Ch. 6 - Assessing Mental Status

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?

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A nurse has just assessed a client using the St. Louis University Mental Status (SLUMS) exam. From his health record, the nurse sees that the client graduated from high school. Which of the following scores would indicate mild cognitive impairment in this client?

25

The nurse suspects that a client is experiencing alcohol abuse. When completing the CAGE questionnaire, the nurse can confirm the client is having guilty feelings when she makes which statement? A. "My family doesn't deserve my bad behavior." B. "In the past I've considered drinking a little less." C. "My husband should stop nagging me about my drinking." D. "I was worried about myself when I needed a glass of wine at 9 o'clock in the morning"

A. "My family doesn't deserve my bad behavior."

A nurse is evaluating a client who may have Alzheimer's disease. Which of the following are warning signs of Alzheimer's disease? Select all that apply. A. Asking the same question over and over again B. Losing one's ability to pay bills C. Gaining 5 pounds or more within a 2-week period D. Getting lost in familiar surroundings E. Neglecting to bathe F. Sleeping longer than 12 hours in a 24-hour period

A. Asking the same question over and over again B. Losing one's ability to pay bills D. Getting lost in familiar surroundings E. Neglecting to bathe

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? A. Do you have any thoughts of wanting to harm or kill yourself? B. Do you hear voices that tell you what to do? C. On a sense of 0 to 10, with 10 being most intense, how suicidal do you feel now? D. Do you have a sense of hope for the future?

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

The nurse is conducting a health history with an older adult who recently lost a spouse. The client reports difficulty sleeping, a lack of appetite, and having one glass of wine each week. The client states, "I don't know how I can go on. Why did God have to take him? I feel so lost without my husband." Which tool should the use to further assess the client? A. Geriatric Depression Scale B. Mini-Cog C. HOPE tool D. SAD PERSONAS

A. Geriatric Depression Scale

A nurse is collecting both subjective and objective data in assessment of a client's mental health. Which of the following are examples of subjective data? Select all that apply. A. History of hospitalization for a mental health problem B. Glasgow Coma Scale score C. History of Alzheimer's disease in a family member D. Use of recreational drugs E. Onset of memory lapses F. Tone, clarity, and pace of speech

A. History of hospitalization for a mental health problem C. History of Alzheimer's disease in a family member D. Use of recreational drugs E. Onset of memory lapses

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

A. Memory and attention

A nurse begins the mental status exam of an older adult. Before assessing the client's thought processes and perceptions, the nurse should first obtain the results of what other assessments? A. Vision and hearing B. Speech and facial expressions C. Vital signs and nutritional status D. Ability to follow commands and move extremities

A. Vision and hearing

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? A. Wernicke's aphasia B. Broca's aphasia C. Dysarthria D. Receptive aphasia

A. Wernicke's aphasia

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 A. aphasia B. dysarthria C. mania D. disorientation

A. aphasia

A female client is assessed to have a score of 6 points on the AUDIT. This would alert the nurse that this client A. has a hazardous alcohol consumption. B. is a heavy drinker. C. is an at risk drinker. D. is not at any risk for alcohol harm.

A. has a hazardous alcohol consumption.

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

B. "What did you eat for breakfast today?"

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? A. Wernicke's aphasia B. Broca's aphasia C. Dysarthria D. Stutter

B. Broca's aphasia

A mental status examination consists of various components. Which assessment data is associated with cognitive function? Select all that apply. A. Client is dressed appropriately for the weather. B. Client is able to successfully multiple 24 times 32. C. Client correctly names the last three presidents of the United States. D. Client's verbal skills are appropriate for age. E. Client reports frequently seeing a dead parent.

B. Client is able to successfully multiple 24 times 32. C. Client correctly names the last three presidents of the United States.

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? A. A review of systems B. Evaluation of insight and judgment C. Questions regarding past behaviors D. Evaluation of medication compliance

B. Evaluation of insight and judgment

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? A. Opens eyes, answers the question, and falls back to sleep B. Opens eyes to a loud voice and answers with confusion C. Awakens only to a vigorous shake or painful stimuli D. Does not respond even to painful stimuli

B. Opens eyes to a loud voice and answers with confusion

When assessing a client, the nurse notes that he is delusional. The nurse would know that delusional thinking can lead to what? A. Insight B. Suicide C. Flight of ideas D. Comorbidity

B. suicide

Which of the following assessment questions is most likely to allow the nurse to assess a client's judgment? A. "What do you think is responsible for your change in mood over the last several weeks?" B. "Do you ever feel like you're hearing or seeing something that others can't see or hear?" C. "How do you plan to meet your responsibilities at work?" D. "In the past, what activities have you found help improve your mood?"

C. "How do you plan to meet your responsibilities at work?"

Which statement represents a clanging speech pattern? A. "The yard is covered in gukkers." B. "I love flowers, I love beer, I love January, I love loving." C. "Peas are good. Trees are wood. I'd leave if I could." D. "See that nurse, it's cold in here, my mother likes pink flowers."

C. "Peas are good. Trees are wood. I'd leave if I could."

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? A. Visual spatial ability B. New learning ability C. Constructional ability D. Time orientation

C. Constructional ability

A client reports ingesting alcohol most nights of the week, smoking marijuana on weekends, and using cocaine with friends when playing poker. Which tool should the nurse use to learn more information about this client's substance use? A. HOPE B. CAGE C. SBIRT D. AUDIT

C. SBIRT

When a nurse asks a client "Do you have any thoughts of wanting to harm or kill yourself?" for what is the nurse assessing? A. Suicide attempts B. Suicide means C. Suicide risk D. Suicide plan

C. Suicide risk

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? A. Dysphonia B. Dysarthria C. Wernicke's aphasia D. Cerebellar dysarthria

C. Wernicke's aphasia

After using the SLUMS tool to test a client's mental status, the nurse calculates a score of 12. The nurse should make A. the nursing diagnosis: Disturbed thought processes related to substance abuse. B. the nursing diagnosis: Ineffective decision making related to loss of memory. C. a referral to the primary health care provided for further evaluation. D. a referral for the family and client to seek mental health counseling.

C. a referral to the primary health care provided for further evaluation.

During a health history, the nurse notes that an older client answers common questions inappropriately. What should the nurse now focus the assessment on to obtain more information about this finding? A. Mood B. Cognition C. Aphasia D. Abstract thinking

C. aphasia

The nurse notes that a client hesitates when responding to questions. With which part of the mental health assessment is this client having difficulty? A. mood B. insight C. attention D. orientation

C. attention

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? A. derailment B. perseveration C. confabulation D. flight of ideas

C. confabulation

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

D. Abstract reasoning

The nurse is assessing a client with a history of Korsakoff syndrome. What would the nurse expect this client might demonstrate? A. Psychotic tendencies B. Incoherence C. Flight of ideas D. Confabulation

D. Confabulation

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

D. Provides a reference point for psychosocial developmental level

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? A. A referral to a neurologist B. A referral to a rheumatologist C. Telling the client nothing has been found D. Screening for depression

D. Screening for depression

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

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

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

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

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