Question 1

During a mental status assessment, which question by the nurse would best assess a person's judgment?

Accepted Answer

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?" B

Question 2

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?

Accepted Answer

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 C

Question 3

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?

Accepted Answer

A)   Global
B)   Broca's
C)   Dysphonic
D)   Wernicke's A

Question 4

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?

Accepted Answer

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."

Question 5

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?

Accepted Answer

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

Question 6

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?

Accepted Answer

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?"

Question 7

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?

Accepted Answer

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?"

Question 8

Which of these individuals would the nurse consider at highest risk for a suicide attempt?

Accepted Answer

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

Question 9

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?

Accepted Answer

A)   Presence of phobias
B)   General intelligence
C)   Sensory-perceptive abilities
D)   Presence of irrational thinking patterns

Question 10

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

Accepted Answer

A)   Blocking
B)   Clanging
C)   Echolalia
D)   Neologism

Question 11

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?

Accepted Answer

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."

Question 12

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?

Accepted Answer

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.

Question 13

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?

Accepted Answer

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."

Question 14

During a mental status examination, the nurse wants to assess a patient's affect. Which question the nurse should ask?

Accepted Answer

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?"

Question 15

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?

Accepted Answer

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.

Question 16

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?

Accepted Answer

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.

Question 17

During an examination, the nurse can assess mental status by which activity?

Accepted Answer

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

Question 18

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?

Accepted Answer

A)   Social phobia
B)   Compulsive disorder
C)   Generalized anxiety disorder
D)   Posttraumatic stress disorder

Question 19

During change of shift report, the nurse hears that a patient is experiencing hallucinations. Which is an example of a hallucination?

Accepted Answer

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.

Question 20

The nurse is assessing the mental status of a child. Which statement about children and mental status is true?

Accepted Answer

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.

Exam 5: Mental Status Assessment