Weber Health Assessment in Nursing

HEALTH ASSESSMENT IN NURSING

Chapter 6 - Assessing mental status and psychosocial developmental level

TEST BANK

1. The nurse is preparing to assess a patient's remote memory. Which question would be most appropriate for the nurse to use? A) "Can you tell me what you have eaten in the last 24 hours?" B) “When did you get your first job?” C) "What did you do last evening?" D) "How are an apple and orange the same?”

2. When assessing the mental status of a 67-year-old woman, the nurse detects some difficulty with free-flow of thought and following directions. Which of the following would the nurse do first? A) Use a Geriatric Depression Scale. B) Refer for further medical evaluation. C) Assess the patient's vision and hearing. D) Refer the patient to social services for home assistance.

3. The nurse performs a Mini-Mental Status Exam on a patient. The total score is 22. Which of the following would be most appropriate for the nurse to do next? A) Refer for further evaluation. B) Evaluate benefits versus risks of a mental health label. C) Assess further for dementia. D) Document this as a normal score.

4. The nurse notes that an older adult patient is wearing layers of clothing on a warm, fall day. Which of the following would be the priority assessment at this time? A) Asking whether the patient often feels cold. B) Assessing the patient's developmental level. C) Reviewing the patient's culture for possible influence. D) Observing the patient's overall hygiene.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 5. A nurse is working in a clinic in a poverty-stricken neighbourhood and sees a female adult patient who states that she has a urinary tract infection. The nurse notes that the patient is unkempt, wearing stained clothing, and has a strong foul body odour. The patient mentions that she was evicted from her apartment two weeks ago. Which nursing diagnosis would the nurse most likely identify for this patient? A) Caregiver role strain related to fatigue. B) Impaired skin integrity related to neurological deficits. C) Deficient fluid volume related to possible urinary tract infection. D) Self-care deficit related to possible homelessness.

6. An instructor is describing psychosocial development to a group of students. Which of the following would the instructor include when describing this concept? Select all that apply. A) Spiritual beliefs B) Cognitive function C) Emotional stability D) Self-concept E) Coping-stress patterns F) Thought patterns

7. A group of students is reviewing material about mental and psychosocial status in preparation for an examination. The students demonstrate understanding of the topic when they identify which of the following as a major system affecting a patient's status? A) Respiratory B) Neurological C) Cardiovascular D) Renal

8. The nurse begins the physical examination of a patient by assessing the patient's mental status. The nurse does this primarily based on which rationale? A) The patient will be less anxious early, providing the nurse with more accurate and reliable data. B) The exam can provide clues about the validity of the patient's responses now and throughout. C) The exam provides data about mental health problems that the patient may be afraid to report. D) The patient's fears about having a serious illness may be alleviated by the results of the exam.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 9. The nurse asks a patient to explain the saying, “people in glass houses shouldn't throw stones.” Which of the following is the nurse assessing? A) Remote memory B) Abstract reasoning C) Judgement D) Concentration

10. Assessment of a patient reveals that he is unresponsive to all stimuli and his eyes remain closed. The nurse documents the patient's level of consciousness as which of the following? A) Obtunded B) Stupor C) Coma D) Lethargy

11. A group of students is reviewing material about assessing mental status. The students demonstrated understanding of the material when they identify which of the following as a cognitive ability to be assessed? A) Orientation B) Posture C) Speech D) Thought processes

12. The nurse is assessing a patient using the Glasgow Coma Scale and obtains a score of 14. The nurse interprets this as indicating which of the following? A) Deep coma B) Coma C) Obtunded D) Alert and oriented

13. A woman brings her 69-year-old husband to the clinic for an evaluation because he has become increasingly forgetful. Which of the following would lead the nurse to suspect that the patient has Alzheimer's disease? Select all that apply. A) “He repeats the same story, word for word, over and over again.” B) “He's good at and enjoys doing the minor repairs in the home.” C) “I have to balance the checkbook now because he just won't do it.” D) “If I don't tell him when to shower, he won't and will fight me on it.” E) “He got lost walking to the pharmacy around the corner the other day.”

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 14. As part of a mental status assessment, the nurse asks a patient to draw the face of a clock. The nurse is assessing which of the following? A) Concentration and orientation. B) Perceptions and thought processes. C) Visual perceptual and constructional ability. D) Expressions and feelings.

15. The nurse is assessing the psychosocial development of a middle-aged patient. Which question would be most appropriate for the nurse to ask? A) “Do you have a close relationship with a partner?” B) “Are you able to solve problems that arise now that you are independent?” C) “Do you find pleasure in your current work or profession? D) “Are you able to cope with the physical changes that are happening?”

16. A nurse is assessing a patient exhibiting decorticate posturing. Which of the following would the nurse observe? A) Extended upper extremities. B) Internally rotated lower extremities. C) Pronated forearms. D) Flexed hands at the side of the body.

17. The nurse observes a patient's entire body posture to be stiff, with his shoulders elevated upward toward the ears. The nurse would most likely interpret this to indicate that the patient is: A) Relaxed B) Anxious C) Feeling powerless D) Restless

18. A nurse is reviewing a depression questionnaire completed by a patient. Which of the following would the nurse interpret as being suggestive of depression? A) “Occasionally I feel like my attention wanders.” B) “I haven't noticed any change in my appetite.” C) “It usually takes me over an hour to fall asleep.” D) “I might wake up once during the night but not often.”

19. When assessing the speech of an older adult patient, which of the following would the nurse expect to find? A) Repetitive B) Rapid C) Moderately paced

20. A nurse completes a Geriatric Depression Scale for an older adult patient. The nurse determines that the patient is not depressed by which score? A) 9 B) 14 C) 20 D) 25

21. A nursing instructor is teaching a group of students about assessing a patient's orientation. The instructor determines that the teaching was successful when the students state that the ability to identify which of the following usually is lost first? A) Time B) Self C) Place D) Family members

22. A nurse asks a patient the following question: “What do you do if you have pain?” The nurse is assessing which of the following? A) Orientation B) Judgement C) Abstract reasoning D) Memory

23. After teaching a class about Erikson's development stages, the instructor determines that the students have understood the information when they identify which of the following as the basic task associated with the older adult? A) Generativity B) Identity C) Ego-integrity D) Intimacy

24. When preparing to obtain information about a patient's mental and psychosocial status, which of the following would the nurse need to do first? A) Question the patient about his or her usual lifestyle and behaviours. B) Perform a neurological examination to determine any deficits. C) Check the patient's level of consciousness for changes. D) Explain the purpose of the exam and types of questions.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 25. A nurse is preparing to assess a patient's mental status using the Mini-Mental State Examination. The nurse would need to complete additional assessment of which of the following? A) Orientation B) Memory C) Thought processes D) Speech