Chapter 6:Assessing Mental Status Including Risk for Substance Abuse

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

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

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

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

3

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

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

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?

Ask the client to recall events that have occurred over the past few weeks

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 a focused neurological assessment on a client who was involved in a motor vehicle accident. The initial Glasgow Coma Scale (GCS) at the scene was recorded as 11. On arrival at the hospital, the nurse records the client's GSC as 13. What is the best action of the nurse?

Continue to monitor the client

Which of the following are cues that a person may have dementia? Select all that apply.

Disorientation; Looking to a family member to answer questions directed to the client; Repeatedly failing to follow instructions

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

Divorced clients; females; chronically ill clients

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

The nurse is screening an older adult client who is exhibiting signs of depression. Which screening tool would be best for the nurse to use during the assessment?

Geriatric Depression Scale

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

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?

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

In coma

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

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

Lethargy

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

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 client?

Patient demonstrates flight of ideas

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

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 nurse assesses an 80-year-old client and documents the following findings. Based on these findings, what action should the nurse take? -making poor decisions occasionally -forgetting what day it is, but easily reoriented -losing things from time to time -occasionally having difficulty finding the right word

Record these as normal findings

Susanne is a 27-year-old woman who has had headaches, muscle aches, and fatigue for the last 2 months. The nurse has completed a thorough history, examination, and laboratory workups, the results of which are normal. What would the next action be?

Screening for depression

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. He has a paternal uncle who had similar symptoms in college. The client admits to smoking cigarettes and drinking alcohol. He denies use of any other substances and feelings of depression or anxiety. TWhen 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 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 suspects that a client is at risk for impaired mental health. What finding did the nurse use to make this clinical determination? Select all that apply.

Sedentary lifestyle; Issues with body image; Ingests alcohol every evening; Involved in a domestic abuse situation

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

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

Which aspects of the mental status exam refer to data about how thoughts connect to one another?

Thought process

The nurse learns during handoff communication during end-of-shift that a client has delirium. What should the nurse expect to assess in this client? Select all that apply.

Vacillates between lucidity and confusion; Experiences visual and auditory hallucinations; completely disoriented to time, place and person

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

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

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

When the nurse asks the client to say "No ifs, ands, or buts," the client tries but is unable to repeat the phrase with fluency. The nurse understands that this may indicate a form of

aphasia

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

A female client is assessed to have a score of 6 points on the AUDIT. This would alert the nurse that this client

has a hazardous alcohol consumption

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