HEALTH ASSESSMENT EXAM 3

In the assessment of a 1-month-old infant, the nurse notices a lack of response to noise or stimulation. The mother reports that in the last week he has been sleeping all of the time, and when he is awake all he does is cry. The nurse hears that the infant's cries are very high pitched and shrill. What is the most appropriate response by the nurse? a. Refer the infant for further testing. b. Talk with the mother about eating habits. c. Do nothing; these are expected findings for an infant this age. d. Tell the mother to bring the baby back in 1 week for a recheck.

ANS: A A high-pitched, shrill cry or cat-sounding screech occurs with central nervous system damage. Lethargy, hyporeactivity, and hyperirritability, as well as the parent's report of significant changes in behavior all warrant referral. The other options are not correct responses.

A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient's deep tendon reflexes? a. Reflexes will be normal. b. Reflexes cannot be elicited. c. All reflexes will be diminished but present. d. Some reflexes will be present, depending on the area of injury.

ANS: A A reflex is a defense mechanism of the nervous system. It operates below the level of conscious control and permits a quick reaction to potentially painful or damaging situations.

The nurse is assessing an older adult's advanced activities of daily living (AADLs), which would include a. Recreational activities b. Meal preparation c. Balancing the checkbook d. Self-grooming activities

ANS: A AADLs are activities that an older adult performs such as occupational and recreational activities. Self-grooming activities are basic ADLs; meal preparation and balancing the checkbook are considered IADLs.

In obtaining a health history on a 74-year-old patient, the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things. With this information, what response should the nurse make? a. "Does the tremor change when you drink alcohol?" b. "Does your family know you are drinking every day?" c. "We'll do some tests to see what is causing the tremor." d. "You really shouldn't drink so much alcohol; it may be causing your tremor."

ANS: A Although not a recommended treatment, senile tremor is relieved by alcohol. The nurse should assess how alcohol affects the tremor and whether the person is abusing alcohol in an effort to relieve the tremor. Asking whether the family knows he drinks daily does not address the issue of the tremor and it is possible cause. Before ordering tests, a thorough assessment should be performed. Telling the patient he shouldn't drink so much and that drinking may be the cause of his tremor is inappropriate and will likely make the patient defensive.

An 85-year-old man has been hospitalized after a fall at home, and his 86-year-old wife is at his bedside. She tells the nurse that she is his primary caregiver. What should the nurse assess the patient's wife for as a sign of possible caregiver burnout? a. Depression b. Weight gain c. Hypertension d. Social phobias

ANS: A Caregiver burden is the perceived strain by the person who cares for an older adult or for a person who is chronically ill or disabled. Caregiver burnout is linked to the caregiver's ability to cope and handle stress. Signs of possible caregiver burnout include multiple somatic complaints, increased stress and anxiety, social isolation, depression, and weight loss. Screening caregivers for depression may also be appropriate.

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 is an example of which speech pattern? a. Echolalia b. Clanging c. Word salad d. Perseveration

ANS: A Echolalia occurs when a person imitates or repeats another's words or phrases, often with a mumbling, mocking, or a mechanical tone. Clanging is word choice based on sound, not meaning, and includes nonsense rhymes and puns. Word salad is an incoherent mixture of words, phrases, and sentences. Perseveration is the persistent repeating of verbal or motor response, even with varied stimuli. The statements in this question describe echolalia.

The nurse discovers speech problems in a patient during an assessment. The patient has spontaneous speech, but it is mostly absent or is reduced to a few stereotypical words or sounds. This finding reflects which type of aphasia? a. Global b. Broca's c. Dysphonic d. Wernicke's

ANS: A 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. Dysphonic aphasia is not a valid condition. The description of the patient in the question does not describe Broca's or Wernicke's aphasia. With Broca's aphasia the person can understand language but cannot express himself using words or language. With Wernicke's or receptive aphasia the person can hear sounds and words but cannot relate them to previous experiences. Speech is fluent, effortless, and well-articulated, but it 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, a great urge to speak is present. Repetition, reading, and writing also are impaired. Dysphonic aphasia is not a valid condition.

During change of shift report, the nurse hears that a patient is experiencing hallucinations. Which is an example of a hallucination? a. Man believes that his dead wife is talking to him. b. Woman hears the doorbell ring and goes to answer it, but no one is there. c. Child sees a man standing in his closet. When the lights are turned on, it is only a dry cleaning bag. d. Man believes that the dog has curled up on the bed, but when he gets closer he sees that it is a blanket.

ANS: A Hallucinations are sensory perceptions for which no external stimuli exist. 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 has dysarthric speech and is lethargic. How should the nurse proceed? a. Defer the rest of the mental status examination. b. Skip the language portion of the examination and proceed onto assessing mood and affect. c. Conduct an in-depth speech evaluation and defer the mental status examination to another time. d. Proceed with the examination and assess the patient for suicidal thoughts because dysarthria is often accompanied by severe depression.

ANS: A 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 of the steps that follow. For example, if consciousness is clouded, then the person cannot be expected to have full attention and to cooperate with new learning. If language is impaired, then a subsequent assessment of new learning or abstract reasoning (anything that requires language functioning) can give erroneous conclusions. Dysarthric speech and lethargy are signs of altered consciousness and answers to questions on the mental status examination may be invalid. The nurse should not proceed with any further part of the mental status examination at this time.

The nurse is assessing the mental status of a child. Which statement about children and mental status is true? a. All aspects of mental status in children are interdependent. b. Children are highly labile and unstable until the age of 2 years. c. A child's mental status is impossible to assess until the child develops the ability to concentrate. d. Children's mental status is largely a function of their parents' level of functioning until the age of 7 years.

ANS: A 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. The other statements are not true. Options B, C, and D are all false statements. 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.

During a mental status examination, the nurse wants to assess a patient's affect. Which question the nurse should ask? a. "How do you feel today?" b. "Would you please repeat the following words?" c. "Have these medications had any effect on your pain?" d. "Has this pain affected your ability to get dressed by yourself?"

ANS: A Mood and affect should be judged by observing body language and facial expression and by directly asking, "How do you feel today?" or "How do you usually feel?" The mood should be appropriate to the person's place and condition and should appropriately change with the topics. Options B, C, and D do not assess affect.

The nurse is reviewing the principles of nociception. During which phase of nociception does the conscious awareness of a painful sensation occur? a. Perception b. Modulation c. Transduction d. Transmission

ANS: A Perception is the third phase of nociception and indicates the conscious awareness of a painful sensation. During this phase, the sensation is recognized by higher cortical structures and identified as pain. Modulation is the fourth phase of nociception in which the pain message is inhibited. Transduction is the first phase of nociception in which neurotransmitters are released and transmit the pain message along sensory afferent nerve fibers to the spinal cord. Transmission is the second phase of nociception in which the pain message moves from the spinal cord to the brain. The conscious awareness of a painful sensation occurs in the perception phase, third phase, of nociception.

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? a. Perform a complete mental status examination. b. Refer him to a psychometrician. c. Plan to integrate the mental status examination into the history and physical examination. d. Reassure his wife that memory loss after a physical shock is normal and will soon subside.

ANS: A Performing a complete mental status examination is necessary when any abnormality in affect or behavior is discovered or when family members are concerned about a person's behavioral changes (e.g., memory loss, inappropriate social interaction) or after trauma, such as a head injury.

While obtaining a health history of a 3-month-old infant from the mother, the nurse asks about the infant's ability to suck and grasp the mother's finger. What is the nurse assessing? a. Reflexes b. Intelligence c. Cranial nerves d. Cerebral cortex function

ANS: A Questions regarding an infant's ability to suck and grasp are assessing the infant's reflexes. Questions regarding reflexes include such questions as, "What have you noticed about the infant's behavior," "Do the infant's sucking and swallowing seem coordinated," and "Does the infant grasp your finger?" The other responses are incorrect.

The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When striking the Achilles heel and quadriceps muscle, the nurse is unable to elicit a reflex. How should the nurse proceed? a. Ask the patient to lock her fingers and pull. b. Document these reflexes as 0 on a scale of 0 to 4+. c. Refer the patient to a specialist for further testing. d. Complete the examination, and then test these reflexes again.

ANS: A Sometimes the reflex response fails to appear. Documenting the reflexes as absent is inappropriate this soon in the examination. The nurse should try to further encourage relaxation, varying the person's position or increasing the strength of the blow. Reinforcement is another technique to relax the muscles and enhance the response. The person should be asked to perform an isometric exercise in a muscle group somewhat away from the one being tested. For example, to enhance a patellar reflex, the person should be asked to lock the fingers together and pull.

The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries very easily and becomes angry. What part of the cerebral lobe is responsible for these behaviors? a. Frontal b. Parietal c. Occipital d. Temporal

ANS: A The frontal lobe has areas responsible for personality, behavior, emotions, and intellectual function. The parietal lobe has areas responsible for sensation; the occipital lobe is responsible for visual reception; and the temporal lobe is responsible for hearing, taste, and smell.

The nurse is assessing a patient's pain. What should the nurse know is the most reliable indicator of pain? a. Subjective report b. Physical examination c. Patient's vital signs d. Results of a computerized axial tomographic scan

ANS: A The subjective report is the most reliable indicator of pain. Physical examination findings can lend support, but the clinician cannot exclusively base the diagnosis of pain on physical assessment findings. Although the physical examination findings, vital signs, and CAT scan findings can lend support, the clinician cannot exclusively base the diagnosis of pain on those findings. The patient's subjective report is the most reliable indicator of pain.

A patient drifts off to sleep when she is not being stimulated. The nurse can easily arouse her by calling her name, but the patient remains drowsy during the conversation. What is the best description of this patient's level of consciousness? a. Lethargic b. Obtunded c. Stuporous d. Semi-coma

ANS: A The term lethargic best describes a patient who drifts off to sleep when not being stimulated, can easily be aroused by calling his or her name, but remains drowsy during conversation. Lethargic (or somnolent) is when the person is not fully alert, drifts off to sleep when not stimulated, and can be aroused when called by name in a normal voice but looks drowsy. He or she appropriately responds 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. Obtunded is a transitional state between lethargy and stupor. Stuporous and semi-coma have the same meaning which is unconscious and responding only to persistent or vigorous shaking or pain.

A patient has a severed spinal nerve as a result of trauma. Which statement is true in this situation? a. Because there are 31 pairs of spinal nerves, no effect results if only one nerve is severed. b. The dermatome served by this nerve will no longer experience any sensation. c. The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve. d. A severed spinal nerve will only affect motor function of the patient because spinal nerves have no sensory component.

ANS: C A dermatome is a circumscribed skin area that is primarily supplied from one spinal cord segment through a particular spinal nerve. The dermatomes overlap, which is a form of biologic insurance; that is, if one nerve is severed, then most of the sensations can be transmitted by the spinal nerve above and the spinal nerve below the severed nerve.

A patient describes feeling an unreasonable, irrational fear of snakes. His fear is so persistent that he can no longer comfortably look at even pictures of snakes and has made an effort to identify all the places he might encounter a snake and avoids them. What is the best description of this patient's condition? a. A snake phobia b. A hypochondriac c. An obsession with snakes d. A delusion that snakes are harmful stemming from an early traumatic incident involving snakes

ANS: A This is an example of a phobia. A phobia is a strong, persistent, irrational fear of an object or situation; the person feels driven to avoid it. The situation in the question is not an example of hypochondria, an obsession, or a delusion. A hypochondriac is a person who is morbidly worried about his/her own health and/or feels sick with no actual basis for that assumption. An obsession is an unwanted, persistent thought or impulse in which logic will not purge him/her from his/her consciousness and is intrusive and senseless. A delusion is a firm, fixed, false belief that is irrational and that a person clings to despite objective evidence to the contrary. Instead, the situation in the question is an example of a phobia. A phobia is a strong, persistent, irrational fear of an object or situation; the person feels driven to avoid it.

During the taking of the health history, a patient tells the nurse that "it feels like the room is spinning around me." How should the nurse document this finding? a. Vertigo b. Syncope c. Dizziness d. Seizure activity

ANS: A True vertigo is rotational spinning caused by a neurologic dysfunction or a problem in the vestibular apparatus or the vestibular nuclei in the brainstem. Syncope is a sudden loss of strength or a temporary loss of consciousness. Dizziness is a light-headed, swimming sensation. Seizure activity is characterized by altered or loss of consciousness, involuntary muscle movements, and sensory disturbances.

The nurse is preparing to perform a functional assessment of an older patient. What is an appropriate approach for the nurse to take? a. Observe the patient's ability to perform the tasks. b. Ask the patient's wife how he does when performing tasks. c. Review the medical record for information on the patient's abilities. d. Ask the patient's physician for information on the patient's abilities.

ANS: A Two approaches are used to perform a functional assessment: (1) asking individuals about their ability to perform the tasks (self-reports), or (2) actually observing their ability to perform the tasks. For people with memory problems, the use of surrogate reporters (proxy reports), such as family members or caregivers, may be necessary, keeping in mind that they may either overestimate or underestimate the person's actual abilities.

During assessment of a patient's pain, the nurse is aware that certain nonverbal behaviors are associated with chronic pain. Which of these behaviors are associated with chronic pain? (Select all that apply.) a. Bracing b. Rubbing c. Moaning d. Sleeping e. Diaphoresis f. Restlessness

ANS: A, B, D Behaviors that have been associated with chronic pain include bracing, rubbing, diminished activity, sighing, and changes in appetite. In addition, those with chronic pain may sleep in an attempt at distraction. The other behaviors are associated with acute pain.

During a mental status assessment, which question by the nurse would best assess a person's judgment? a. "Do you feel that you are being watched, followed, or controlled?" b. "Tell me what you plan to do once you are discharged from the hospital." c. "What does the statement, 'People in glass houses shouldn't throw stones,' mean to you?" d. "What would you do if you found a stamped, addressed envelope lying on the sidewalk?"

ANS: B 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 the option with the envelope), 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.

When assessing the intensity of a patient's pain, which question by the nurse is appropriate? a. "What does your pain feel like?" b. "How much pain do you have now?" c. "How does pain limit your activities?" d. "What makes your pain better or worse?"

ANS: B Asking the patient "how much pain do you have?" is an assessment of the intensity of a patient's pain; various intensity scales can be used. Asking "what does your pain feel like" assesses the quality of pain. Asking whether pain limits one's activities assesses the degree of impairment and quality of life. Asking what makes one's pain better or worse assesses alleviating or aggravating factors. Asking "what does your pain feel like" assesses the quality of pain. Asking whether pain limits one's activities assesses the degree of impairment and quality of life. Asking what makes one's pain better or worse assesses alleviating or aggravating factors. To assess the intensity of pain, the nurse should ask the patient "how much pain do you have?" This is an assessment of the intensity of a patient's pain; various intensity scales can be used.

. The assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception, the nurse decides to complete the test as quickly as possible. When the nurse applies the sharp point of the pin on his arm several times, he is only able to identify these as one "very sharp prick." What would be the most accurate explanation for this? a. The patient has hyperesthesia as a result of the aging process. b. This response is most likely the result of the summation effect. c. The nurse was probably not poking hard enough with the pin in the other areas. d. The patient most likely has analgesia in some areas of arm and hyperalgesia in others.

ANS: B At least 2 seconds should be allowed to elapse between each stimulus to avoid summation. With summation, frequent consecutive stimuli are perceived as one strong stimulus. The other responses are incorrect.

A patient repeats, "I feel hot. Hot, cot, rot, tot, got. I'm a spot." What term should the nurse use to document this? a. Blocking b. Clanging c. Echolalia d. Neologism

ANS: B Clanging is word choice based on sound, not meaning, and includes nonsense rhymes and puns. This is not an example of blocking, echolalia, or neologism. Blocking is when a person experiences sudden interruption in train of thought and unable to complete sentences which seems r/t strong emotion. Echolalia is an imitation or the repetition of another person's words or phrases. Neologism involves coining a new word, which is inventing or making up words that have no real meaning except for the person. The statement in the question is an example of clanging.

What controls humans' ability to perform very skilled movements such as writing? a. Basal ganglia b. Corticospinal tract c. Spinothalamic tract d. Extrapyramidal tract

ANS: B Corticospinal fibers mediate voluntary movement, particularly very skilled, discrete, and purposeful movements, such as writing. The corticospinal tract, also known as the pyramidal tract, is a newer, "higher" motor system that humans have that permits very skilled and purposeful movements. The other responses are not r/t skilled movements. The basal ganglia are large bands of gray matter buried deep within the two cerebral hemispheres that from the subcortical-associated motor system and help to initiate and coordinate movement and control automatic associated movements of the body (e.g. arm swing alternating with the legs during walking). The spinothalamic tract is one of the major sensory pathways of the CNS and has two parts. The lateral spinothalamic tract carries pain and temperature sensations and the anterior spinothalamic tract carries crude touch. The extrapyramidal tracts include all the motor nerve fibers originating in the motor cortex, basal ganglia, brainstem, and spinal cord that are outside the pyramidal tract and maintains muscle tone and control body movements, especially gross automatic movements such as walking.

During a functional assessment of an older person's home environment, which statement or question by the nurse is most appropriate regarding common environmental hazards? a. "These low toilet seats are safe because they are nearer to the ground in case of falls." b. "Do you have a relative or friend who can help to install grab bars in your shower?" c. "These small rugs are ideal for preventing you from slipping on the hard floor." d. "It would be safer to keep the lighting low in this room to avoid glare in your eyes."

ANS: B Environmental hazards within the home can be a potential constraint on the older person's day-to-day functioning. Common environmental hazards, including inadequate lighting, loose throw rugs, curled carpet edges, obstructed hallways, cords in walkways, lack of grab bars in tub and shower, and low and loose toilet seats, are hazards that could lead to an increased risk for falls and fractures. Environmental modifications can promote mobility and reduce the likelihood of the older adult falling.

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 what behavior? a. Social phobia b. Compulsive disorder c. Generalized anxiety disorder d. Posttraumatic stress disorder

ANS: B Repetitive ritualistic actions, such as handwashing, that a person feels driven to perform are compulsions. These behaviors are done to decrease anxiety and prevent a catastrophe (e.g. contamination [fear of germs], violence, perfectionism, and superstitions). A social phobia is a persistent and irrational fear of being in social situations. Generalized anxiety disorder is a pattern of excessive worrying and morbid fear about anticipated "disasters" in the job, personal relationships, health, or finances. With PSTD the person relieves the trauma many times, intrusively and unwillingly. The same feelings of helplessness, fear, or horror recur. Avoidance of any trigger associated with the trauma occurs, and the person has hypervigilance, sleep problems, and difficulty concentrating, leading to feelings of being permanently damaged. The repetitive behavior of handwashing in this question is a behavior characteristic of compulsive disorder. People with compulsive disorder feel driven to perform repetitive, ritualistic actions in an attempt to decrease anxiety and prevent a catastrophe (e.g. contamination [fear of germs], violence, perfectionism, and superstitions.

The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding? a. Extinction b. Stereognosis c. Graphesthesia d. Tactile discrimination

ANS: B Stereognosis is the person's ability to recognize objects by feeling their forms, sizes, and weights. Astereognosis is an inability to identify objects correctly, and it occurs in sensory cortex lesions. Extinction tests the person's ability to feel sensations on both sides of the body at the same point. Graphesthesia is the ability to "read" a number by having it traced on the skin. Tactile discrimination tests fine touch.

The nurse is preparing to use the Lawton IADL instrument as part of an assessment. Which statement about the Lawton IADL instrument is true? a. The nurse uses direct observation to implement this tool. b. The Lawton IADL instrument is designed as a self-report measure of performance rather than ability. c. This instrument is not useful in the acute hospital setting. d. This tool is best used for those residing in an institutional setting.

ANS: B The Lawton IADL instrument is designed as a self-report measure of performance rather than ability. Direct testing is often not feasible, such as demonstrating the ability to prepare food while a hospital inpatient. Attention to the final score is less important than identifying a person's strengths and areas where assistance is needed. The instrument is useful in acute hospital settings for discharge planning and continuously in outpatient settings. It would not be useful for those residing in institutional settings because many of these tasks are already being managed for the resident.

The nurse needs to determine an older adult's competence and maintenance of life skills in order to determine the most suitable living situation for them. What tool should the nurse use for this assessment? a. Katz Index of ADL b. Lawton IADL scale c. Montreal Cognitive Assessment (MoCA) d. Mini-Mental State Examination (MMSE)

ANS: B The Lawton IADL scale was originally developed to determine competence and maintenance of life skills such as shopping, cooking, and managing finances in a meaningful way. IADLS are a prerequisite for independent living and contains 8 items: use of telephone, shopping, meal preparation, housekeeping, laundry, transportation, self-medication, and management of finances. It is a self-report measure of performance rather than ability and is useful for discharge planning in acute hospital settings and for ongoing measurement of function in outpatient settings. It would not be useful for those residing in institutional settings because many of the tasks are already being managed for the resident. The Katz Index of ADL is based on the concept of physical disability and measures physical function in older adults and the chronically ill. The Katz ADL is valuable for planning specific types of assistance that the older person may need, rather than determining the most suitable living situation. The Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE) are cognitive assessments.

When using the various instruments to assess an older person's ADLs, what should the nurse keep in mind as a disadvantage of these instruments? a. Reliability of the tools b. Lack of confidentiality during the assessment c. Self or proxy reporting of functional activities d. Insufficient details concerning the deficiencies identified

ANS: C A disadvantage of many of the ADL and IADL instruments is the self or proxy reporting of functional activities. The other responses are not correct.

A patient will be ready to be discharged from the hospital soon, and the patient's family members are concerned about whether the patient is able to walk safely outside alone. Which tool or test would be best to assess this? a. Lawton IADL scale b. Timed Up and Go Test c. Katz Index of ADL scale d. Geriatric Depression Test

ANS: B The Timed Up and Go Test (TUG) is a reliable and valid test to quantify functional mobility. The test is quick, requires little training and no special equipment, and is appropriate to use in many settings including hospitals and clinics. The practitioner observes and times the patient as he or she rises from a chair, walks 10 feet, turns, walks back to the chair, and sits down. Factors to note are sitting balance, transferring from sitting to standing, pace and stability of gait, ability to turn without staggering, and sitting back down in the chair. An older person who takes longer than 12 seconds to complete the test is at high risk for falling and may need further evaluation. The Lawton IADL instrument is designed as a self-report measure of performance rather than ability. Direct testing is often not feasible, such as demonstrating the ability to prepare food while a hospital inpatient. Attention to the final score is less important than identifying a person's strengths and areas where assistance is needed. The instrument is useful in acute hospital settings for discharge planning and continuously in outpatient settings. It would not be useful for those residing in institutional settings because many of these tasks are already being managed for the resident. The Katz Index of ADL is based on the concept of physical disability and measures physical function in older adults and the chronically ill. The Katz ADL is valuable for planning specific types of assistance that the older person may need, rather than determining the most suitable living situation. The Geriatric Depression Test is a tool to screen for depression, not physical mobility.

The nurse is preparing to conduct a mental status examination. Which statement is true regarding the mental status examination? a. A patient's family is the best resource for information about the patient's coping skills. b. Gathering mental status information during the health history interview is usually sufficient. c. Integrating the mental status examination into the health history interview takes an enormous amount of extra time. d. To get a good idea of the patient's level of functioning, performing a complete mental status examination is usually necessary.

ANS: B The full mental status examination is a systematic check of emotional and cognitive functioning. The steps described, however, rarely need to be taken in their entirety. Usually, one can assess mental status through the context of the health history interview. A patient's family is not the best resource for information about the patient's coping skills. The nurse can gain ample data to assess mental health and coping skills during the health history with the mental health examination integrated into it.

Which statement concerning the areas of the brain is true? a. The cerebellum is the center for speech and emotions. b. The hypothalamus controls body temperature and regulates sleep. c. The basal ganglia are responsible for controlling voluntary movements. d. Motor pathways of the spinal cord and brainstem synapse in the thalamus.

ANS: B The hypothalamus is a vital area with many important functions: body temperature controller, sleep center, anterior and posterior pituitary gland regulator, and coordinator of autonomic nervous system activity and emotional status. The cerebellum controls motor coordination, equilibrium, and balance. The basal ganglia control autonomic movements of the body. The motor pathways of the spinal cord synapse in various areas of the spinal cord, not in the thalamus.

A mother of a 1-month-old infant asks the nurse why it takes so long for infants to learn to roll over. What is the reason for this? a. A demyelinating process must be occurring with her infant. b. Myelin is needed to conduct the impulses, and the neurons of a newborn are not yet myelinated. c. The cerebral cortex is not fully developed; therefore, control over motor function gradually occurs. d. The spinal cord is controlling the movement because the cerebellum is not yet fully developed.

ANS: B The infant's sensory and motor development proceeds along with the gradual acquisition of myelin, which is needed to conduct most impulses. Very little cortical control exists, and the neurons are not yet myelinated. The other responses are not correct.

What are the two parts of the nervous system? a. Motor and sensory b. Central and peripheral c. Peripheral and autonomic d. Hypothalamus and cerebral

ANS: B The nervous system can be divided into two parts—central and peripheral. The central nervous system includes the brain and spinal cord. The peripheral nervous system includes the 12 pairs of cranial nerves (CNs), the 31 pairs of spinal nerves, and all of their branches. Motor and sensory refer to the two types of nerve tract pathways in the CNS. Peripheral and autonomic both are part of the peripheral part of the nervous system. The peripheral nervous system has two parts, the somatic and autonomic. The hypothalamus and cerebral are parts of the brain.

During an assessment of the cranial nerves (CNs), the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. These findings indicate dysfunction of which cranial nerve(s)? a. Motor component of CN IV b. Motor component of CN VII c. Motor and sensory components of CN XI d. Motor component of CN X and sensory component of CN VII

ANS: B The nurse's findings all reflect motor dysfunction, none are sensory. The specific cranial nerve affected is the facial nerve (CN VII). Cranial nerve IV, the trochlear nerve, innervates a muscle in the eye muscle and is responsible for eye movement, not the symptoms this patient is experiencing. The nurse's findings all reflect motor dysfunction, none are sensory, therefore options c and d can be eliminated because they each contain a sensory component.

During the neurologic assessment of a "healthy" 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find? a. Firm, rigid resistance to movement b. Mild, even resistance to movement c. Slight pain with some directions of movement d. Hypotonic muscles as a result of total relaxation.

ANS: B Tone is the normal degree of tension (contraction) in voluntarily relaxed muscles. It shows a mild resistance to passive stretching. Normally the nurse will notice a mild, even resistance to movement. The other responses are not correct.

When assessing a patient's pain, the nurse records that the patient has visceral pain. Which condition would the patient have stated in order for the nurse document visceral pain? a. A hip fracture b. Cholecystitis c. Second-degree burns d. Pain after a leg amputation

ANS: B Visceral pain originates from the larger interior organs, such as the gallbladder, liver, or kidneys. A fractured hip and second-degree burns would cause somatic pain and pain after an amputation is phantom pain.

The nurse is evaluating a patient's pain. Which is an example of acute pain? a. Fibromyalgia b. Arthritic pain c. Kidney stones d. Lower back pain

ANS: C Acute pain is short term and self-limiting, often follows a predictable trajectory, and dissipates after an injury heals, such as with surgery, trauma, and kidney stones. The other conditions are examples of chronic pain in which the pain continues for 6 months or longer and does not stop when the injury heals. Fibromyalgia, arthritic pain, and lower back pain are examples of nonmalignant chronic pain (pain that continues for 6 months or longer and does not stop when the injury heals), not acute pain.

The nurse is planning health teaching for a 65-year-old woman who has had a cerebrovascular accident (stroke) and has aphasia. Which of these questions is most important to use when assessing the mental status of this patient? a. "Please count backward from 100 by 7." b. "I will name three items and ask you to repeat them in a few minutes." c. "Please point to articles in the room and parts of the body as I name them." d. "What would you do if you found a stamped, addressed envelope on the sidewalk?"

ANS: C Additional tests for people with aphasia include 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). Aphasia is a disorder of language comprehension. To assess the mental status of a patient with aphasia, the nurse should ask questions to assess her comprehension. The other options do not assess a person's comprehension.

When taking the health history on a patient with a seizure disorder, the nurse assesses whether the patient has an aura. Which of these would be the best question for obtaining this information? a. "Does your muscle tone seem tense or limp?" b. "After the seizure, do you spend a lot of time sleeping?" c. "Do you have any warning sign before your seizure starts?" d. "Do you experience any color change or incontinence during the seizure?"

ANS: C Aura is a subjective sensation that precedes a seizure; it could be auditory, visual, or motor. The other questions do not solicit information about an aura.

A patient repeatedly seems to 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." How should the nurse record this on his chart? a. Blocking b. Neologism c. Circumlocution d. Circumstantiality

ANS: C Circumlocution is a roundabout expression, substituting a phrase when one cannot think of the name of the object. The statement in the question is not an example of blocking, neologism, or circumstantiality. Blocking is when a person experiences sudden interruption in train of thought and unable to complete sentences which seems r/t strong emotion. Neologism involves coining a new word which is inventing or making up words that have no real meaning except for the person. Circumstantiality is when a person talks excessively with unnecessary detail and delays reaching the point. Their sentences have a meaningful connection but are irrelevant. The statement in the question is an example of circumlocution which is a roundabout expression, substituting a phrase when one cannot think of the name of the object.

The nurse knows that which statement is true regarding the pain experienced by infants? a. Infants feel pain less than adults do. b. The FPS-R can be used to assess pain in infants. c. A procedure that induces pain in adults will also induce pain in the infant. d. Pain in infants can only be assessed by physiologic changes, such as an increased heart rate.

ANS: C If a procedure or disease process causes pain in an adult, then it will also cause pain in an infant. Physiologic changes cannot be exclusively used to confirm or deny pain because other factors, such as medications, fluid status, or stress, may cause physiologic changes. The FPS-R can be used starting at age 4 years.

The nurse is preparing to assess an older adult and discovers that the older adult is in severe pain. Which statement about pain and the older adult is true? a. Pain is inevitable with aging. b. Older adults with cognitive impairments feel less pain. c. Alleviating pain should be a priority over other aspects of the assessment. d. Completion of the assessment should take priority so that care decisions can be made.

ANS: C If the older adult is experiencing pain or discomfort, then the depth of knowledge gathered through the assessments will suffer. Alleviating pain should be a priority over other aspects of the assessment. Remembering that older adults with cognitive impairment do not feel less pain is paramount.

The nurse is conducting a patient interview. Which statement made by the patient should the nurse more fully explore to assess the mental status during the interview? a. "I sleep like a baby." b. "I have no health problems." c. "I never did too good in school." d. "I am not currently taking any medications."

ANS: C In every mental status examination, the following factors from the health history that could affect the findings should be noted: 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, noting this level as the patient's normal baseline and not expecting a level of 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 stating that he/she sleeps like a ba by, has no health problems, or is currently not taking any medications are not r/t the patient's mental status.

The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, what would the nurse suspect? a. Hyperalgesia b. Hyperesthesia c. Peripheral neuropathy d. Lesion of sensory cortex

ANS: C Loss of vibration sense occurs with peripheral neuropathy (e.g., diabetes and alcoholism). Peripheral neuropathy is worse at the feet and gradually improves as the examiner moves up the leg, as opposed to a specific nerve lesion, which has a clear zone of deficit for its dermatome. The other responses are incorrect.

The nurse is administering a Mini-Cog test to an older adult woman. When asked to draw a clock showing the time of 10:45, the patient drew a clock with the numbers out of order and with an incorrect time. This result indicates which finding? a. Amnesia b. Delirium c. Cognitive impairment d. Attention-deficit disorder

ANS: C The Mini-Cog is a newer instrument that screens for cognitive impairment, often found with dementia. The result of an abnormal drawing of a clock and time indicates a cognitive impairment.

During an examination, the nurse can assess mental status by which activity? a. Examining the patient's electroencephalogram b. Observing the patient as he or she performs an intelligence quotient (IQ) test c. Observing the patient and inferring health or dysfunction d. Examining the patient's response to a specific set of questions

ANS: C Mental status cannot be directly scrutinized like the characteristics of skin or heart sounds. Its functioning is inferred through an assessment of an individual's behaviors, such as consciousness, language, mood and affect, and other aspects. Mental status cannot be directly scrutinized through tests such as an electroencephalogram, intelligence quotient (IQ) test, or responses to questions. Instead, the functioning of mental status is inferred through an assessment of an individual's behaviors, such as consciousness, language, mood and affect, and other aspects.

The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status? a. Mental status assessment diagnoses specific psychiatric disorders. b. Mental disorders occur in response to everyday life stressors. c. Mental status functioning is inferred through the assessment of an individual's behaviors. d. Mental status can be directly assessed, similar to other systems of the body (e.g., heart sounds, breath sounds).

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

The nurse is teaching a class on pain at a local retirement community. Which statement about the pain experienced by older adults should the nurse include in the instructions? a. "Older adults must learn to tolerate pain." b. "Pain is a normal process of aging and is to be expected." c. "Pain indicates a pathologic condition or an injury and is not a normal process of aging." d. "Older individuals perceive pain to a lesser degree than do younger individuals."

ANS: C Pain indicates a pathologic condition or an injury and should never be considered something that an older adult should expect or tolerate. Pain is not a normal process of aging, and no evidence suggests that pain perception is reduced with aging. Older adults should not be expected to learn to tolerate pain as pain is not a normal process of aging, and no evidence suggests that pain perception is reduced with aging. Instead, pain indicates a pathologic condition or an injury.

When assessing aging adults, what is one of the first things the nurse should assess before making judgments about the aging person's mental status? a. Presence of phobias b. General intelligence c. Sensory-perceptive abilities d. Presence of irrational thinking patterns

ANS: C Presence of phobias, general intelligence, and presence of irrational thinking patterns are not one of the first things a nurse should assess before making a judgment about an aging person's mental status. 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, which produce frustration, suspicion, and social isolation and make the person appear confused.

During an assessment of an 80-year-old patient, the nurse notices the following: an inability to identify vibrations at her ankle and to identify the position of her big toe, a slower and more deliberate gait, and a slightly impaired tactile sensation. All other neurologic findings are normal. How should the nurse interpret these findings? a. CNS dysfunction b. Lesion in the cerebral cortex c. Normal changes attributable to aging d. Demyelination of nerves attributable to a lesion

ANS: C Some aging adults show a slower response to requests, especially for those calling for coordination of movements. The findings listed are normal in the absence of other significant abnormal findings. The other responses are incorrect.

The nurse is performing the Denver II screening test on a 12-month-old infant during a routine well-child visit. What should the nurse tell the infant's parents about the Denver II screening test? a. Tests three areas of development: cognitive, physical, and psychological b. Will indicate whether the child has a speech disorder so that treatment can begin c. Is a screening instrument designed to detect children who are slow in development d. Is a test to determine intellectual ability and may indicate whether problems will develop later in school

ANS: C The Denver II is a screening instrument designed to detect developmental delays in infants and preschoolers. It tests four functions: gross motor, language, fine motor-adaptive, and personal-social. The Denver II is not an intelligence test; it does not predict current or future intellectual ability. It is not diagnostic; it does not suggest treatment regimens. The Denver II does not asses cognitive, physical, and psychological domains; is not an intelligence test and it does not predict current or future intellectual ability; and does not diagnose speech disorders or suggest treatment regimens.

A 45-year-old woman is at the clinic for a mental status assessment. Which describes the expecting findings on the Four Unrelated Words Test? a. Invents four unrelated words within 5 minutes b. Invents four unrelated words within 30 seconds c. Recalls four unrelated words after a 30-minute delay d. Recalls four unrelated words after a 60-minute delay

ANS: C 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 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 people under 60 years is an accurate three- or four-word recall after a 5-, 10-, and 30-minute delay.

The nurse is providing instructions to newly hired graduates for the mini-mental state examination (MMSE). Which statement best describes this examination? a. Scores below 30 indicate cognitive impairment. b. The MMSE is a good tool to evaluate mood and thought processes. c. This examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness. d. The MMSE is a useful tool for an initial evaluation of mental status. Additional tools are needed to evaluate cognition changes over time.

ANS: C The MMSE is a quick, easy test of 11 questions and is used for initial and serial evaluations and can demonstrate a worsening or an improvement of cognition over time and with treatment. It evaluates cognitive functioning, not mood or thought processes. MMSE 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. What should the nurse expect when performing the mental status portion of the assessment? a. Will have no decrease in any of his abilities, including response time. b. Will have difficulty on tests of remote memory because this ability typically decreases with age. c. May take a little longer to respond, but his general knowledge and abilities should not have declined. d. Will exhibit a decrease in his response time because of the loss of language and a decrease in general knowledge.

ANS: C The aging process leaves the parameters of mental status mostly intact. General knowledge does not decrease, and little or no loss in vocabulary occurs. Response time is slower than in a youth. It takes a little longer for the brain to process information and to react to it. Recent memory, which requires some processing, is somewhat decreased with aging, but remote memory is not affected.

A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain most concerns the nurse? a. Thalamus b. Brainstem c. Cerebellum d. Extrapyramidal tract

ANS: C The cerebellar system coordinates movement, maintains equilibrium, and helps maintain posture. So the nurse would be most concerned about this area of the brain. The thalamus is the primary relay station where sensory pathways of the spinal cord, cerebellum, and brainstem form synapses on their way to the cerebral cortex. The brainstem consists of the midbrain, pons, and medulla and has various functions, especially concerning autonomic centers. The extrapyramidal tract maintains muscle tone for gross automatic movements, such as walking. The thalamus is the primary relay station where sensory pathways of the spinal cord, cerebellum, and brainstem form synapses on their way to the cerebral cortex. The brainstem consists of the midbrain, pons, and medulla and has various functions, especially concerning autonomic centers. The extrapyramidal tract maintains muscle tone for gross automatic movements, such as walking. With this patient's unsteady gait and balance problems, the nurse would be most concerned with the cerebellum.

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. What should the nurse expect during this patient's tests of cognitive function? a. May display some disruption in thought content. b. Will state, "I am so relieved to be out of intensive care." c. Will be oriented to place and person, but the patient may not be certain of the date. d. May show evidence of some clouding of his level of consciousness.

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

During the taking of the health history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: "He can't even remember how to button his shirt." When assessing his sensory system, which action by the nurse is most appropriate? a. The nurse would perform the tests, knowing that mental status does not affect sensory ability. b. The nurse would proceed with an explanation of each test, making certain that the wife understands. c. Before testing, the nurse would assess the patient's mental status and ability to follow directions. d. The nurse would not test the sensory system as part of the examination because the results would not be valid.

ANS: C The nurse should ensure the validity of the sensory system testing by making certain that the patient is alert, cooperative, comfortable, and has an adequate attention span. Otherwise, the nurse may obtain misleading and invalid results.

A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurologic examination? a. Glasgow Coma Scale b. Neurologic recheck examination c. Complete neurologic examination d. Screening neurologic examination

ANS: C The nurse should perform a complete neurologic examination on an individual who has neurologic concerns (e.g., headache, weakness, loss of coordination) or who is showing signs of neurologic dysfunction. The Glasgow Coma Scale is used to define a person's level of consciousness. The neurologic recheck examination is appropriate for those who are demonstrating neurologic deficits. The screening neurologic examination is performed on seemingly well individuals who have no significant subjective findings from the health history.

A patient with a lack of oxygen to his heart will have pain in his chest and possibly in the shoulder, arms, or jaw. The nurse knows that the best explanation why this occurs is which one of these statements? a. A problem exists with the sensory cortex and its ability to discriminate the location. b. The lack of oxygen in his heart has resulted in decreased amount of oxygen to the areas experiencing the pain. c. The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere. d. A lesion has developed in the dorsal root, which is preventing the sensation from being transmitted normally.

ANS: C The sensory cortex is arranged in a specific pattern, forming a corresponding map of the body. Pain in the right hand is perceived at a specific spot on the map. Some organs, such as the heart, liver, and spleen, are absent from the brain map. Pain originating in these organs is referred because no felt image exists in which to have pain. Pain is felt by proxy, that is, by another body part that does have a felt image. The other responses are not correct explanations.

The area of the nervous system that responsible for mediating reflexes? a. Medulla b. Cerebellum c. Spinal cord d. Cerebral cortex

ANS: C The spinal cord is the main highway for ascending and descending fiber tracts that connect the brain to the spinal nerves; it is responsible for mediating reflexes. The medulla is the continuation of the spinal cord in the brain that contains all ascending and descending fiber tracts. Pyramidal decussation (crossing of the motor fibers) occurs here. The cerebellum is a coiled structure located under the occipital lobe that is concerned with motor coordination of voluntary movements, equilibrium, and muscle tone. The cerebral cortex is the outer layer of nerve cell bodies and is the center for a human's highest functions, governing thought, memory, reasoning, sensation, and voluntary movement.

While gathering equipment after an injection, a nurse accidentally received a prick from an improperly capped needle. To interpret this sensation, which of these areas must be intact? a. Corticospinal tract, medulla, and basal ganglia b. Pyramidal tract, hypothalamus, and sensory cortex c. Lateral spinothalamic tract, thalamus, and sensory cortex d. Anterior spinothalamic tract, basal ganglia, and sensory cortex

ANS: C The spinothalamic tract contains sensory fibers that transmit the sensations of pain, temperature, and crude or light touch. Fibers carrying pain and temperature sensations ascend the lateral spinothalamic tract, whereas the sensations of crude touch form the anterior spinothalamic tract. At the thalamus, the fibers synapse with another sensory neuron, which carries the message to the sensory cortex for full interpretation. The other options are not correct.

The nurse is performing an assessment on a 29-year-old woman who visits the clinic reporting "always dropping things and falling down." While testing rapid alternating movements, the nurse notices that the woman is unable to pat both of her knees. Her response is extremely slow and she frequently misses. What should the nurse suspect? a. Lesion of CN IX b. Vestibular disease c. Dysfunction of the cerebellum d. Inability to understand directions

ANS: C The symptoms this patient has been experiencing indicate dysfunction of the cerebellum. The cerebellum is concerned with motor coordination of voluntary movements, equilibrium, and muscle tone. When a person tries to perform rapid, alternating movements, responses that are slow, clumsy, and sloppy are indicative of cerebellar disease. Vestibular disease causes problems with balance and vertigo. Lesions of CN IX cause problems swallowing or gagging. Inability to understand directions would be r/t a problem in Wernicke's area in the brain and is not associated with dropping things or falling down.

The nurse is planning to assess new memory with a patient. Which is the best way for the nurse to do this? a. Administer the FACT test. b. Ask him to describe his first job. c. Give him the Four Unrelated Words Test. d. Ask him to describe what television show he was watching before coming to the clinic.

ANS: C To assess new memory, the nurse should ask questions that can be corroborated, which screens for the occasional person who confabulates or makes up answers to fill in the gaps of memory loss. The Four Unrelated Words Test tests the person's ability to lay down new memories and is a highly sensitive and valid memory test. The FACT test, describing his first job, or describing the television show he was watching before coming to the clinic, does not test new memory.

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

ANS: C When the person expresses feelings of hopelessness, despair, or grief, assessing the risk for physical harm to him or herself is important. This process begins with more general questions. If the answers are affirmative, then the assessment continues with more specific questions.

During a routine well-person checkup, the daughter of an older patient mentions to the nurse notices she has noticed her mother is less attentive and sometimes unable to recall events from a previous day. The daughter said this does not happen all the time, but that she has noticed it twice in the last month. Which test would be best to assess this patient's mental status? a. Timed Up and Go Test (TUG) b. Montreal Cognitive Assessment (MoCA) c. Mini-Mental State Examination (MMSE) d. Geriatric Depression Scale, short form

ANS: C While both the Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE) assess cognition and can be completed in approximately 10 minutes by pen and paper only, the MoCA is more sensitive in detecting mild cognitive impairment and includes assessments of frontal executive function and spatial attention. The Timed Up and Go Test (TUG) is a reliable and valid test to quantify functional mobility, not cognitive ability. The Geriatric Depression Scale, short form, assesses for depression and changes in the level of depression, not mental status.

The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding? a. Positive Babinski sign b. Plantar reflex abnormal c. Plantar reflex present d. Plantar reflex 2+ on a scale from "0 to 4+"

ANS: C With a reflex hammer, the nurse should draw a light stroke up the lateral side of the sole of the foot and across the ball of the foot, similar to an upside-down J. The normal response is plantar flexion of the toes and sometimes of the entire foot. A positive Babinski sign is abnormal and occurs with the response of dorsiflexion of the big toe and fanning of all toes. The plantar reflex is not graded on a 0 to 4+ scale.

The nurse is assessing a patient who is admitted with possible delirium. Which of these are manifestations of delirium? (Select all that apply.) a. Person experiences agnosia. b. Person demonstrates apraxia. c. Develops over a short period d. Person exhibits memory impairment or deficits. e. Occurs as a result of a medical condition, such as systemic infection

ANS: C, D, E Delirium is a disturbance of consciousness that develops over a short period and may be attributable to a medical condition. Memory deficits may also occur. Apraxia and agnosia occur with dementia. Agnosia and apraxia are not symptoms of delirium.

During an admission assessment of a patient with dementia, the nurse assesses for pain because the patient has recently had several falls. Which of these are appropriate for the nurse to assess in a patient with dementia? (Select all that apply.) a. Ask the patient, "Do you have pain?" b. Have the patient rate pain on a 1-to-10 scale. c. Assess the patient's breathing independent of vocalization. d. Note whether the patient is calling out, groaning, or crying. e. Observe the patient's body language for pacing and agitation.

ANS: C, D, E Patients with dementia may say "no" when, in reality, they are very uncomfortable because words have lost their meaning. Patients with dementia become less able to identify and describe pain over time, although pain is still present. People with dementia communicate pain through their behaviors. Agitation, pacing, and repetitive yelling may indicate pain and not a worsening of the dementia. (See Figure 10-10 for the Pain Assessment in Advanced Dementia [PAINAD] scale, which may also be used to assess pain in persons with dementia.)

A 60-year-old woman has developed reflexive sympathetic dystrophy after arthroscopic repair of her shoulder. Which is a key feature of this condition? a. Affected extremity will eventually regain its function. b. Pain is felt at one site but originates from another location. c. Patient's pain will be associated with nausea, pallor, and diaphoresis. d. Slightest touch, such as a sleeve brushing against her arm, causes severe and intense pain.

ANS: D A key feature of reflexive sympathetic dystrophy is that a typically innocuous stimulus can create a severe, intensely painful response. The affected extremity becomes less functional over time.

Which of these statements about the peripheral nervous system is correct? a. The CNs enter the brain through the spinal cord. b. Efferent fibers carry sensory input to the central nervous system through the spinal cord. c. The peripheral nerves are inside the central nervous system and carry impulses through their motor fibers. d. The peripheral nerves carry input to the central nervous system by afferent fibers and away from the central nervous system by efferent fibers.

ANS: D A nerve is a bundle of fibers outside of the central nervous system. The peripheral nerves carry input to the central nervous system by their sensory afferent fibers and deliver output from the central nervous system by their efferent fibers. The other responses are not r/t the peripheral nervous system.

A patient has been admitted to the hospital with vertebral fractures r/t osteoporosis. She is in extreme pain. How should the nurse document this type of pain? a. Referred b. Cutaneous c. Visceral d. Deep somatic

ANS: D Deep somatic pain comes from sources such as the blood vessels, joints, tendons, muscles, and bone. Referred pain is felt at one site but originates from another location. Cutaneous pain is derived from the skin surface and subcutaneous tissues. Visceral pain originates from the larger, interior organs. The pain that the patient in the question is experiencing is deep somatic pain.

During an examination, the nurse notes that a patient is exhibiting flight of ideas. Which statement by the patient is an example of flight of ideas? a. "My stomach hurts. Hurts, spurts, burts." b. "Kiss, wood, reading, ducks, onto, maybe." c. "I wash my hands, wash them, wash them. I usually go to the sink and wash my hands." d. "Take this pill? The pill is red. I see red. Red velvet is soft, soft as a baby's bottom."

ANS: D 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. Options A, B, and C are not examples of a flight of ideas that have an association.

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 will want to ask her which of these questions? a. "How are things going with the trial?" b. "How are things going with your job?" c. "Tell me about your recent engagement!" d. "Are you having any disturbing dreams?"

ANS: D Following a traumatic event outside the range of usual human experience that involves actual or threatened death or violence, such as rape, many people experience posttraumatic stress disorder (PTSD). One of the symptoms of PTSD is sleep problems. With PTSD the person relieves the trauma many times, intrusively and unwillingly. The same feelings of helplessness, fear, or horror recur. Avoidance of any trigger associated with the trauma occurs, and the person has hypervigilance, sleep problems, and difficulty concentrating, leading to feelings of being permanently damaged. The nurse should assess for symptoms of PTSD and options A, B, and C do not assess for those symptoms.

The nurse is assessing an older adult's functional ability. Which definition correctly describes one's functional ability? a. It denotes an older person's cognitive level. b. It is the measure of the expected changes of aging that one is experiencing. c. It describes the individual's motivation to live independently. d. It refers to one's ability to perform activities necessary to live in modern society.

ANS: D Functional ability refers to one's ability to perform activities necessary to live in modern society and can include driving, using the telephone, or performing personal tasks such as bathing and toileting.

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. Which is an appropriate conclusion for the nurse draw? a. She probably does not have any problems. b. She is only trying to shock people and that her dress should be ignored. c. She has a manic syndrome because of her abnormal dress and grooming. d. More information should be gathered to decide whether her dress is appropriate.

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

In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side? a. Normal reflexes b. Lack of reflexes c. Diminished reflexes d. Hyperactive reflexes

ANS: D Hyperreflexia is the exaggerated reflex observed when the monosynaptic reflex arc is released from the influence of higher cortical levels. This response occurs with upper motor neuron lesions (e.g., a cerebrovascular accident). The other responses are incorrect.

A patient is complaining of severe knee pain after twisting it during a basketball game and is requesting pain medication. Which action by the nurse is appropriate? a. Completing the physical examination first and then giving the pain medication b. Telling the patient that the pain medication must wait until after the x-ray images are completed c. Evaluating the full range of motion of the knee and then medicating for pain d. Administering pain medication and then proceeding with the assessment

ANS: D In cases in which the cause of acute pain is uncertain, establishing a diagnosis is a priority, but symptomatic treatment of pain should be given while the investigation is proceeding. With occasional exceptions (e.g., the initial examination of the patient with an acute condition of the abdomen), it is rarely justified to defer analgesia until a diagnosis is made. A comfortable patient is better able to cooperate with diagnostic procedures.

The nurse is assessing orientation in a 79-year-old patient. Which of these responses would lead the nurse to conclude that this patient is oriented? a. "I know my name is John. I couldn't tell you where I am. I think it is 2010, though." b. "I know my name is John, but to tell you the truth, I get kind of confused about the date." c. "I know my name is John; I guess I'm at the hospital in Spokane. No, I don't know the date." d. "I know 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—2010."

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

The nurse is reviewing the principles of pain. Which type of pain is due to an abnormal processing of the pain impulse through the peripheral or central nervous system? a. Visceral b. Referred c. Cutaneous d. Neuropathic

ANS: D Neuropathic pain implies an abnormal processing of the pain message. The other types of pain are named according to their sources. Visceral pain originates from the larger internal organs and is often described as dull, deep, squeezing, or cramping. Referred pain is the pain that is felt at a particular site but originates from another location. Cutaneous pain is derived from skin surface and subcutaneous tissues and is usually well localized and easy to pinpoint.

When beginning to assess a person's spirituality, which question by the nurse would be most appropriate? a. "Do you believe in God?" b. "What religious faith do you follow?" c. "Do you believe in the power of prayer?" d. "How does your spirituality relate to your health care decisions?"

ANS: D Open-ended questions provide a foundation for future discussions. The other responses are easily answered by one-word replies and are closed questions.

A patient has had arthritic pain in her hips for several years since a hip fracture. She is able to move around in her room and has not offered any complaints so far this morning. However, when asked, she states that her pain is "bad this morning" and rates it at an 8 on a 1-to-10 scale. What is the likely reason for this? a. The patient is addicted to her pain medications and cannot obtain pain relief. b. The patient does not want to trouble the nursing staff with her complaints. c. The patient is not in pain but rates it high to receive pain medication. d. The patient has experienced chronic pain for years and has adapted to it.

ANS: D Persons with chronic pain typically try to give little indication that they are in pain and, over time, adapt to the pain. As a result, they are at risk for underdetection

A 4-year-old boy is brought to the emergency department by his mother. She says he points to his stomach and says, "It hurts so bad." Which pain assessment tool would be the best choice when assessing this child's pain? a. Descriptor scale b. Numeric rating scale c. Brief pain inventory d. Faces Pain Scale—Revised (FPS-R)

ANS: D Rating scales can be introduced at the age of 4 or 5 years. The FPS-R is designed for use by children and asks the child to choose a face that shows "how much hurt (or pain) you have now." Young children should not be asked to rate pain by using numbers. A 4-year-old should not be asked to use a descriptor scale, numeric rating scale, or brief pain inventory as they do not have the ability to accurately describe or rate pain intensity on a numerical scale. Although rating scales can be introduced at the age of 4 or 5 years, the FPS-R scale should be used. The FPS-R scale is designed for use by children and asks the child to choose a face that shows "how much hurt (or pain) you have now."

A patient states that the pain medication is "not working" and rates his postoperative pain at a 10 on a 1-to-10 scale. Which of these assessment findings indicates an acute pain response to poorly controlled pain? a. Confusion b. Depression c. Hyperventilation d. Increased blood pressure and pulse

ANS: D Responses to poorly controlled acute pain include tachycardia, elevated blood pressure, and hypoventilation. Confusion and depression are associated with poorly controlled chronic pain. Confusion and depression are associated with poorly controlled chronic pain, not acute pain. Hypoventilation, not hyperventilation, is a sign of poorly controlled acute pain. Typical responses to poorly controlled acute pain include tachycardia, elevated blood pressure, and hypoventilation.

The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? a. Patient demonstrates the ability to hear normal conversation. b. When patient sticks out tongue it is midline and without tremors or deviation. c. Patient follows an object with his or her eyes without nystagmus or strabismus. d. Patient moves the head and shoulders against resistance with equal strength.

ANS: D The following normal findings are expected when testing the spinal accessory nerve (CN XI): The patient's sternomastoid and trapezius muscles are equal in size; the person can forcibly rotate the head both ways against resistance applied to the side of the chin with equal strength; and the patient can shrug the shoulders against resistance with equal strength on both sides. Checking the patient's ability to hear normal conversation checks the function of CN VIII. Having the patient stick out the tongue checks the function of CN XII. Testing the eyes for nystagmus or strabismus is performed to check CNs III, IV, and VI.

When the nurse is testing the triceps reflex, what is the expected response? a. Flexion of the hand b. Pronation of the hand c. Flexion of the forearm d. Extension of the forearm

ANS: D The normal response of the triceps reflex is extension of the forearm. The normal response of the biceps reflex causes flexion of the forearm. The other responses are incorrect.

A 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. When conducting the mental status examination for this patient, what should the nurse assess first? a. Affect and mood b. Memory and affect c. Cognitive abilities d. Level of consciousness

ANS: D The sequence of steps for a mental status examination forms a hierarchy in which the most basic functions (consciousness, language) are assessed first. The first steps must be assessed accurately to ensure validity for the steps that follow (i.e., if consciousness is clouded, the person cannot be expected to have full attention and to answer accurately or cooperate with new learning).

When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. How should the nurse document this finding? a. Ataxia b. Lack of coordination c. Negative Homan sign d. Positive Romberg sign

ANS: D This is an abnormal, or positive, Romberg test. Abnormal findings for the Romberg test include swaying, falling, and a widening base of the feet to avoid falling. A positive Romberg sign is a loss of balance that is increased by the closing of the eyes. Ataxia is an uncoordinated or unsteady gait. Homan sign is used to test the legs for deep-vein thrombosis. Ataxia is an uncoordinated or unsteady gait. Homan sign is used to test the legs for deep-vein thrombosis. These findings are an abnormal, or positive, Romberg test. Abnormal findings for the Romberg test include swaying, falling, and a widening base of the feet to avoid falling.

During a recent interview, a patient diagnosed with schizophrenia shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but then laughs loudly at the content. What is the best description of this behavior? a. Confusion b. Ambivalence c. Depersonalization d. Inappropriate affect

ANS: D This is an example of inappropriate affect. An inappropriate affect is an affect clearly discordant with the content of the person's speech. The patient's behavior is not an example of confusion, ambivalence, or depersonalization. Confusion is a disturbance of consciousness characterized by inability to engage in orderly thought or by lack of power to distinguish, choose, or act decisively. Ambivalence is the existence of opposing emotions toward an idea, object, or person. Depersonalization is a loss of identity, feeling of being estranged, or perplexed about one's own identity and meaning of existence. The example in the question demonstrates inappropriate affect. An inappropriate affect is an affect clearly discordant with the content of the person's speech.

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

ANS: D This patient appears to have symptoms of attention-deficit/hyperactivity disorder (ADHD) (restless, fidgeting, excess talking). The nurse should assess the patient's attention span. 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. Options A, B, and C do not assess attention span.

A 70-year-old woman tells the nurse that every time she gets up in the morning or after she's been sitting for a while, she gets "really dizzy" and feels like she is going to fall over. What is the best response by the nurse? a. "Have you been extremely tired lately?" b. "You probably just need to drink more liquids." c. "I'll refer you for a complete neurologic examination." d. "You need to get up slowly when you've been lying down or sitting."

ANS: D This patient's symptoms are unlikely r/t being tired or dehydration and would not require a complete neurological examination at this time. Instead, they are likely due to normal aging. Aging is accompanied by a progressive decrease in cerebral blood flow. In some people, this decrease causes dizziness and a loss of balance with a position change. These individuals need to be taught to get up slowly. The other responses are incorrect.

A patient has had a cerebrovascular accident (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 description of this patient's problem? a. Echolalia b. Global aphasia c. Broca's aphasia d. Wernicke's aphasia

ANS: D This type of communication illustrates Wernicke's or receptive aphasia. The person can hear sounds and words but cannot relate them to previous experiences. Speech is fluent, effortless, and well-articulated, but it 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, a great urge to speak is present. Repetition, reading, and writing also are impaired. Echolalia is an imitation or the repetition of another person's words or phrases. With global aphasia, spontaneous speech is absent or reduced to a few stereotyped words or sounds and comprehension is absent or reduced to only a person's own name and a few select words. With Broca's aphasia the person can understand language but cannot express himself using words or language.

When assessing the quality of a patient's pain, the nurse should ask which question? a. "When did the pain start?" b. "Is the pain a stabbing pain?" c. "Is it a sharp pain or dull pain?" d. "What does your pain feel like?"

ANS: D To assess the quality of a person's pain, the patient is asked to describe the pain in his or her own words. Asking when the pain started does not assess the quality of pain. To assess the quality of a person's pain, the patient is asked to describe the pain in his or her own words, not providing descriptions of types of pain for the patient to confirm or deny.

Which of these individuals would the nurse consider at highest risk for a suicide attempt? a. Man who jokes about death b. Woman who, during a past episode of major depression, attempted suicide c. Adolescent who just broke up with her boyfriend and states that she would like to kill herself d. Older adult man who tells the nurse that he is going to "join his wife in heaven" tomorrow and plans to use a gun

ANS: D When the person expresses feelings of sadness, hopelessness, despair, or grief, assessing any possible risk for physical harm to him or herself is important. The interview should begin with more general questions. If the nurse hears affirmative answers, then he or she should 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 risk.

The nurse is assessing the abilities of an older adult. Which activities are considered IADLs? (Select all that apply.) a. Walking b. Toileting c. Feeding oneself d. Preparing a meal e. Grocery shopping f. Balancing a checkbook

ANS: D, E, F Typically, IADL tasks include shopping, meal preparation, housekeeping, laundry, managing finances, taking medications, and using transportation. The other options listed are ADLs r/t self-care.