Question 1

The nurse would plan to use the Nipissing District Developmental Screen with a child who is:

Accepted Answer

A)  3 years old.
B)  16 years old.
C)  8 years old with a developmental delay.
D)  having difficulty with gross motor skills. A

Question 2

When interviewing a patient,it is important for the nurse to obtain some basic history.Which of the following statements should be explored more fully during an interview? The patient states that he:

Accepted Answer

A)  "sleeps like a baby."
B)  has no health problems.
C)  "never did too good in school."
D)  is currently not taking any medication. C

Question 3

The nurse is planning health education for a 65-year-old woman who has had a cerebrovascular accident (stroke)and is aphasic.Which of the following is most important to use when assessing mental health in this situation?

Accepted Answer

A)  "Please count back from 100 by sevens."
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?" C

Question 4

A 45-year-old woman is at the clinic for a mental health assessment.When giving her the Four Unrelated Words Test,the nurse would be concerned if the patient:

Accepted Answer

A)  could not give four unrelated words within 5 minutes.
B)  could not give four unrelated words within 30 seconds.
C)  could not recall four unrelated words after a 30-minute delay.
D)  could not recall four unrelated words after a 60-minute delay.

Question 5

A patient describes an unreasonable,irrational fear of snakes.The feeling is so persistent that he can no longer even look at pictures of snakes without feeling uncomfortable.He has tried to identify all the places where he might encounter snakes and avoids them.The nurse recognizes that:

Accepted Answer

A)  he has a snake phobia.
B)  he is a hypochondriac.Snakes are usually harmless.
C)  he has an obsession.In this case,it is about snakes.
D)  he has a delusion that snakes are harmful.It must stem from an early traumatic incident involving snakes.

Question 6

The nurse is assessing orientation in a 79-year-old patient.Which of the following responses would lead the nurse to conclude that this patient is oriented?

Accepted Answer

A)  "I know that my name is John.I couldn't tell you where I am.I think this year is 2009,though."
B)  "I know that my name is John,but to tell you the truth,I get kind of confused about the date."
C)  "I know that my name is John;I guess I'm at the hospital in Victoria.No,I don't know the date."
D)  "I know that my name is John.I am at the hospital in Victoria.I couldn't tell you what date it is,but I know that it is February of a new year-2009."

Question 7

When examining a patient,the nurse can assess mental health by:

Accepted Answer

A)  examining the patient's electroencephalogram.
B)  observing the patient as he or she performs an IQ test.
C)  observing the patient and inferring health or dysfunction.
D)  examining the patient's response to a specific set of questions.

Question 8

The nurse is assessing a 75-year-old male patient.At the beginning of the mental status portion of the assessment,the nurse expects that this patient:

Accepted Answer

A)  will have no decrease in any of his abilities,including response time.
B)  will have difficulty on tests of remote memory because this typically decreases with age.
C)  may take a little longer to respond,but his general knowledge and abilities should not have declined.
D)  will have had a decrease in his response time because of language loss and a decrease in general knowledge.

Question 9

A patient keeps saying,"I feel hot.Hot,cot,rot,tot,got.I'm a spot." This is an illustration of:

Accepted Answer

A)  blocking.
B)  clanging.
C)  echolalia.
D)  neologism.

Question 10

The nurse is planning to assess new memory with a patient.The best way to do this would be to:

Accepted Answer

A)  administer the FACT test.
B)  ask him to describe his first job to you.
C)  give him the Four Unrelated Words Test.
D)  ask him to describe the last TV show he watched before coming to the clinic.

Question 11

An example of a cognition area for the mental health examination is:

Accepted Answer

A)  Speech
B)  Orientation
C)  Perception
D)  Judgement

Question 12

The nurse has completed a Set Test on a 70-year-old woman who has exhibited some dramatic behaviour changes,according to her family.Her score on the Set Test is 14.How will the nurse interpret this result?

Accepted Answer

A)  It indicates delirium.
B)  It indicates dementia.
C)  It may indicate dementia,but further testing is needed.
D)  It is within normal limits.

Question 13

Which of the following questions would best assess a person's judgement?

Accepted Answer

A)  "Do you feel that you are being watched,followed,or controlled?"
B)  "Tell me about what you plan to do once you are discharged from the hospital."
C)  "What does the saying,'People in glass houses shouldn't throw stones' mean to you?"
D)  "What would you do if you found a stamped,addressed envelope on the sidewalk?"

Question 14

Which of the following statements about mental health assessment is true?

Accepted Answer

A)  The mental health assessment diagnoses specific psychiatric disorders.
B)  Mental disorders occur in response to everyday life stressors.
C)  Mental status is inferred through assessment of an individual's behaviours.
D)  Mental health can be assessed directly,just like the characteristics of any other body system (e.g. ,cardiac and breath sounds) .

Question 15

Which of the following are characteristics of delirium? (Select all that apply. )

Accepted Answer

A)  Develops over a short period of time
B)  Presence of apraxia
C)  Memory impairment or deficits
D)  Occurs as a result of a medical condition,such as systemic infection
E)  Presence of agnosia

Question 16

A 30-year-old female patient is describing feelings of hopelessness and depression.She has attempted self-mutilation and has a history of prior suicide attempts.She describes difficulty sleeping at night and has lost 4.5 kg (10 lb)in the past month.Which of the following is the nurse's best response in this situation?

Accepted Answer

A)  "Do you own any lethal 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 feeling resolves within a few weeks."

Question 17

When assessing older adults,the nurse knows that one of the first things that should be assessed before drawing conclusions about their mental health is:

Accepted Answer

A)  the presence of phobias.
B)  their general intelligence.
C)  the presence of irrational thinking patterns.
D)  their sensory-perceptive abilities.

Question 18

A 45-year-old woman suffered a head injury in a car accident.A few months after recovering from her injuries,she is unable to differentiate between hot and cold and is unsure of how to dress for the weather.This is an example of:

Accepted Answer

A)  mania.
B)  agnosia.
C)  dementia.
D)  amnestic disorder.

Question 19

A patient has been in the critical 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 health examination.During the cognitive function tests,the nurse would expect that he:

Accepted Answer

A)  might display some disruption in thought content.
B)  might state,"I am so relieved to be out of critical care."
C)  might be oriented to place and person but not be certain of the date.
D)  might show evidence of some clouding of consciousness.

Question 20

A 23-year-old patient is in the clinic and appears anxious.Her speech is rapid.She is fidgety and in constant motion.Which of the following questions or statements would be most appropriate for the nurse to use in this situation to assess attention span?

Accepted Answer

A)  "How do you usually feel? Is this normal behaviour for you?"
B)  "I am going to say four words.In a few minutes,I will ask you to recall them."
C)  "Please describe the meaning of the phrase,'looking through rose-coloured glasses'."
D)  "Please pick up the pencil in your left hand,move it to your right hand,and place it on the table."

Exam 6: Mental Health Assessment