Question 1

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

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.

Question 2

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?

Accepted Answer

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.

Question 3

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

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.

Question 4

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?

Accepted Answer

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.

Question 5

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

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.

Question 6

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?

Accepted Answer

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).

Question 7

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?

Accepted Answer

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.

Question 8

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?

Accepted Answer

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.

Question 9

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?

Accepted Answer

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.

Question 10

The nurse is providing instructions to newly hired graduates for the mini-mental state examination (MMSE). Which statement best describes this examination?

Accepted Answer

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.

Question 11

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

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.

Question 12

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

Accepted Answer

Hallucinations are sensory perceptions for which no external stimuli exist. They may strike any sense: visual, auditory, tactile, olfactory, or gustatory.

Question 13

The nurse is assessing a patient who is admitted with possible delirium. Which of these are manifestations of delirium? (Select all that apply.)

Accepted Answer

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.

Question 14

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

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.

Question 15

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

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.

Question 16

The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status?

Accepted Answer

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.

Question 17

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

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.

Quiz 5: Mental Status Assessment