schizophrenia

Major depressive episode

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 rumors 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? Major depressive episode Manic episode Dysthymic disorder Schizophrenia

Manic episode

During the health-history interview, which of the following components of cognitive function can the nurse quickly assess? Memory and attention Judgment and behavior Calculation and language Abstract thinking and perceptions

Memory and attention

A gerontologic nurse is assessing the speech of an older adult client. Which of the following would the nurse characterize as an expected assessment finding? Repetition Rapid speech Moderate pace Loud tone

Moderate pace

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? Assesses long-term memory Estimates the ability to cope with mental disorders Determines the likelihood of participating in a healthy lifestyle Provides a reference point for psychosocial developmental level

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 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? Generalized anxiety disorder Psychotic disorder due to a medical illness Substance-induced psychotic disorder Schizophrenia

Schizophrenia

The intensive care nurse is working with a client who has increased intracranial pressure secondary to a traumatic brain injury. The nurse is performing the hourly assessment of the client's level of consciousness and observes that the client's eyes are closed. How should the nurse first stimulate the client to assess for arousability? Gently shake the client's right shoulder and then his left shoulder. Rub the client's sternum with the knuckles. Speak to the client clearly from a close distance. Press down on one of the client's nail beds.

Speak to the client clearly from a close distance.

As part of a mental status assessment, the nurse asks a client to draw the face of a clock. This will allow the nurse to assess which of the following domains of mental status? Concentration and orientation Perceptions and thought processes Visual perceptual and constructional ability Expressions and feelings

Visual perceptual and constructional ability

A nurse wants to assess a client's orientation. The nurse recognizes that which orientation is usually lost first when the client is confused? Person Place Time Location

Time

A nursing instructor is teaching a group of students about assessing a client's orientation. The instructor determines that the teaching was successful when the students state that the ability to identify which of the following usually is lost first? Time Self Place Family members

Time

The nurse finds no adequate medical or physical explanation for the symptoms a client is experiencing. This would be considered a somatoform symptom. True False

True

The nurse completes the mental health assessment before continuing with a head-to-toe assessment. Why did the nurse use this approach? Requires little energy by the nurse to complete Is the easiest and shortest assessment to complete Validates the information the client provides during the rest of the assessment Ensures that this part of the assessment is completed before the client becomes fatigued

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 one of the four CAGE questions. answered "yes" to three of the four CAGE questions. answered "no" to all of the four CAGE questions. answered "no" to three of the four CAGE questions.

answered "yes" to three of the four CAGE questions.