NUR310G Health Assessment Exam 1 Due Points 50 Questions 50 Time Limit 80 Minutes
Instructions
Attempt History Attempt Time Score LATEST Attempt 1 60 minutes 40.5 out of 50
Score for this quiz: 40.5 out of 50
This attempt took 60 minutes.
Question 1
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Which of these individuals would the nurse consider at highest risk for a suicide attempt?
Woman who, during a past episode of major depression, attempted suicide
Man who jokes about death
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rrect Answe 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."
When the person expresses feelings of sadness, hopelessness, despair, or grief, assessing any possible risk for physical harm to him or herself is important. The interview should begin with more general questions. If the nurse hears affirmative answers, then he or she should continue with more specific questions. A precise suicide plan to take place in the next 24 to 48 hours with use of a lethal method constitutes high risk.
Question 2
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A patient is admitted to the unit after a motorcycle accident. The nurse begins the mental status examination and finds that the patient has dysarthric speech and arouses only to painful stimuli. How should the nurse proceed?
Proceed with the examination and assess the patient for suicidal thoughts because dysarthria is often accompanied by severe depression.
r Defer the rest of the mental status examination.
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An elderly client with pneumonia is being treated in the intensive care unit (ICU). He is acutely agitated, restless, and disoriented. The nurse
documents his level of consciousness as:
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Question 3
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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.
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. Dysarthric speech and lethargy are signs of altered consciousness and answers to questions on the mental status examination may be invalid. The nurse should not proceed with any further part of the mental status examination at this time.
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CCoorrrreecctt!!Delirious
Demented
Drowsy
Manic
Delirium is marked by disorientation, agitation, restlessness, poor attention span, impaired judgment.
Question 4
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During a mental status examination, the nurse wants to assess a patient’s mood. Which question the nurse should ask?
“Has this pain affected your ability to get dressed by yourself?” “Would you please repeat the following words?” “Have these medications had any effect on your pain?” “How do you feel today?”
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