Chapter 6: Assessing Mental Status and Substance Abuse

Which assessment notation describes a client's level of consciousness?

"Client was alert and cooperative during the assessment."

When does the nurse screen for alcohol and drug use?

Every client/every client history

A client has been diagnosed with stomach cancer and has a comorbidity of depression. For what would it be important to assess in this client?

suicide

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?"

When assessing the client's ability to make sound judgments, what question should the nurse ask?

"How do you plan to pay rent if you lose your job?"

As part of the mental status examination, a nurse assesses the cognitive abilities of a client. Which question should the nurse ask to assess the judgment ability in the client?

"What do you do if you have pain?"

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

3

Which client statements suggest to the nurse that the client is experiencing a somatic symptom? Select all that apply.

"I can't recall doing anything to cause this back pain I've been having." "My partner complains that I'm just not as interested in sex as I was before the baby was born." "I can't have this headache; I've got final exams tomorrow."

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?

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

When considering high-yield screening questions, which question would likely gather the most relevant information concerning a client's mental status?

"Over the last 2 weeks, have your become less interested in your hobbies?"

Which of the following questions would be most helpful in beginning an initial assessment interview for a client who has just been admitted to a psychiatric inpatient unit?

"What brings you into the hospital today?"

The nurse documents findings from the client's Mini-Mental State Examination. The following information will be documented as a result of this test.

Orientation, memory, and cognitive function.

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

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

During an admission assessment, the nurse asks a client the meaning of the proverb, "people in glass houses should not throw stones." The nurse is assessing the client's what?

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

When the nurse asks the client to explain similarities and differences between objects, what cognitive ability is being tested?

Abstract reasoning.

The nurse suspects that a client may have an alcohol problem. Which of the following assessments should the nurse use to confirm this suspicion?

CAGE questionnaire

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?

Broca's aphasia

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?

Constructional ability

When depression goes undiagnosed, what consequences occur eight times more frequently than in the general population?

Death

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?

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 judgment

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.

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

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

The nurse needs to assess the visual, perceptual, and constructional ability of a client. Which of the following assessments should the nurse use?

Have the client draw the face of a clock

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

In coma

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

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

Lethargy

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?

Manic episode

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

When the mental health nurse ask the client "Do you recall what month and year this is?" The nurse is assessing which part of the mental status examination?

Orientation

The client is brought to the clinic by his son, who states, "My father just doesn't seem to be able to function as well as he used to." When assessing this client the nurse is aware that she will be a what?

Patient advocate

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 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

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 and language

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

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

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?

Vision and hearing

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

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.

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.

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

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

An auditory hallucination is considered an alteration in which component of the mental health assessment?

perceptions