Quiz 2

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1.

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

2. The nurse is assessing mental status in children. Which of the following statements is true?
a. All aspects of mental status in children are interrelated.
b. Children are highly labile and unstable until the age of 2 years.
c. Until the age of 7 years, children’s mental status is largely a function of their parents’ mental
status.
d. Children’s mental status is impossible to assess until they develop the ability to concentrate.

3. 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:
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.

3. When assessing older adults, the nurse knows that one of the first things that should be assessed
before drawing conclusions about their mental status is:
a. the presence of phobias.
b. their general intelligence.
c. the presence of irrational thinking patterns.
d. their sensory-perceptive abilities

4. Which of the following statements about the mental status examination is true?
a. A patient’s family is the best resource for information about the patient’s coping skills.
b. It is usually sufficient to gather mental status information during the health history interview.
c. It takes an enormous amount of extra time to integrate the mental status examination into the
health history interview.
d. It is usually necessary to perform a complete mental status examination to get a good idea of
the patient’s level of functioning.

5. 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 of the
following statements reflects the nurse’s best course of action?
a. The nurse should plan to perform a complete mental status examination.
b. It would be most appropriate to refer him to a psychometrician.
c. The nurse should plan to integrate the mental status examination into history taking and
physical examination.
d. The nurse should reassure his wife that memory loss after a physical shock is normal and the
problem will correct itself soon.

6. 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 her other clothes. Her hair is dyed pink with black
streaks. She has several piercings in her nares and ears and is wearing an earring on her eyebrow
and heavy black makeup. The nurse concludes:
a. she probably does not have any problems at all.
b. she is just trying to shock people and her appearance should be ignored.
c. she has manic syndrome because of her abnormal way of dressing and grooming.
d. more information should be gathered to decide whether her way of dressing is appropriate.

7. 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. During
the cognitive function tests, the nurse would expect that he:
a. might display some disruption in thought content.
b. might state, “I am so relieved to be out of intensive 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.

8. To assess affect, the nurse should ask the patient:


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 dress yourself?”

9. Which of the following questions would best assess a person’s judgement?


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?”

10. Which of the following individuals would the nurse consider at highest risk for a suicide attempt?
a. A man who jokes about death
b. A woman who, during a past episode of major depression, attempted suicide
c. An adolescent who has just broken up with her boyfriend and states that she wants to kill
herself
d. An older adult who tells the nurse that he is going to “join his wife in heaven” tomorrow and
plans to shoot himself

1.
social circumstances, role responsibilities, loss, change, threat ROLE RELATIONSHIP

TYPE YOUR ANSWER


3.
nurse observation, physical exam findings, information from health records, results from clinical tests –
OBJECTIVE DATA
1.
function of bladder/bowel/skin, regularity/control, perceived problems, changes

Elimination

Dysfunctional

Pattern Focus

Cross Links
2.
perceived health and well being and how health is managed, health and safety practices, use of health care
system, access to health care
Self Concept/Self Perception

Sexuality/Reproductive

Health Perception/Management

Coping/Stress/Tolerance
3.
what the client states, health history

Dysfunctional

Nursing Process

Values/Beliefs

Subjective Data
4.

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