Chapter 6 Prep U

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An adult client who had a baby 2 weeks ago is brought to the ED because her boyfriend has noticed she has not been herself since they brought the baby home. The client's appearance is unkempt, her hair is a mess, and she appears not to have bathed for several days. What could these findings reflect? Depression Mania Poor nutrition Need for more time to recover from childbirth

An auditory hallucination is considered an alteration in which component of the mental health assessment? perceptions thought processes affect Insight

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?" "What are the parts of a watch?" "Do you think that life is not worth living?" "What do you think is wrong?"

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 review of systems Evaluation of insight and judgment Questions regarding past behaviors Evaluation of medication compliance

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? SLUMS exam CAM CAGE questionnaire GCS

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

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? Dementia Violence Suicide Noncompliance

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

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? 35 29 25 17

A nurse uses the Glasgow Coma Scale to assess a client's response to stimuli. The client receives a score of 10. Which of the following is the client's status? Fully conscious Confused In need of emergency attention Comatose

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? Visual spatial ability New learning ability Constructional ability Time orientation

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? Generalized anxiety disorder Psychotic disorder due to a medical illness Substance-induced psychotic disorder Schizophrenia

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? Impaired memory related to dementia Risk for powerlessness related to prolonged disability Impaired verbal communication related to hearing loss Anxiety related to awareness of increasing memory loss

If a nurse suspects that a client is depressed, asking the client about any suicidal thoughts: will stimulate thoughts of suicide is important, but not an early priority will stimulate clients to act on suicidal ideation is important and will not stimulate the thought of suicide

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

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? Not engaging in conversation Inability to remember the date No idea where a wallet may be located Forgot the word to describe indigestion

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

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? Appearance and behavior Mood Thoughts and perceptions Speech and language

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 Hallucination Fugue state Aphasia

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 Repeatedly and apparently unintentionally follows instructions Uses appropriate and comprehensible words Appears oriented

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?" "When did you get your first job?" "When were you last hospitalized?" "How is an apple different from an orange?"

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 Memory Concentration Orientation

The client has a Glasgow Coma Score of 7. The nurse understands this client is considered to be what? In coma To have no impairments To have minimal impairments Is in a deep coma

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 Diagnostician Surrogate decision maker Family liaison

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 Anticipatory grieving Fear Mental status change

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 Delusions Psychosis Confabulation

The nurse is administering the Depression Questionnaire to a client. Which of the following symptoms listed on the questionnaire would most indicate depression? Eating much less than usual and only with personal effort Never taking longer than 30 minutes to fall asleep Slight weight loss in the past 2 weeks Occasionally feeling indecisive

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? Do you hear voices that tell you what to do? On a sense of 0 to 10, with 10 being most intense, how suicidal do you feel now? Do you have a sense of hope for the future?

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 Concentration Memory Insight

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 Perform the SLUMS exam Ask the client to pick up a pencil with the left hand, move it to the right, and then hand it to her Ask the client today's date

The patient has difficulty when the nurse asks him to say "No ifs, ands, or buts." The nurse understands that this may indicate a form of aphasia dysarthria mania Disorientation

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

Which Glasgow Coma Score indicates the client is in a deep coma? 3 8 14 15

Which question asked by the nurse assesses judgment of the client? "What will you do if you feel the need to use cocaine again?" "How did you and your siblings get along as children?" "What did you have for breakfast?" "Where are you right now?"

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 Serving as a "good historian" Finding the right words easily

A, B, C

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 Married with 2 children Ingests alcohol every evening Involved in a domestic abuse situation

A, B, D, E

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? Illusion Hallucination Fugue state Perseveration

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? Major depressive episode Manic episode Dysthymic disorder Schizophrenia

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? Derailment Flight of ideas Circumstantiality Incoherence

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? Wernicke's aphasia Broca's aphasia Dysarthria Stutter

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? mania depression Parkinson's disease obsessive-compulsive disorder

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 person is usually lost first and orientation to time is usually lost last. Orientation to time is usually lost first and orientation to person is usually lost last. Orientation to person is usually lost first and orientation to place is usually lost last. Orientation to time is usually lost first and orientation to place is usually lost last.

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 one of the four CAGE questions. answered "yes" to three of the four CAGE questions. answered "no" to all of the four CAGE questions. answered "no" to three of the four CAGE questions.

The nurse documents findings from the client's Mini-Mental State Examination. The following information will be documented as a result of this test. Mood, feelings, expressions, and perceptions. Orientation, memory, and cognitive function. Energy level, satisfaction, and social participation. Appropriateness of dress, grooming, and eye contact.

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

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

Which clients are most at risk for depressive symptoms? (Select all that apply.) Married clients Divorced clients Females Males Chronically ill clients

B, C, E

A 24-year-old secretary comes to your clinic complaining of difficulty sleeping, severe nightmares, and irritability. She states it all began 6 months ago when she went to a fast food restaurant at midnight. While she was waiting in her car, a man entered through the passenger door and put a gun to her head. He had her drive to a remote area where he took her money and threatened to kill her. When the gun jammed he panicked and ran off. Ever since, the client has had these symptoms. She states she jumps at every noise and refuses to drive at night. Her anxiety has had such a marked influence on her job performance she is afraid she will be fired. She denies any recent illnesses or injuries. Her past medical history is unremarkable. Examination reveals a nervous woman appearing her stated age, with otherwise unremarkable findings. What anxiety disorder is most consistent with this presentation? Specific phobia Acute stress disorder Posttraumatic stress disorder Generalized anxiety disorder

A 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? Ask the client about his education level Give the client the history form to read silently Have the client read a few sentences out loud Assess the client's hearing in both ears

After assessing a client, 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 client'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? Ineffective Role Performance Risk for Infection Risk for Suicide Risk for Self-Mutilation

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

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 and dementia are one in the same disorder. finding out why she is depressed will help determine the cause of her dementia. depression often mimics signs and symptoms of dementia. it is the most accurate tool to determine the stage of dementia.

The nurse completes the mental health assessment before continuing with a head-to-toe assessment. Why did the nurse use this approach? Requires little energy by the nurse to complete Is the easiest and shortest assessment to complete Validates the information the client provides during the rest of the assessment Ensures that this part of the assessment is completed before the client becomes fatigued

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 confabulation Patient is depressed Patient demonstrates flight of ideas Patient demonstrates schizophrenia

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

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? Dysphonia Dysarthria Wernicke's aphasia Cerebellar dysarthria

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

What intervention will the nurse implement initially for a client who has reported experiencing unexplained, severe neck pain for more than 2 months? Request a consult with physical therapy. Provide education regarding exercises that focus on strengthening neck muscles. Screen for possible depression. Inquire about possible pain medication abuse.

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 attempts Suicide means Suicide risk Suicide plan

When considering high-yield screening questions, which question would likely gather the most relevant information concerning a client's mental status? "Have any of your first-degree relatives ever been diagnosed with anxiety?" "Do you think that you have experienced any depression during the last 6 months?" "Over the last 2 weeks, have your become less interested in your hobbies?" "What types of things tend to trigger your anxieties?"

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

Which assessment notation describes a client's level of consciousness? "Client was inattentive to the questions being asked." "Client answered questions both logically and coherently." "Client was alert and cooperative during the assessment." "Client demonstrated difficulty with recalling events occurring this morning."

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

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? derailment perseveration confabulation flight of ideas

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