Chapter 5: Mental Status Assessment

A patient describes feeling an unreasonable, irrational fear of snakes. It is so persistent that he can no longer comfortably even look at pictures of snakes and has made an effort to identify all the places he might encounter a snake and avoids them. The nurse recognizes that: 1.He has a snake phobia. 2.He is a hypochondriac. Snakes are usually harmless. 3.He has an obsession. In this case, it is with snakes. 4.He has a delusion that snakes are harmful. It must stem from an early traumatic incident involving snakes.

ANS:1 A phobia is a strong, persistent, irrational fear of an object or situation; the person feels driven to avoid it.

A woman has come to the clinic to seek help with a substance abuse problem. She admits to using cocaine just before arrival. Which of the following describes what the nurse would expect to find when examining this woman? 1.Dilated pupils, pacing, psychomotor agitation 2.Dilated pupils, unsteady gait, aggressiveness 3.Pupil constriction, lethargy, apathy, dysphoria 4.Constricted pupils, euphoria, decreased temperature

ANS: 1 A cocaine user's appearance includes pupillary dilation, tachycardia or bradycardia, elevated or lowered blood pressure, sweating, chills, nausea, vomiting, and weight loss. The person's behavior includes euphoria, talkativeness, hypervigilance, pacing, psychomotor agitation, impaired social or occupational functioning, fighting, grandiosity, and visual or tactile hallucinations

During morning rounds, the nurse asks a patient, "How are you today?" The patient responds, "You today, you today, you today!" and mumbles the words. This speech pattern is an example of: 1.Echolalia 2.Clanging 3.Word salad 4.Perseveration

ANS: 1 Echolalia occurs when a person imitates or repeats another's words or phrases, often with a mumbling, mocking, or mechanical tone.

The nurse would plan to use the Behavioral Checklist with a child who is: 1.8 years old. 2.16 years old. 3.5 years old, just before kindergarten. 4.having difficulty with gross motor skills.

ANS: 1 For school-age children, ages 7 to 11 years, who have grown beyond the age when developmental milestones are very useful, the Behavioral Checklist is an additional tool that can be given to the parent along with the history.

A patient repeats, "I feel hot. Hot, cot, rot, tot, got. I'm a spot." This is an illustration of: 1.blocking. 2.clanging. 3.echolalia. 4.neologism.

ANS: 2 Clanging is word choice based on sound, not meaning, and includes nonsense rhymes and puns.

A patient has been diagnosed with schizophrenia. During a recent interview, he shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying and laughs loudly at the content. This behavior is a display of: 1.confusion. 2.ambivalence. 3.depersonalization. 4.inappropriate affect.

ANS: 4 An inappropriate affect is an affect clearly discordant with the content of the person's speech.

A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. The nurse concludes: 1.she probably doesn't have any problems at all. 2.she is just trying to shock people and her dress should be ignored. 3.she has manic syndrome because of her abnormal dress and grooming. 4.that more information should be gathered to decide whether her dress is appropriate.

ANS: 4 Grooming and hygiene should be noted. The person is clean and well groomed, hair is neat and clean, women have moderate or no makeup, men are shaved or their beards or moustaches are well groomed. Use care in interpreting clothing that is disheveled, bizarre, or in poor repair because these sometimes reflect the person's economic status or a deliberate fashion trend.

A 26-year-old woman was robbed and beaten a month ago. She is returning to the clinic today for a follow-up assessment. The nurse would want to be certain to ask her: 1."How are things going with the trial?" 2."How are things going with your job?" 3."Tell me about your recent engagement!" 4."Are you having any disturbing dreams?"

ANS: 4 In posttraumatic stress disorder the person has been exposed to a traumatic event. The traumatic event is persistently re-experienced by recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions; recurrent distressing dreams of the event; and acting or feeling as if the traumatic event were recurring.

A patient seems to repeatedly have difficulty coming up with a word. He says, "I was on my way to work and when I got there, the thing that you step into that goes up in the air, was so full that I decided to take the stairs." The nurse will note on his chart that he is using/experiencing: 1.blocking. 2.neologism. 3.circumlocution. 4.circumstantiality.

ANS: 3 Circumlocution is a roundabout expression, substituting a phrase when one cannot think of the name of the object.

Which of the following statements is an example of flight of ideas? 1."My stomach hurts. Hurts, spurts, burts." 2."Kiss, wood, reading, ducks, onto, maybe." 3."Take this pill? The pill is red. I see red. Red velvet is soft, soft as a baby's bottom." 4."I wash my hands, wash them, wash them. I usually go to the sink and wash my hands."

ANS: 3 Flight of ideas is demonstrated by an abrupt change, rapid skipping from topic to topic, and practically continuous flow of accelerated speech. Topics usually have recognizable associations or are plays on words.

A patient drifts off to sleep when she is not being stimulated. The nurse can arouse her easily when calling her name, but she remains drowsy during the conversation. The best description of this patient's level of consciousness would be: 1.lethargic. 2.obtunded. 3.stuporous. 4.semialert.

ANS: 1 Lethargic (or somnolent) is when the person is not fully alert, drifts off to sleep when not stimulated, can be aroused when called by name in a normal voice but looks drowsy. He or she responds appropriately to questions or commands, but thinking seems slow and fuzzy. He or she is inattentive and loses the train of thought. Spontaneous movements are decreased.

1. Which of the following are manifestations of delirium? Select all that apply. 1.Develops over a short period of time 2.The person is experiencing apraxia. 3.Memory impairment or deficits 4.Occurs as a result of a medical condition, such as systemic infection 5.The person is experiencing agnosia.

ANS: 1, 3, 4 Delirium is a disturbance of consciousness that develops over a short period of time and may be due to a medical condition. Memory deficits may also occur.

Which of the following questions would best assess a person's judgment? 1."Do you feel that you are being watched, followed, or controlled?" 2."Tell me about what you plan to do once you are discharged from the hospital." 3."What does the statement, 'People in glass houses shouldn't throw stones,' mean to you?" 4."What would you do if you found a stamped, addressed envelope lying on the sidewalk?"

ANS: 2 A person exercises judgment when he or she can compare and evaluate the alternatives in a situation and reach an appropriate course of action. Rather than testing the person's response to a hypothetical situation (as illustrated in option 4), the nurse should be more interested in the person's judgment about daily or long-term goals, the likelihood of acting in response to delusions or hallucinations and the capacity for violent or suicidal behavior.

During an interview, the nurse notes that the patient gets up several times to wash her hands even though they are not dirty. This is an example of: 1.social phobia. 2.compulsive disorder. 3.generalized anxiety disorder. 4.posttraumatic stress disorder.

ANS: 2 Repetitive behaviors, such as handwashing, are behaviors that the person feels driven to perform in response to an obsession. The behaviors are aimed at preventing or reducing distress or preventing some dreaded event or situation.

The nurse has completed a Set Test on a 70-year-old woman who has had some dramatic behavior changes, according to her family. Her score on the Set Test is a 14. How will the nurse interpret this result? 1.It indicates delirium. 2.It indicates dementia. 3.It may indicate dementia, but further testing is needed. 4.It is within normal limits.

ANS: 2 Set Test scores of less than 15 indicate dementia. Scores between 15 and 24 show less association with dementia and should be evaluated carefully. No one with a score over 25 has been found to have dementia.

When assessing aging adults, the nurse knows that one of the first things that should be assessed before making judgments about their mental status is: 1.the presence of phobias. 2.their general intelligence. 3.the presence of irrational thinking patterns. 4.their sensory-perceptive abilities.

ANS: 4 Age-related changes in sensory perception can affect mental status. For example, vision loss (as detailed in Chapter 14) may result in apathy, social isolation, and depression. Hearing changes are common in older adults. This problem produces frustration, suspicion, and social isolation and makes the person look confused.

The nurse has decided to administer the Set Test to Mr. C., 70. To administer this test the nurse needs to: 1.ask him to name 10 fruits, animals, colors, and towns. The nurse will tell him that he or she will be available to help if he gets stuck. 2.ask him to name 10 items based on the categories in the acronym FACT. The nurse will tell him that there is no hurry to do this. 3.ask him to name 10 items based on the categories in the acronym FACT. If he has difficulty, the nurse may prompt his memory. 4.ask him to name 10 items based on the categories in the acronym FACT. Tell him this test is timed and he can only have 2 minutes to take it.

ANS: 2 The Set Test was developed specifically for use with an aging population. The test is easy to administer and takes less than 5 minutes. Ask the person to name 10 items in each of four categories or sets: fruits, animals, colors, and towns (FACT). Do not coach, prompt, or hurry the person.

Which of the following statements is true regarding the mental status examination? 1.A patient's family is the best resource for information about the patient's coping skills. 2.It is usually sufficient to gather mental status information during the health history interview. 3.It takes an enormous amount of extra time to integrate the mental status examina- tion into the health history interview. 4.It is usually necessary to perform a complete mental status examination to get a good idea of the patient's level of functioning.

ANS: 2 The full mental status examination is a systematic check of emotional and cognitive functioning. The steps described here, though, rarely need to be taken in their entirety. Usually, one can assess mental status through the context of the health history interview.

The nurse is planning health teaching for a 65-year-old woman who has had a cerebrovascular accident, or stroke, and is aphasic. Which of the following is most important to use when assessing mental status in this situation? 1."Please count back from 100 by seven." 2."I will name three items and ask you to repeat them in a few minutes." 3."Please point to articles in the room and parts of the body as I name them." 4."What would you do if you found a stamped, addressed envelope on the sidewalk?"

ANS: 3 Additional tests for persons with aphasia include the following: word comprehension—asking the individual to point to articles in the room or parts of the body; reading—asking the person to read available print; and writing—asking the person to make up and write a sentence.

The nurse is planning to assess new memory with a patient. The best way to do this would be to: 1.administer the FACT Test. 2.ask him to describe his first job to you. 3.give him the Four Unrelated Words Test. 4.ask him to describe what TV show he was watching before coming to the clinic

ANS: 3 Ask questions that can be corroborated. This screens for the occasional person who confabulates or makes up answers to fill in the gaps of memory loss. New learning— the Four Unrelated Words Test tests the person's ability to lay down new memories. It is a highly sensitive and valid memory test.

The nurse is assessing mental status in children. Which of the following statements is true? 1.All aspects of mental status in children are interrelated. 2.Children are highly labile and unstable until the age of 2 years. 3.Children's mental status is largely a function of their parents' level of functioning until the age of 7 years. 4.Children's mental status is impossible to assess until the child develops the ability to concentrate.

ANS: 1 It is difficult to separate and trace the development of just one aspect of mental status. All aspects are interdependent. For example, consciousness is rudimentary at birth because the cerebral cortex is not yet developed. The infant cannot distinguish the self from the mother's body.

Which type of aphasia is the most common and severe form—spontaneous speech is absent or it is reduced to a few stereotyped words or sounds? 1.Global aphasia 2.Broca's aphasia 3.Dysphonic aphasia 4.Wernicke's aphasia

ANS: 1 Global aphasia is the most common and severe form of aphasia. Spontaneous speech is absent or reduced to a few stereotyped words or sounds, and prognosis for language recovery is poor.

Which of the following examples would be a hallucination? 1.A man believes that his dead wife is talking to him. 2.A woman hears the doorbell ring and goes to answer it, but no one is there. 3.A child sees a man standing in his closet. When the lights are turned on it is only a dry cleaning bag. 4.A man believes that the dog has curled up on the bed, but when he gets closer he sees that it is a blanket.

ANS: 1 Hallucinations are sensory perceptions for which there are no external stimuli. They may strike any sense: visual, auditory, tactile, olfactory, or gustatory.

A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient's speech is dysarthric and that she is lethargic. The nurse's best approach regarding this examination is to: 1.plan to defer the rest of the mental status examination. 2.skip the language portion of the examination and go on to assess mood and affect. 3.do an in-depth speech evaluation and defer the mental status examination to another time. 4.go ahead and assess for suicidal thoughts because dysarthria is often accompanied by severe depression.

ANS: 1 In the mental status examination the sequence of steps forms a hierarchy in which the most basic functions (consciousness, language) are assessed first. The first steps must be accurately assessed to ensure validity for the steps to follow. That is, if consciousness is clouded, then the person cannot be expected to have full attention and to cooperate with new learning. If language is impaired, subsequent assessment of new learning or abstract reasoning (anything that requires language functioning) can give erroneous conclusions

A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse's best course of action? 1.The nurse should plan to perform a complete mental status examination. 2.It would be most appropriate to refer him to a psychometrician. 3.The nurse should plan to integrate the mental status examination into the history and physical examination. 4.The nurse should reassure his wife that memory loss after a physical shock is normal and will subside soon.

ANS: 1 It is necessary to perform a full mental status examination when any abnormality in affect or behavior is discovered and in the following situation: family members are concerned about a person's behavioral changes (e.g., memory loss, inappropriate social interaction).

To assess affect, the nurse should ask the patient: 1."How do you feel today?" 2."Would you please repeat the following words?" 3."Have these medications had any effect on your pain?" 4."Has this pain affected your ability to get dressed by yourself?"

ANS: 1 Judge mood and affect by body language and facial expression and by asking directly, "How do you feel today?" or "How do you usually feel?" The mood should be appropriate to the person's place and condition and change appropriately with topics.

In an interview with a patient, it will be important for the nurse to ascertain some basic history information. Which of the following statements should be explored more fully during an interview? The patient states that he: 1."sleeps like a baby." 2.has no health problems. 3."never did too good in school." 4.is currently not taking any medication.

ANS: 3 In every mental status examination, note these factors from the health history that could affect the findings: any known illnesses or health problems, such as alcoholism or chronic renal disease; current medications, the side effects of which may cause confusion or depression; the usual educational and behavioral level—note that factor as the normal baseline and do not expect performance on the mental status examination to exceed it; and responses to personal history questions, indicating current stress, social interaction patterns, and sleep habits.

A patient states, "I feel so sad all of the time. I can't feel happy even doing things I used to like to do." He also states that he is tired, sleeps poorly, and has no energy. To differentiate between dysthymic disorder and a major depressive disorder, the nurse should ask which question? 1."Have you had any weight changes?" 2."Are you having any thoughts of suicide?" 3."How long have you been feeling this way?" 4."Are you having feelings of worthlessness?"

ANS: 3 Major depressive disorder is characterized by one or more major depressive episodes (i.e., at least 2 weeks of depressed mood or loss of interest accompanied by at least four additional symptoms of depression). Dysthymic disorder is characterized by at least 2 years of depressed mood for more days than not, accompanied by additional depressive symptoms.

When examining a patient, the nurse can assess mental status by: 1.examining the patient's electroencephalogram. 2.observing the patient as he or she performs an IQ test. 3.observing the patient and inferring health or dysfunction. 4.examining the patient's response to a specific set of questions.

ANS: 3 Mental status cannot be scrutinized directly like the characteristics of skin or heart sounds. Its functioning is inferred through assessment of an individual's behavior.

Which of the following statements is true regarding the assessment of mental status? 1.Mental status assessment diagnoses specific psychiatric disorders. 2.Mental disorders occur in response to everyday life stressors. 3.Mental status functioning is inferred through assessment of an individual's behaviors. 4.Mental status can be assessed directly, just like other systems of the body (e.g., cardiac and breath sounds).

ANS: 3 Mental status functioning is inferred through assessment of an individual's behaviors. It cannot be assessed directly like characteristics of the skin or heart sounds.

A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if: 1.she could not invent four unrelated words within 5 minutes. 2.she could not invent four unrelated words within 30 seconds. 3.she could not recall four unrelated words after a 30-minute delay. 4.she could not recall four unrelated words after a 60-minute delay.

ANS: 3 The Four Unrelated Words Test tests the person's ability to lay down new memories. It is a highly sensitive and valid memory test. It requires more effort than does the recall of personal or historic events. To the person, say, "I am going to say four words. I want you to remember them. In a few minutes I will ask you to recall them." After 5 minutes, ask for the four words. The normal response for persons under 60 years is an accurate three- or four-word recall after a 5-, 10-, and 30-minute delay

Which of the following statements best describes the Mini-Mental State Examination? 1.Scores below 30 indicate cognitive impairment. 2.It is a good tool to evaluate mood and thought processes. 3.It is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness. 4.It is useful for an initial evaluation of mental status. Additional tools are needed to evaluate cognition changes over time.

ANS: 3 The Mini-Mental State Exam is a quick, easy test of 11 questions. It is used for initial and serial evaluations and can demonstrate worsening or improvement of cognition over time and with treatment. It evaluates cognitive functioning, not mood or thought processes. It is a good screening tool to detect dementia and delirium and to differentiate these from psychiatric mental illness.

The nurse is assessing a 75-year-old man. As the nurse beings the mental status portion of the assessment, the nurse expects that this patient: 1.will have no decrease in any of his abilities, including response time. 2.will have difficulty on tests of remote memory because this typically decreases with age. 3.may take a little longer to respond, but his general knowledge and abilities should not have declined. 4.will have had a decrease in his response time because of language loss and a decrease in general knowledge.

ANS: 3 The aging process leaves the parameters of mental status mostly intact. There is no decrease in general knowledge and little or no loss in vocabulary. Response time is slower than in youth. It takes a bit longer for the brain to process information and react to it.

A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit and the admitting nurse is planning to perform a mental status examination on him. During the tests of cognitive function the nurse would expect that he: 1.may display some disruption in thought content. 2.will state, "I am so relieved to be out of intensive care." 3.will be oriented to place and person but may not be certain of the date. 4.may show evidence of some clouding of his level of consciousness.

ANS: 3 The nurse can discern the orientation of cognitive function through the course of the interview or can tactfully ask directly. "Some people have trouble keeping up with the dates while in the hospital. Do you know today's date?" Many hospitalized people normally have trouble with the exact date but are fully oriented on the remaining items.

A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self-mutilation and has a history of prior suicide attempts. She describes difficulty sleeping at night and has lost 10 pounds in the past month. Which of the following is the nurse's best response in this situation? 1."Do you have a weapon?" 2."How do other people treat you?" 3."Are you feeling so hopeless that you feel like hurting yourself now?" 4."Oftentimes people feel hopeless, but the feelings resolve within a few weeks."

ANS: 3 When the person expresses feelings of hopelessness, despair, or grief, it is important to assess for risk of physical harm to himself or herself. Begin this process with more general questions. If the answers are affirmative, continue with more specific questions.

A 23-year-old patient in the clinic appears anxious. Her speech is rapid. She is fidgety and in constant motion. Which of the following questions or statements would be most appropriate for the nurse to use in this situation to assess attention span? 1."How do you usually feel? Is this normal behavior for you?" 2."I am going to say four words. In a few minutes, I will ask you to recall them." 3."Please describe the meaning of the phrase, 'Looking through rose-colored glasses.'" 4."Please pick up the pencil in your left hand, move it to your right hand, and place it on the table."

ANS: 4 Attention span is evaluated by assessing the individual's ability to concentrate and complete a thought or task without wandering. Giving a series of directions to follow is one method used to assess attention span.

A 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of the fluid and electrolyte imbalance. The nurse will assess his: 1.affect and mood. 2.memory and affect. 3.thought processes and memory. 4.level of consciousness and cognitive abilities.

ANS: 4 Delirium is a disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention. It is also a change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.

The nurse is assessing orientation in a 79-year-old patient. Which of the following responses would lead the nurse to conclude that this patient is oriented? 1."I know that my name is John. I couldn't tell you where I am. I think it is 2007, though." 2."I know that my name is John, but to tell you the truth, I get kind of confused about the date." 3."I know that my name is John; I guess I'm at the hospital in Spokane. No, I don't know the date." 4."I know that my name is John. I am at the hospital in Spokane. I couldn't tell you what date it is, but I know that it is February of a new year—2007."

ANS: 4 Many aging persons experience social isolation, loss of structure without a job, a change in residence, or some short-term memory loss. These factors affect orienta- tion and the person may not provide the precise date or complete name of the agency. You may consider aging persons oriented if they know generally where they are and the present period. That is, consider them oriented to time if the year and month are correctly stated. Orientation to place is accepted with the correct identifi- cation of the type of setting (e.g., the hospital) and the name of the town.

A 45-year-old woman is brought to the emergency department with a head injury after her car hit a tree. A few months after recovering from her injuries, she is unable to learn new information or recall previously learned information. This is an example of:1. 1.mania. 2.agnosia. 3.dementia. 4.amnestic disorder.

ANS: 4 The development of a memory impairment (inability to learn new information or recall previously learned information) in the absence of other significant cognitive impairments may be due to pathology such as closed head trauma.

The nurse is performing a mental status assessment on a 5-year-old girl. Her parents are undergoing a bitter divorce and are worried about the effect it is having on their daughter. Which statement might lead the nurse to be concerned about the girl's mental status? 1.She clings to her mother whenever the nurse is in the room. 2.She appears angry and will not make eye contact with the nurse. 3.Her mother states that she has begun to ride a tricycle around their yard. 4.Her mother states that her daughter prefers to play with toddlers instead of kids her own age while in day care.

ANS: 4 The mental status assessment of infants and children covers behavioral, cognitive, and psychosocial development and examines how the child is coping with his or her environment. Essentially, follow the same A-B-C-T guidelines as for the adult, with special consideration for developmental milestones. The best examination "technique" arises from thorough knowledge of developmental milestones as described in Chapter 2. Abnormalities are often problems of omission (e.g., the child does not achieve a milestone as expected).

A patient has had a cerebrovascular accident, or stroke. He is trying very hard to communicate. He seems driven to speak and says, "I buy obie get spirding and take my train." What is the best way for the nurse to communicate with this patient? 1.Use speech because he will understand even if the nurse cannot understand him. 2.Abandon all attempts to communicate with him. His aphasia is irreversible. 3.Give him a pencil and paper because reading and writing abilities will not be impaired. 4.Support his efforts to communicate and use pantomime and gestures to communicate when possible.

ANS: 4 This illustrates receptive aphasia. Speech is fluent, effortless, and well articulated. Output has many paraphasias (word substitutions that are malformed or wrong) and neologisms (made-up words) and often lacks substantive words. Speech can be totally incomprehensible. Often there is a great urge to speak. Essentially, it is a defect of auditory comprehension. Repetition, reading, and writing are also impaired.

Which of the following individuals would the nurse consider at highest risk for a suicide attempt? 1.A man who jokes about death 2.A woman who, during a past episode of major depression, attempted suicide 3.An adolescent who has just broken up with her boyfriend and states that she would like to kill herself 4.An elderly man who tells the nurse that he is going to "join his wife in heaven" tomorrow and plans to use a gun

ANS: 4 When the person expresses feelings of sadness, hopelessness, despair, or grief, it is important to assess any possible risk of physical harm to himself or herself. Begin with more general questions. If you hear affirmative answers, continue with more specific questions. A precise suicide plan to take place in the next 24 to 48 hours with use of a lethal method constitutes high ris