Quiz 2 Health Assess

A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she could not ____ four unrelated words____.

• Recall; after a 30-minute delay

• Recall; after a 10-minute delay

• Recall; after a 50-minute delay

• Recall; after a 5-minute delay

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

• Do you feel that you are being watched, followed, or controlled?

• Tell me what you plan to do once you are discharged from the hospital.

• What does the statement, People in glass houses shouldn’t throw stones, mean to you?

• What would you do if you found a stamped, addressed envelope lying on the sidewalk?

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

• Man believes that his dead wife is talking to him.

• Women see's her daughter in her dreams.

• Man tells you his doctor is in the same building as the hospital.

Answer explanation

Hallucinations are sensory perceptions for which no external stimuli exist.

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. For the mental status examination, the nurse should first assess the patients:

• Affect and mood

• Memory and affect

• Language abilities

• Level of consciousness and cognitive abilities

Answer explanation

Delirium is a disturbance of consciousness

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

• Person is experiencing apraxia.

• Develops over a short period.

• Person is exhibiting memory impairment or deficits.

• Occurs as a result of a medical condition, such as systemic infection.

• Person is experiencing agnosia.

Four main headings of mental status assessment:

• A-B-C-T Agination, Belittled, Coherent

  and Thought processes.

• A-B-C-T Appearance, Behavior, Cognition

  and Thought processes.

• A-B-C-T Appearance, Broad spectrum, Citation

  and Thorough.

The nurse is performing a mental status assessment on a 5-year-old girl. Her parents are undergoing a bitter divorce and are worried about the effect it is having on their daughter. Which action or statement might lead the nurse to be concerned about the girls mental status?

• Her mother states that the child seems normal, but plays by herself a lot.

• Her mother states that her daughter prefers to play with toddlers instead of kids her own age

  while in daycare.

• Her mother states she has older friends and prefers them over children her own age.

• Her mother states her daughter has not eaten in a couple of days, that she prefers to snack over eating meals.

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

• How do you feel today?

• Would you please repeat the following words?

• Have these medications had any effect on your pain?

• Has this pain affected your ability to get dressed by yourself?

Tags

CCSS.RI.11-12.3

CCSS.RI.11-12.5

CCSS.RI.8.3

CCSS.RI.9-10.3

CCSS.RI.9-10.5

Which of these individuals would the

nurse consider at highest risk for a suicide attempt?

• Man who jokes about death

• Woman who, during a past episode of major depression, attempted suicide

• Adolescent who just broke up with her boyfriend and states that she would like to kill herself.

• Older adult man who tells the nurse that he is going to join his wife in heaven tomorrow

  and plans to use a gun.

The CIWA-Ar scale can measure 10 symptoms. What are the scales to determine this?

• <8 to 10

  indicate minimal to mild withdrawal.

• 8 to 15 indicate moderate withdrawal

• 15 or more indicate severe withdrawal

• <8 indicates development of withdrawal