Mental Status Chapter 19

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?"

"What will you do if you feel the need to use cocaine again?" -Questions such as "What will you do if you feel the need to use cocaine again?" assess the individual's judgment and ability to solve problems. -An aspect of orientation is assessed by asking the individual where they are. -Asking what the individual had for breakfast assesses short-term memory. -Whereas asking about relationships with siblings assesses long-term memory.

The nurse is performing an initial assessment of a client with suicidal ideation. What would the nurse consider "lethal" examples of suicidal ideations? (Select all that apply.) -Access to the means -Sad mood -Hints or jokes about suicide -History of suicide attempts -Specific plan

-History of suicide attempts -Access to the means -Specific plan -Suicidal clients may joke or hint about suicide to test the nurse's comfort about the subject. -Sad mood may be related to suicidal thoughts but is not considered lethal. -A history of suicide attempts, an access to the means such as possession of a gun, and a specific plan to commit suicide are considered "lethal" suicidal ideations.

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? -New learning ability -Constructional ability -Visual spatial ability -Time orientation

Constructional ability Asking the client to reproduce a clock face without visual aids is a way of testing constructional ability. --->Learning, visual ability, and orientation are not directly assessed during this task.

The nurse finds no adequate medical or physical explanation for the symptoms a client is experiencing. This would be considered a somatoform symptom. -True -False

True

The nurse uses the Mini-Mental State Examination to assess a client. For which reason is this assessment tool most likely used? -dementia -depression -schizophrenia -bipolar disorder

dementia -The Mini-Mental State Examination is a brief questionnaire which has been widely used to screen clients for cognitive dysfunction or dementia. --->The Mini-Mental State Examination is NOT routinely used to assess depression, schizophrenia, or bipolar disorder.

A new nurse asks the charge nurse what the Mini-Mental Status Examination tests. What is the appropriate response by the charge nurse? -"This examination tests the mood, feelings, thought processes, and perceptions of the client" -"This scale allows for tracking of the client's response to stimulation and early detection of changes" -"Testing of remote and recent memory makes this test useful to track the progression of dementia in a client" -"A quick tool that is useful to examine the orientation, memory, speech, and cognitive functions"

"A quick tool that is useful to examine the orientation, memory, speech, and cognitive functions" -The Mini-Mental Status Examination is a quick standard measure to evaluate a person's orientation, memory, speech, and cognitive functions. -It does not test mood, feelings, expressions, thought processes, or perceptions. -A client's response to stimulation is tested by the Glasgow Coma Scale. -Testing memory is only one part of the observation of cognitive ability of a client.

An 88-year-old woman has been admitted to the acute medical unit for the treatment of a urinary tract infection that is thought to be progressing to urosepsis. When assessing the client's orientation, how should the nurse best gauge the client's orientation to time? -"Are you able to tell me today's date?" -"Can you tell me approximately what time it is right now?" -"Can you tell me the date and the day of the week?" -"Are you able to tell the month and the year that we're in?"

"Are you able to tell the month and the year that we're in?" -Some older clients may seem confused, especially in a new or acute care setting, but most know who and where they are and the current month and year. -Asking for the time of day, exact date, or the day of the week may be unnecessarily specific and may lead to incorrect inferences.

The nurse is seeing a client at the local community mental health clinic. The client states, "I want to kill myself. I have nothing to live for; no one would miss me." What is the priority question the nurse should ask the client? -"What about your family - don't you care about them?" -"When do you plan to kill yourself?" -"What has caused you to have such feelings?" -"Do you have a specific plan for killing yourself?"

"Do you have a specific plan for killing yourself?" A person with a specific plan and access to the means is considered to have very "lethal" suicidal ideation.

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?" -"How do you plan to meet your responsibilities at work?" -"Do you ever feel like you're hearing or seeing something that others can't see or hear?" -"In the past, what activities have you found help improve your mood?"

"How do you plan to meet your responsibilities at work?" -Asking the client to explain his or her response to financial, interpersonal, or logistical challenges can yield insight into the client's judgment. -Asking the client to explain the cause of mood changes can help the clinician gauge the client's insight but not judgement, while asking about seeing and hearing things addresses perception, specifically hallucinations. -Asking about previous successful coping strategies can be useful but does not assess judgment.

A 21-year-old woman has been admitted to the emergency department following an accident that is suspected of being a suicide attempt. When assessing the client's perceptions, what question should the nurse ask the client? -"How would you describe your health these days?" -"Are you able to smell and taste as well as you've been able to in the past?" -"If you found a stamped envelope on the street, what would you do?" -"Can you tell me the circumstances surrounding your accident?"

"How would you describe your health these days?" -Overall thought processes and perceptions can be elicited with an open-ended question such as "How would you describe your health these days?" -The question about an envelope assesses judgment. -Physical senses are not the focus of the assessment of perception in the mental health context. -Perception will not likely be gauged by asking the client to explain her injuries.

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?"

"What did you eat for breakfast today?" -Recent memory or short term memory asks the client about things and events that are happening currently. --->Asking the client what they ate for breakfast is testing recent memory. -Asking the client their birth date tests remote memory. -How an orange and an apple are different tests a client's ability for abstract reasoning. -If a client can tell the nurse why they are at the clinic, this assesses the client's orientation (location).

The nurse is preparing to assess a client's remote memory. Which question would be most appropriate for the nurse to use? -"What did you do last evening?" -"How are an apple and orange the same?" -"When did you get your first job?" -"Can you tell me what you have eaten in the last 24 hours?"

"When did you get your first job?" -Asking the client about when he or she got his or her first job gives information about the client's remote memory or past events. -Asking about what the client ate in the past 24 hours, or what he or she did last evening, provides information about the client's recent memory. -Asking how an apple and orange are similar tests abstract reasoning

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. -Involved in a domestic abuse situation -Issues with body image -Married with 2 children -Sedentary lifestyle -Ingests alcohol every evening

-Sedentary lifestyle -Issues with body image -Ingests alcohol every evening -Involved in a domestic abuse situation -Factors that place a client at risk for impaired mental health include unhealthy lifestyle choices such as a --sedentary lifestyle --low self-concept --substance abuse --exposure to violence -Marital status and number of children are not identified as factors that place a client at risk for impaired mental health.

An experienced nurse is training a novice nurse on how to perform mental health assessments. The novice nurse asks the colleague exactly what "mental health" means. The experienced nurse responds by citing the 2010 definition of the World Health Organization (WHO), which states that mental health requires which of the following components? Select all that apply. -Ability to earn a high school diploma or equivalent -Ability to cope with the normal stresses of life -An IQ that is 100 or greater -A state of well-being -Ability to make a contribution to one's community -Ability to work productively

-A state of well-being -Ability to cope with the normal stresses of life -Ability to work productively -Ability to make a contribution to one's community -WHO defines mental health as "a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community." -Neither an IQ of 100 or greater nor the ability to earn a high school diploma or equivalent is required for mental health.

A nurse is evaluating a client who may have Alzheimer's disease. Which of the following are warning signs of Alzheimer's disease? Select all that apply. -Getting lost in familiar surroundings -Losing one's ability to pay bills -Neglecting to bathe -Asking the same question over and over again -Gaining 5 pounds or more within a 2-week period -Sleeping longer than 12 hours in a 24-hour period

-Asking the same question over and over again -Losing one's ability to pay bills -Getting lost in familiar surroundings -Neglecting to bathe -Asking the same question over and over again, losing one's ability to pay bills, getting lost in familiar surroundings, and neglecting to bathe are all warning signs of Alzheimer's disease. -Gaining 5 pounds or more within a 2-week period and sleeping longer than 12 hours in a 24-hour period are symptoms of depression, not Alzheimer's disease.

An adult daughter of a client with Alzheimer disease asks what can be done to prevent the development of the disease. What should the nurse recommend to the daughter? Select all that apply. -Ingest a moderate amount of alcohol -Spend time with other people -Eat a nutritious diet -Keep the mind active -Engage in physical exercise

-Eat a nutritious diet -Keep the mind active -Engage in physical exercise -Spend time with other people

A nurse has begun a new job at a mental health facility. The supervisor is explaining to the nurse the features included in the definition of a mental disorder, according to the DSM-5. Which of the following should the supervisor mention to the nurse? Select all that apply. -Results in clinically significant distress or disability -Is an expectable response to common stressors and losses -Reflects an underlying psychobiologic dysfunction -Is a behavioral or psychological syndrome or pattern that occurs in an individual -Is primarily a result of social deviance or conflicts with society

-Is a behavioral or psychological syndrome or pattern that occurs in an individual -Reflects an underlying psychobiologic dysfunction -Results in clinically significant distress or disability -The proposed DSM-5 definition for a mental disorder contains the following features: --a behavioral or psychological syndrome or pattern that occurs in an individual --reflects an underlying psychobiologic dysfunction --the consequences of which are clinically significant distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning). -The definition does not include: --an expectable response to common stressors and losses (e.g., the loss of a loved one) or a culturally sanctioned response to a particular event (for example, trance states in religious rituals) --a mental disorder is not primarily a result of social deviance or conflicts with society.

Which of the following are cues that a person may have dementia? Select all that apply. -Looking to a family member to answer questions directed to the client -Serving as a "good historian" -Disorientation -Repeatedly failing to follow instructions -Finding the right words easily

-Looking to a family member to answer questions directed to the client -Disorientation -Repeatedly failing to follow instructions Some cues that the client may have dementia include: --being disoriented --being a "poor historian" --deferring to relatives to answer questions directed to the client --repeatedly and apparently unintentionally failing to follow instructions --having difficulty finding the right words or using inappropriate or incomprehensible words --having difficulty following conversations. -Signs of dementia do not include being a good historian or being able to find the right words easily.

The nurse participates in a health fair being sponsored by a local community. Which information being provided is a protective factor against substance abuse? Select all that apply. -After school employment opportunities -Antidrug use policies at the schools -Parental monitoring -Academic competence -Strong neighborhood activities

-Parental monitoring -Academic competence -Strong neighborhood activities -Antidrug use policies at the schools -The National Institute on Drug Abuse recommends protective factors to prevent substance abuse, which include parental monitoring, academic competence, strong neighborhood attachment, and antidrug policies at the schools. -After school employment opportunities are not identified as protective factors to prevent substance abuse.

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 -25 -29 -17

25 -For clients with a high school education -->a score of 20-27 on the SLUMS exam indicates mild cognitive impairment (MCI) -For clients with less than high school education --->a score of 14-19 indicates MCI. -For clients with a high school education --->a score of 1-19 indicates dementia and -For clients with less than high school education --->a score of 1-14 indicates dementia.

A nurse is caring for a client in the mental health unit. The client states, "They are poisoning my food by telepathy." This is an example of which types of delusion? -Paranoid -Erotomanic -Somatic -Grandiose

Paranoid This is an example of a paranoid delusion which is caused by false suspicions.

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

Patient advocate The nurse may assess the change in the client and will be the advocate and detective, determining when the change occurred and what was new in the treatment.

During the mental status assessment of a new client, the nurse has asked the client to describe some of the similarities and differences between a tennis ball and a soccer ball. Despite adequate time and cuing, the client is unable to state any similarities or differences. The nurse should document what assessment finding? -An inability to follow directions accurately -A deficit in practical intelligence -A deficit in abstract reasoning -A lack of spatial orientation

A deficit in abstract reasoning -Asking a client to describe similarities and/or differences between two objects that are alike allows the nurse to assess the client's abstract reasoning. -This is not synonymous with intelligence and does not providing insight into the client's ability to follow directions. -This task is unrelated to spatial orientation.

During assessment, the nurse asks a client to explain what the following means: "A penny saved is a penny earned." The nurse is assessing which of the following? -Affect -Abstract reasoning -Attention -Concentration

Abstract reasoning -When assessing abstract reasoning and comprehension, the client is given a proverb such as "a penny saved is a penny earned" and asked to interpret it. -Affect is assessed by observing the client's outward expression of emotion. -Attention and concentration are assessed by having a client subtract a specific number from a starting number and work backward or asking a client to spell "world" backward.

A nurse is providing care for a client who has hepatic encephalopathy secondary to chronic alcohol abuse. The nurse's assessment reveals that the client often provides incorrect answers to assessment questions. As well, the client makes statements that are not grounded in reality. What nursing diagnosis is suggested by these assessment data? -Impaired Verbal Communication related to hepatic encephalopathy AMB confusion -Ineffective Coping related to alcohol abuse -Ineffective Health Maintenance related to alcohol abuse AMB decreased cognition -Acute Confusion related to hepatic encephalopathy

Acute Confusion related to hepatic encephalopathy -Statements like those described in the scenario suggests acute confusion, a nursing diagnosis that is consistent with the client's medical diagnosis. -Communication is not the essence of the client's problem. -Ineffective health maintenance and ineffective coping are plausible, but neither is directly indicated by the assessment data.

When assessing the mental status of a 67-year-old woman, the nurse detects some difficulty with free-flow of thought and following directions. Which of the following would the nurse do first? -Refer for further medical evaluation. -Use a Geriatric Depression Scale. -Assess the client's vision and hearing. -Refer the client to social services for home assistance.

Assess the client's vision and hearing. -The nurse needs to assess the client's vision and hearing before assuming that the findings are abnormal. -Deficits in either area can impact the client's responses. -A Geriatric Depression Scale would be used if depression was suspected. -If after additional evaluation, the client continues to have similar responses, a referral for further medical evaluation may be warranted. -If further assessment reveals that the client is having difficulty with activities of daily living, a referral to social services may be indicated.

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? -Dysarthria -Stutter -Broca's aphasia -Wernicke's aphasia

Broca's aphasia -In Broca's aphasia, clients articulate very slowly and with great effort. -Nouns, verbs, and important adjectives are usually present, and only small grammatical words are dropped from speech. -Broca's area is on the lateral portion of the frontal lobes.

What is a useful tool when assessing a client for alcohol abuse? -CAGE -HOPE -SAD PERSONAS -QUIT

CAGE -The CAGE tool assesses for alcoholism by asking questions about the need to cut down on drinking, feeling annoyed by criticism of drinking, having guilt about drinking, and taking an "eye-opening" drink first thing in the morning. -HOPE is used to assess spirituality -SAD PERSONAS is used to assess risk of suicide -QUIT is not an assessment tool.

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

CAGE questionnaire -The CAGE assessment is a quick questionnaire used to determine if an alcohol assessment is needed. -The St. Louis University Mental Status (SLUMS) exam assesses for cognitive impairment. -The Glasgow Coma Scale (GCS) assesses a client's response to stimuli. -The Confusion Assessment Method (CAM) is used to assess for confusion.

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 -GCS -CAM -CAGE questionnaire

CAM -If further assessment is needed to distinguish delirium from other types of cognitive impairment, use the Confusion Assessment Method (CAM). -The St. Louis University Mental Status (SLUMS) exam assesses for cognitive impairment. -The CAGE assessment is a quick questionnaire used to determine if an alcohol assessment is needed. -The Glasgow Coma Scale (GCS) assesses a client's response to stimuli.

The nurse requests the client to come into the dining area for lunch. The client states, "I can't come right now. I can't leave the bathroom!" The nurse observes the client has been washing his hands for 30 minutes. What is this type of behavior considered? -Phobia -Compulsion -Obsession -Confabulation

Compulsion This client is experiencing compulsions, which are repetitive mental acts or physical behaviors that a person feels driven to perform: --->to reduce anxiety or distress --->prevent a dreaded event or situation --->respond to an obsession

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? -Uses appropriate and comprehensible words -Repeatedly and apparently unintentionally follows instructions -Defers to family members to answer questions directed to the client -Appears oriented

Defers to family members to answer questions directed to the client Some cues that a client may have dementia include seeming disoriented, being a "poor historian," deferring to a family member to answer questions directed to the client, repeatedly and apparently unintentionally failing to follow instructions, having difficulty finding the right words or using inappropriate or incomprehensible words, and having difficulty following conversations.

An emergency department nurse has utilized the Confusion Assessment Method (CAM) in the assessment of a 79-year-old client with a new onset of urinary incontinence. This assessment tool will allow the nurse to confirm the presence of what health problem? -Delirium -Psychosis -Schizophrenia -Vascular dementia

Delirium The CAM assesses for delirium; it does not assess for dementia, schizophrenia, or psychosis.

An older adult is admitted for altered cognition. The spouse indicates the client has becoming more forgetful over time. The nurse assesses the client's cognition using the Mini-Cog. The client is able to draw a clock correctly but is unable to recall the three words given at the beginning of the assessment. What do the results suggest to the nurse? -Dementia -Depression -Delusion -Delirium

Dementia -Dementia is an irreversible state of confusion that develops over time. -If the client is unable to recall the three words or draws an abnormal clock, dementia is indicated. -The nurse would use the Geriatric Depression Scale to assess for depression in the older adult. -Delirium is an acute reversible condition in any client across the lifespan and can be attributed to some underlying medical condition or substance abuse. -A delusion is a false belief the person holds despite lack of supportive evidence.

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 a sense of hope for the future? -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 any thoughts of wanting to harm or kill yourself? -The priority is for the nurse would be to conduct a suicide assessment. --->The best question for the nurse to ask first is Do you have any thoughts of wanting to harm or kill yourself? -The risk for suicide is not assessed using 0 to 10 scale. -Asking about having a sense of hope for the future would be included in a spirituality assessment. -The question, "Do you hear voices that tell you what to do?" assesses for auditory hallucinations.

A teenage client tried to commit suicide by slashing both wrists after the client's significant other broke up with the client. The client was admitted to a behavioral unit 1 week ago. The client has responded well to treatment and is looking forward to going home. What is the most important client outcome in this situation? -Does not harm self -Demonstrates appropriate behavior with other clients -Identifies personal strengths and weaknesses -States, "I feel much better, and I am ready to go home"

Does not harm self -Nurses use assessment information to identify client outcomes. -Some outcomes related to mental health problems include the client does not harm self, the client demonstrates appropriate social interactions, and the client identifies personal strengths. ***The most important outcome involves the client's safety, which is directly related to not harming self.

Which of the following is the most important skill a nurse needs when conducting a mental status assessment? -Well-developed writing skills -Rapid interpretive skills -Effective listening skills -Thorough assessment skills

Effective listening skills Rapid interpretation, well-honed writing skills, and thorough assessment skills are moot without empathic and focused listening.

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

Evaluation of insight and judgment -The mental status examination is a central aspect of the psychiatric assessment process that assesses current cognitive and affective functioning through data collection on: ---appearance ---behavior ---level of consciousness ---speech ---thought content and processes ---cognitive ability ---mood and affect ---insight ---judgment. ---->This assessment relies almost exclusively on observation rather than inquiry and is expected to change during treatment.

When does the nurse screen for alcohol and drug use? -At-risk client/initial assessment -Every client/every interaction -Every client/every client history -At-risk client/every client history

Every client/every client history Screening for alcohol and drug use is part of every client history.

When preparing to obtain information about a client's mental and psychosocial status, what would the nurse do first? -Perform a neurological examination to determine any deficits. -Question the client about their usual lifestyle and behaviors. -Check the client's level of consciousness for changes. -Explain the purpose of the exam and types of questions.

Explain the purpose of the exam and types of questions. -Before asking questions to determine the client's mental and psychosocial status, explain the purpose of this part of the examination. -Explain that some questions to be asked may sound silly or irrelevant, but that it will help to determine how certain thought processes and activities of daily living are affecting the client's current health status. -Questions related to lifestyle and behaviors, assessment of level of consciousness, and neurological examination would be completed later as the nurse progresses through the history and physical examination.

A nurse is conducting a mental status assessment of a 70-year-old male client who is being treated for depression. What would the nurse consider when assessing the client's facial expression and eye contact? -Facial expression should be disregarded if the client has a diagnosed mental illness. -The nurse should inform the client that his facial expression is being assessed. -Reduced eye contact is an age-related physiological change. -Eye contact is strongly influenced by cultural norms.

Eye contact is strongly influenced by cultural norms. -Eye contact and facial expressions, such as smiling, differ widely between cultures. -Reduced eye contact is not an age-related physiological change. -Informing the client that his facial expression is being assessed will likely confound the assessment results. -Mental illness does not preclude assessment of eye contact and facial expression.

A group of students is reviewing material about assessing mental status. The students demonstrated understanding of the material when they identify which of the following as a cognitive ability to be assessed? -Speech -Posture -Orientation -Thought processes

Orientation -Cognitive abilities include orientation, concentration, recent and remote memory, abstract reasoning, judgment, visual perception, and constructional ability. -Posture, speech, and thought processes are components of a comprehensive mental status examination.

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

Flight of ideas -This represents flight of ideas, because the ideas are connected in some logical way. -Derailment, or loosening of associations, has more disconnection within clauses. -Circumstantiality is characterized by the client speaking "around" the subject and using excessive detail, though thoughts are meaningfully connected. -Incoherence lacks meaningful connection and often has odd grammar or word use.

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

Forgot the word to describe indigestion -A typical age-related change in mental functioning would be occasionally forgetting a word to use. -Not engaging in conversation, inability to remember the date, and having no idea where a wallet may be located are signs of Alzheimer disease.

The nurse is assessing a client's immediate and short-term memory. Which of the following would be most appropriate? -Questioning the client about an event that has occurred within the past several months. -Giving the client a simple scenario and having him identify what would be the best response. -Giving the client three words and asking him to recite them now and then in 5 minutes. -Asking the client to tell the nurse the date, time, and current location.

Giving the client three words and asking him to recite them now and then in 5 minutes. -To check immediate and short-term memory, the nurse gives the client three unrelated words to remember and asks him or her to recite them right after telling them and at 5-minute and 15-minute intervals during the interview. -To test recent memory, the nurse may question about a holiday or world event within the past few months. -Giving the client a scenario and asking him for the best response evaluates judgment. -Asking the client the about date, time, and current location evaluates orientation.

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

Hallucination -A hallucination is a subjective sensory perception without real external stimuli. ---->The client can hear, see, smell, taste, or feel something that does not exist in reality. -In this case, his sister has passed away and cannot be speaking to him, although in his mind he can hear her. --->This is an example of an auditory hallucination, but hallucinations can occur with any of the five senses.

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

Have the client read a few sentences out loud -Speech is influenced by experience, education level, and culture. -If the client is having trouble with speech, the nurse should ask the client to name objects in the room, read from printed material, or write a sentence. -Asking about education level may intimidate the client and project judgment by the nurse. -Giving the client a history form to read silently will not assist in assessing speech. -Assessing hearing does not help with assessing the ability of the client to formulate words.

A nurse utilizes the Alcohol Use Disorders Identification Test (AUDIT) as part of the standard admission protocol. After obtaining a score of 9 from a recently admitted client, the nurse should recognize the possibility of which of the following? -Alcoholism -Imminent liver disease -Hazardous and harmful alcohol use -Acute pancreatitis

Hazardous and harmful alcohol use -Total scores of 8 or more on the AUDIT are recommended as indicators of hazardous and harmful alcohol use, as well as possible alcohol dependence. -A score of 9 does not necessarily suggest liver disease, pancreatitis, or alcoholism.

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

Ineffective coping -Ineffective coping would be most appropriate. -Anticipatory grieving occurs prior to change. -There is no evidence of fear or mental status change.

The nurse suspects a client has undiagnosed Alzheimer disease but changes the care plan after talking with a family member. What information caused the nurse to alter the client's plan of care? -Ingests a 6-pack of beer every evening -Follows a Mediterranean eating plan -Diagnosed with osteoarthritis of both knees -Surgery for spinal stenosis two years ago

Ingests a 6-pack of beer every evening -Drinking in some older adults may cause symptoms of forgetfulness or confusion which could be mistaken for signs of Alzheimer disease. -A Mediterranean eating plan, previous spinal surgery, or osteoarthritis would NOT cause symptoms similar to Alzheimer disease.

A nurse is assessing a client who is exhibiting decorticate posturing. Which of the following would the nurse observe? -Flexed hands at the side of the body -Pronated forearms -Extended upper extremities -Internally rotated lower extremities

Internally rotated lower extremities -Decorticate posturing is manifested by the hands drawn up to the chest and internally rotated lower extremities. -Decerebrate posturing is manifested by adducted and extended upper extremities, pronated forearms, and flexed hands along the side of the body.

A nurse asks a client the following question: "What do you do if you have pain?" The nurse is assessing which of the following aspects of cognitive function? -Orientation -Judgment -Abstract reasoning -Memory

Judgment -Asking a client about what he or she does or would do if he or she has pain evaluates a client's judgment. -Asking about the client's name, time, and place evaluates his or her orientation. -Asking a client to compare and contrast things evaluates abstract reasoning. -Asking the client about recent and past events evaluates memory.

The nurse observes a client in the day room laughing uncontrollably and within 5 minutes sitting in the corner sobbing. This behavior continues throughout the day. What term would the nurse use in documenting this behavior? -Elation -Lability -Blunted affect -Euphoria

Lability -Lability is a quick change of expression of mood or feelings. -Elation is a high degree of confidence, boastfulness, uncritical optimism, and joy accompanied by increased motor activity. -Blunted affect is a severe reduction in emotional expressiveness. -Euphoria is an excessive sense of emotional and physical well-being inappropriate to the actual situation or environmental stimuli.

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

Lethargy -Opening the eyes, answering questions, and falling back asleep describes lethargy. -Being completely unresponsive to all stimuli with the eyes closed describes a coma. -Being awakened with vigorous or painful stimuli describes stupor. -Opening the eyes to loud voices, responding slowly with confusion, and being unaware of the environment describes obtunded.

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.

Orientation to time is usually lost first and orientation to person is usually lost last. When assessing orientation to time, place, and person remember that orientation to time is usually lost first and orientation to person is usually lost last.

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.

Orientation, memory, and cognitive function. Cognitive abilities include orientation, concentration, recent and remote memory, abstract reasoning, judgment, visual perception, and constructional ability.

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 -Dysthymic disorder -Schizophrenia -Manic episode

Manic episode Mania consists of a persistently elevated mood for at least 1 week with symptoms such as --inflated self-esteem --decreased need for sleep --pressured speech --racing thoughts --involvement in high-risk activities (e.g., drug use, spending sprees, indiscriminate sexual activity). ---->In this case, the client has racing thoughts and pressured speech, a decreased need for sleep, and engagement in high-risk activities (spending sprees).

A gerontologic nurse is assessing the speech of an older adult client. Which of the following would the nurse characterize as an expected assessment finding? -Loud tone -Moderate pace -Repetition -Rapid speech

Moderate pace -Normally, in older adults, responses may be slowed, but speech should be clear and moderately paced. -Slow, repetitive speech is characteristic of depression or Parkinson's disease. -Loud, rapid speech may occur in manic phases of bipolar disorder.

The nurse assesses the client to have a Glasgow Coma score of 15. The nurse anticipates what degree of impairment? -None -Minimal -Coma -Deep coma

None A Glasgow Coma Score of 15 would indicate no impairments. All other scores indicate some degree of impairment up to and including deep coma.

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

Opens eyes to a loud voice and answers with confusion -The obtunded client opens the eyes to a loud voice and answers with confusion. -If the client opens eyes, answers the question, and falls back to sleep, the client is said to be lethargic. -If the client awakens to a vigorous shake or painful stimuli, he is in the stupor stage. -If the client is unresponsive even to painful stimuli, the client is in a coma.

The nurse utilizes the Depression Questionnaire on a client who has recently moved to a long-term care facility. The total score is 22. What would the nurse to do next? -Assess further for dementia. -Document this as a normal score. -Evaluate benefits versus risks of a mental health label. -Refer for further evaluation.

Refer for further evaluation. A score of 22 denotes very severe depression --->referral is clearly warranted. -Dementia is not indicated by this score.

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

Schizophrenia -Onset of schizophrenia generally happens in the late teens to early 20s. -It often is seen in other family members. -Symptoms must be present for at least 6 months and must have at least two features of: (1) delusions (thieves are stealing his programs) (2) hallucinations (technicians sending telepathic signals) (3) disorganized speech (4) disorganized behavior (5) negative symptoms such as a flat affect. -The catalysts of delirium and substance ingestion that denote a psychotic disorder due to medical illness and substance-induced psychotic disorder are absent. -Generalized anxiety is not present.

Susanne is a 27-year-old woman who has had headaches, muscle aches, and fatigue for the last 2 months. The nurse has completed a thorough history, examination, and laboratory workups, the results of which are normal. What would the next action be? -Telling the client nothing has been found -A referral to a neurologist -Screening for depression -A referral to a rheumatologist

Screening for depression -Although the nurse may consider referrals to help with diagnosis and treatment of this client, screening is a time-efficient way to recognize depression. --->This will allow her to be treated more expediently. -The nurse may tell the client that no answer is clear yet, but also that he or she will not stop investigating until the client has gotten the help she needs. -Research has shown that health care providers routinely fail to screen for depression.

The intensive care nurse is working with a client who has increased intracranial pressure secondary to a traumatic brain injury. The nurse is performing the hourly assessment of the client's level of consciousness and observes that the client's eyes are closed. How should the nurse first stimulate the client to assess for arousability? -Gently shake the client's right shoulder and then his left shoulder. -Rub the client's sternum with the knuckles. -Speak to the client clearly from a close distance. -Press down on one of the client's nail beds.

Speak to the client clearly from a close distance. When assessing the level of consciousness, always begin with the least noxious stimulus: verbal, tactile, to painful.

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

Suicide Other risk factors are: --prior suicide attempts --delusional or psychotic thinking --family history of suicide, mental disorders, or substance abuse --family violence, including physical or sexual abuse --firearms in the home --incarceration

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

Suicide risk Suicide risk is assessed by asking, "Do you have any thoughts of wanting to harm or kill yourself?" --->This question does not assess attempts at suicide, means of suicide, or plans of suicide.

The nurse assesses an older adult using the Mini-Mental Status Exam. The total score obtained is 24. Which interpretation by the nurse is correct? -The client is not depressed. -The client is cognitively impaired. -The client is cognitively intact. -The client is seriously depressed.

The client is cognitively intact. -A score of 24 on the Mini-Mental Status Exam is indicative of cognitive intactness. -A score of 23 or lower is indicative of cognitive impairment. -The Mini-Mental Status Exam does not assess depression.

A nurse in the emergency department is utilizing the SAD PERSONAS assessment guide during the mental status assessment of a client. What is the most likely rationale for the nurse's choice of this assessment tool? -The client may have major depression. -The client may have a high risk for suicide. -The client may be using alcohol excessively. -The client may have schizophrenia or psychosis.

The client may have a high risk for suicide. -SAD PERSONAS is an assessment tool that can be used to screen for suicide risk. -It does not directly address the signs and symptoms of depression, schizophrenia, psychosis, or substance abuse.

The nurse begins the physical examination of a newly admitted client by assessing the client's mental status. What is the nurse's best rationale for performing the mental status exam early in the assessment? -The exam provides data about mental health problems that the client may be afraid to report. -The exam can provide clues about the validity of the client's responses now and throughout. -The client's fears about having a serious illness may be alleviated by the results of the exam. -The client will be less anxious, providing the nurse with more accurate and reliable data.

The exam can provide clues about the validity of the client's responses now and throughout. -Assessing mental status at the very beginning of the head-to-toe examination provides clues regarding the validity of the subjective information provided by the client during the history and throughout the exam. -Thus it is best to determine validity of client responses before completing the entire physical exam only to learn that the client's answers to questions may have been inaccurate. -Assessing mental status first will not necessarily lessen a client's anxiety or fears about a serious illness. -The exam can provide data about mental health problems. However, this is not the primary reason for performing the exam at the very beginning.

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

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

A nurse begins the mental status exam of an older adult. Before assessing the client's thought processes and perceptions, the nurse should first obtain the results of what other assessments? -Vision and hearing -Speech and facial expressions -Ability to follow commands and move extremities -Vital signs and nutritional status

Vision and hearing -When assessing the mental status of an older adult ****the nurse should first check vision and hearing before assuming the client has a mental problem. -Speech may be affected by a decrease in hearing. -Vital signs and nutritional status give the nurse an impression of overall hemodynamic stability. -Ability to follow commands and moving the extremities is a part of a client's cognitive ability.

As part of a mental status assessment, the nurse asks a client to draw the face of a clock. This will allow the nurse to assess which of the following domains of mental status? -Concentration and orientation -Perceptions and thought processes -Visual perceptual and constructional ability -Expressions and feelings

Visual perceptual and constructional ability -Asking a client to draw the face of a clock tests the client's visual perceptual and constructional ability. -Concentration is evaluated by noting the client's ability to focus and stay attentive. -Orientation is tested by asking the client to state his or her name and the names of family members, time, day or season, and place. -Thought processes and perceptions are evaluated by asking the client to say more about or verbalize his or her understanding of the current situation. -Expressions and feelings are evaluated by asking the client how he or she is feeling and about plans for the future.

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? -Dysarthria -Wernicke's aphasia -Dysphonia -Cerebellar dysarthria

Wernicke's aphasia -Wernicke's aphasia is rapid speech that lacks meaning. It is caused by a lesion in the posterior superior temporal lobe. -Dysphonia is a voice volume disorder, caused by an issue within the larynx or impairment of cranial nerve X. -Dysarthria is a defect in the muscles that control speech. -Cerebellar dysarthria is irregular uncoordinated speech caused by multiple sclerosis.

A 75-year-old homemaker brings her 76-year-old husband to the clinic. She states that 4 months ago he had a stroke; ever since she has been frustrated with his problems with communication. They were at a restaurant after church one Sunday when he suddenly became quiet. When she realized something was wrong, he was taken to the hospital by ambulance. He spent 2 weeks in the hospital with right-sided weakness and difficulty speaking. After hospitalization he was in a rehab center where he regained the ability to walk and most of the use of his right hand. He also began to speak more, but she says that much of the time "he doesn't make any sense." She gives an example that when she reminded him the car needed to be serviced he told her "I will change the Kool-Aid out of the sink myself with the ludrip." She says that these sayings are becoming frustrating. She wants the nurse to tell her what is wrong and what can be done about it. What type of aphasia does the client have? -Receptive aphasia -Dysarthria -Wernicke's aphasia -Broca's aphasia

Wernicke's aphasia -With Wernicke's aphasia, the client can speak effortlessly and fluently, but his words often make no sense. -Words can be malformed or completely invented. -Wernicke's area is found on the temporal lobes.

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.

answered "no" to all of the four CAGE questions. The CAGE assessment is a quick questionnaire used to determine if an alcohol assessment is needed. --->If two or more of these questions is answered yes, then further assessment is advised.

When the nurse asks the client to say "No ifs, ands, or buts," the client tries but is unable to repeat the phrase with fluency. The nurse understands that this may indicate a form of -disorientation -dysarthria -aphasia -mania

aphasia

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

attention -A client having difficulty with attention has difficulty responding to questions. -Mood is a sustained emotion that provides information about the client's view of the world. -Insight is an awareness that symptoms or behaviors are normal or abnormal. -Orientation is an awareness of person, place, and time.

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

confabulation -Confabulation is the fabrication of facts or events in response to questions in order to fill in the gaps from impaired memory. -Derailment is tangential speech with shifting topics that are loosely connected or unrelated. -Perseveration is persistent repetition of words or ideas. -Flight of ideas is an almost continuous flow of accelerated speech with abrupt changes from one topic to the next.

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

depression often mimics signs and symptoms of dementia. -The Geriatric Depression Scale is used if depression is suspected in the older client. --->Read the questions to the client if the client cannot read.

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

is important and will not stimulate the thought of suicide -Many clinicians avoid the topic of self-harm or suicide because they worry that broaching it will implant the idea in the client's mind. -There is little risk that talking about suicide with someone who is not already thinking about it will prompt him or her to do it. -Consequently, the issue should be prioritized and directly addressed with clients who are or may be depressed.