A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self-mutilation and has a history of suicide attempts. She describes difficulty sleeping at night and has lost 10 pounds in the past month.
Which of these statements or questions is the nurse's best response in this situation?
a.
Do you have a weapon?
b.
How do other people treat you?
c.
Are you feeling so hopeless that you feel like hurting yourself now?
d.
People often feel hopeless, but the feelings resolve within a few weeks.
Question 2The nurse is providing instructions to newly hired graduates for the mini-mental state examination (MMSE). Which statement best describes this examination?
a. Scores below 30 indicate cognitive impairment.
b. The MMSE is a good tool to evaluate mood and thought processes.
c. This examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness.
d. The MMSE is useful tool for an initial evaluation of mental status. Additional tools are needed to evaluate cognition changes over time.
Question 3The nurse is planning health teaching for a 65-year-old woman who has had a cerebrovascular accident (stroke) and has aphasia. Which of these questions is most important to use when assessing mental status in this patient?
a. Please count backward from 100 by seven.
b. I will name three items and ask you to repeat them in a few minutes.
c. Please point to articles in the room and parts of the body as I name them.
d. What would you do if you found a stamped, addressed envelope on the sidewalk?
Question 4The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status?
a. Mental status assessment diagnoses specific psychiatric disorders.
b. Mental disorders occur in response to everyday life stressors.
c. Mental status functioning is inferred through the assessment of an individual's behaviors.
d. Mental status can be directly assessed, similar to other systems of the body (e.g., heart sounds, breath sounds).
Question 5A 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 patient's:
a. Affect and mood
b. Memory and affect
c. Language abilities
d. Level of consciousness and cognitive abilities
Question 6A patient states, I feel so sad all of the time. I can't feel happy even doing things I used to like to do. He also states that he is tired, sleeps poorly, and has no energy. To differentiate between a dysthymic disorder and a major depressive disorder,
a. Have you had any weight changes?
b. Are you having any thoughts of suicide?
c. How long have you been feeling this way?
d. Are you having feelings of worthlessness?
Question 7A 23-year-old patient in the clinic appears anxious. Her speech is rapid, and she is fidgety and in constant motion. Which of these questions or statements would be most appropriate for the nurse to use in this situation to assess attention span?
a. How do you usually feel? Is this normal behavior for you?
b. I am going to say four words. In a few minutes, I will ask you to recall them.
c. Describe the meaning of the phrase, 'Looking through rose-colored glasses.'
d. Pick up the pencil in your left hand, move it to your right hand, and place it on the table.
Question 8A 26-year-old woman was robbed and beaten a month ago. She is returning to the clinic today for a follow-up assessment. The nurse will want to ask her which one of these questions?
a. How are things going with the trial?
b. How are things going with your job?
c. Tell me about your recent engagement
d. Are you having any disturbing dreams?
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