Chapter 6 Health Assessment: Assessing mental status and substance abuse

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.

Which question is appropriate for a nurse to ask a client to assess the client's recent memory?

"What did you eat for breakfast today?"

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?"

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

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

3

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

In coma

An older patient is demonstrating mental status changes. Which question would the nurse ask when conducting a mini-mental state examination of this patient?

"What is today's date?"

Which question asked by the nurse assesses judgment of the patient?

"What will you do if you feel the need to use cocaine again?"

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

-Divorced patients -Females -Chronically ill patients

The nurse is preparing to conduct a mental status examination with a patient. Which areas will the nurse include when assessing the patient's appearance and behavior? (Select all that apply.) You Selected:

-Posture -Level of consciousness -Facial expression

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

Euphoric

With which of the following is the documentation most consistent?

A patient who has had a recent stroke

The nurse is completing a mental health assessment. When the nurse asks the patient to interpret a proverb, the nurse is assessing which of the following?

Abstract reasoning

A nursing instructor is discussing mental health assessment with a class of nursing students. While reviewing risk factors for mental illness, what would the instructor be sure to identify as a factor that cannot be changed?

Age

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

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

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

The nurse is admitting a patient 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 judgement

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

A nurse rA nurse performs an admission assessment and notices that a client's speech is slow and the client has difficulty answering some of the questions. How can the nurse differentiate the cause of the client's slow speech?

Have the patient read a few sentences out loud.

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

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 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 rumours 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

A nurse reviews the documentation of the nurse on the previous shift and finds that the client was obtunded. The nurse anticipates the client will respond to stimulation in what manner?

Opens eyes to a loud voice and answers with confusion

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 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 patient?

Patient demonstrates flight of ideas

The nursing instructor talks with the student nurse on the adult psychiatric unit. The student tells the instructor that cradle cap appears to be around a specific client's face. The instructor explains that this may be an indication of long-term lack of care as a consequence of what disorder?

Schizophrenia

After assessing a patient, the nurse noted the following: he was tearful, he tried to kill himself before coming into the hospital, he had no immediate plan for another suicide attempt, he was unable to concentrate, and he reported having trouble sleeping and having little or no appetite. The nurse also noted that the patient's appearance was unkempt, that he spoke in a low monotone, and that he was unable to establish and maintain eye contact. Based on this information, which nursing diagnoses would be the most appropriate?

Risk for suicide

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 behaviour 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 neighbourhood 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 patient is articulate, makes spontaneous comments, and speaks at a normal rate. For which section of the history is this information important?

Speech and language

When a nurse asks a patient "Do you have any thoughts of wanting to harm or kill yourself?" for what is the nurse assessing?

Suicide Ideation

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

Time

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