Exam Review 2 -  Define the behaviors that are considered in...

NURS 301-P

Health Assessment Exam Review 2

Chapter 5 Mental Status Exam  Define the behaviors that are considered in an assessment of a person’s mental status  Describe relevant developmental care related to the mental status examination  State the purpose of a mental status assessment  Complete a Mini-Mental state examination

MULTIPLE CHOICE

• During an examination, the nurse can assess mental status by which activity?
• Examining the patient’s electroencephalogram
• Observing the patient as he or she performs an intelligence quotient (IQ) test
• Observing the patient and inferring health or dysfunction
• Examining the patient’s response to a specific set of questions

ANS: C

Mental status cannot be directly scrutinized like the characteristics of skin or heart sounds. Its functioning is inferred through an assessment of an individual’s behaviors, such as consciousness, language, mood and affect, and other aspects.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: p. 67 MSC: Client Needs: Psychosocial Integrity

• The nurse is assessing the mental status of a child. Which statement about children and mental

status is true?

• All aspects of mental status in children are interdependent.
• Children are highly labile and unstable until the age of 2 years.
• Children’s mental status is largely a function of their parents’ level of functioning

until the age of 7 years.

• A child’s mental status is impossible to assess until the child develops the ability to

concentrate.

ANS: A

Separating and tracing the development of only one aspect of mental status is difficult. All aspects are interdependent. For example, consciousness is rudimentary at birth because the cerebral cortex is not yet developed. The infant cannot distinguish the self from the mother’s body. The other statements are not true.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: p. 68 MSC: Client Needs: Psychosocial Integrity

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• The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the

assessment, the nurse expects that this patient:

• Will have no decrease in any of his abilities, including response time.
• Will have difficulty on tests of remote memory because this ability typically

decreases with age.

• May take a little longer to respond, but his general knowledge and abilities should

not have declined.

• Will exhibit had a decrease in his response time because of the loss of language

and a decrease in general knowledge.

ANS: C

The aging process leaves the parameters of mental status mostly intact. General knowledge does not decrease, and little or no loss in vocabulary occurs. Response time is slower than in a youth.It takes a little longer for the brain to process information and to react to it. Recent memory, which requires some processing, is somewhat decreased with aging, but remote memory is not affected.

PTS: 1 DIF: Cognitive Level: Analyzing (Analysis) REF: p. 68 MSC: Client Needs: Psychosocial Integrity

• When assessing aging adults, the nurse knows that one of the first things that should be assessed

before making judgments about their mental status is:

• Presence of phobias
• General intelligence
• Presence of irrational thinking patterns
• Sensory-perceptive abilities

Y eah I k no w br o , I ju st g et sick an d tir ed o f th e sam e p r o m ises

ANS: D

Age-related changes in sensory perception can affect mental status. For example, vision loss (as detailed in Chapter 14) may result in apathy, social isolation, and depression. Hearing changes are common in older adults, which produces frustration, suspicion, and social isolation and makes the person appear confused.

PTS: 1 DIF: Cognitive Level: Analyzing (Analysis) REF: p. 68 MSC: Client Needs: Psychosocial Integrity

• The nurse is preparing to conduct a mental status examination. Which statement is true regarding

the mental status examination?

• A patient’s family is the best resource for information about the patient’s coping

skills.

• Gathering mental status information during the health history interview is usually

sufficient.

• Integrating the mental status examination into the health history interview takes an

enormous amount of extra time.

• To get a good idea of the patient’s level of functioning, performing a complete

mental status examination is usually necessary.

ANS: B 2 / 4

The full mental status examination is a systematic check of emotional and cognitive functioning.The steps described, however, rarely need to be taken in their entirety. Usually, one can assess mental status through the context of the health history interview.

PTS: 1 DIF: Cognitive Level: Applying (Application) REF: p. 68 MSC: Client Needs: Psychosocial Integrity

• 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 statement reflects the nurse’s best course of action?

• Perform a complete mental status examination.
• Refer him to a psychometrician.
• Plan to integrate the mental status examination into the history and physical

examination.

• Reassure his wife that memory loss after a physical shock is normal and will soon

subside.

ANS: A

Performing a complete mental status examination is necessary when any abnormality in affect or behavior is discovered or when family members are concerned about a person’s behavioral changes (e.g., memory loss, inappropriate social interaction) or after trauma, such as a head injury.

PTS: 1 DIF: Cognitive Level: Applying (Application) REF: p. 69 MSC: Client Needs: Psychosocial Integrity

• The nurse is conducting a patient interview. Which statement made by the patient should the

nurse more fully explore during the interview?

• “I sleep like a baby.”
• “I have no health problems.”
• “I never did too good in school.”
• “I am not currently taking any medications.”

ANS: C

In every mental status examination, the following factors from the health history that could affect the findings should be noted: any known illnesses or health problems, such as alcoholism or chronic renal disease; current medications, the side effects of which may cause confusion or depression; the usual educational and behavioral level, noting this level as the patient’s normal baseline and not expecting a level of performance on the mental status examination to exceed it; and responses to personal history questions, indicating current stress, social interaction patterns, and sleep habits.

PTS: 1 DIF: Cognitive Level: Analyzing (Analysis) REF: p. 69 MSC: Client Needs: Psychosocial Integrity

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• A patient is admitted to the unit after an automobile accident. The nurse begins the mental status

examination and finds that the patient has dysarthric speech and is lethargic. The nurse’s best

approach regarding this examination is to:

• Plan to defer the rest of the mental status examination.
• Skip the language portion of the examination, and proceed onto assessing mood

and affect.

• Conduct an in-depth speech evaluation, and defer the mental status examination to

another time.

• Proceed with the examination, and assess the patient for suicidal thoughts because

dysarthria is often accompanied by severe depression.

ANS: A

In the mental status examination, the sequence of steps forms a hierarchy in which the most basic functions (consciousness, language) are assessed first. The first steps must be accurately assessed to ensure validity of the steps that follow. For example, if consciousness is clouded, then the person cannot be expected to have full attention and to cooperate with new learning. If language is impaired, then a subsequent assessment of new learning or abstract reasoning (anything that requires language functioning) can give erroneous conclusions.

PTS: 1 DIF: Cognitive Level: Analyzing (Analysis) REF: p. 69 MSC: Client Needs: Psychosocial Integrity

• 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 the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. The nurse concludes that:

• She probably does not have any problems.
• She is only trying to shock people and that her dress should be ignored.
• She has a manic syndrome because of her abnormal dress and grooming.
• More information should be gathered to decide whether her dress is appropriate.

ANS: D

Grooming and hygiene should be noted—the person is clean and well groomed, hair is neat and clean, women have moderate or no makeup, and men are shaved or their beards or moustaches are well groomed. Care should be taken when interpreting clothing that is disheveled, bizarre, or in poor repair because these sometimes reflect the person’s economic status or a deliberate fashion trend.

PTS: 1 DIF: Cognitive Level: Applying (Application) REF: p. 70 MSC: Client Needs: Psychosocial Integrity

• 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 tests of cognitive function, the nurse would expect that he:

• May display some disruption in thought content.
• Will state, “I am so relieved to be out of intensive care.”
• Will be oriented to place and person, but the patient may not be certain of the date.
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