WorksheetsQuiz 2 Health Assess
Total questions: 21
Worksheet time: 42mins
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.
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
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?
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
A patient with a known history of heavy alcohol use has been admitted to the ICU after he was found unconscious outside a bar. The nurse closely monitors him for symptoms of withdrawal. Which of these symptoms may occur during this time? Select all that apply.
Bradycardia
Coarse tremor of the hands
Transient hallucinations
Somnolence
Sweating
A patient is brought to the emergency department. He is restless, has dilated pupils, is sweating, has a runny nose and tearing eyes, and complains of muscle and joint pains. His girlfriend thinks he has influenza, but she became concerned when his temperature went up to 39.4 C. She admits that he has been a heavy drug user, but he has been trying to stop on his own. The nurse suspects that the patient is experiencing withdrawal symptoms from which substance?
Alcohol
Heroin
Crack cocaine
Sedatives
A woman has come to the clinic to seek help with a substance abuse problem. She admits to using cocaine just before arriving. Which of these assessment findings would the nurse expect to find when examining this woman?
Dilated pupils, pacing, and psychomotor agitation.
Dilated pupils, unsteady gait, and aggressiveness.
Pupil constriction, lethargy, apathy, and dysphoria
Constricted pupils, euphoria, and decreased temperature
A patient visits the clinic to ask about smoking cessation. He has smoked heavily for 30 years
and wants to stop cold turkey. He asks the nurse, What symptoms can I expect if I do this?
Which of these symptoms should the nurse share with the patient as possible symptoms of
nicotine withdrawal? Select all that apply.
Headaches
Hunger
Sleepiness
Sweating
Restlessness Nervousness
The nurse is reviewing aspects of substance abuse in
preparation for a seminar. Which of these statements illustrates the concept of tolerance to an illicit substance?
The person Requires an increased amount of the
substance to produce the same effect.
YES
NO
How many drinks a day is acceptable for men, women, and pregnant women?
<=2
<=1
0
<=3
<=2
1
<=4
<=3
2
<=5
<=4
3
During an assessment, the nurse asks a female patient, How many alcoholic drinks do you have a week? Which answer by the patient would indicate at-risk drinking?
a. I may have one or two drinks a week.
b. I usually have three or four drinks a week.
c. Ill have a glass or two of wine every now and then.
d. I have seven or eight drinks a week, but I never get drunk.
The nurse is conducting a class on alcohol and the effects of alcohol on the body. How many standard drinks (each containing 14 grams of alcohol) per day in men are associated with increased deaths from cirrhosis, cancers of the mouth, esophagus, and injuries?
a. 2
b. 4
c. 6
d. 8
The nurse is assessing bruising on an injured patient. Which color indicates a new bruise that is less than 2 hours old?
Red
Purple-blue
Greenish-brown
Brownish-yellow
During an examination, the nurse notices a patterned injury on a patient's back. Which of these would cause such an injury?
Blunt force
Friction abrasion
Stabbing from a kitchen knife
Whipping from an extension cord
Which term refers to a wound produced by the tearing or splitting of body tissue,
usually from blunt impact over a bony surface?
Abrasion
Contusion
Laceration
Hematoma
