When assessing aging adults, what is one of the first things the nurse should assess before making judgments about the aging person’s mental status
NURS330 Individual Assessment
Chapter 5 Quiz
Question 1When assessing aging adults, what is one of the first things the nurse should assess before making judgments about the aging person’s mental status?
Presence of phobias
General intelligence
Sensory-perceptive abilities
Presence of irrational thinking patterns
Question 2A patient repeats, “I feel hot. Hot, cot, rot, tot, got. I’m a spot.” What term should the nurse use to document this?
Blocking
Clanging
Echolalia
Neologism
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 the mental status of this patient?
“Please count backward from 100 by 7.”
“I will name three items and ask you to repeat them in a few minutes.”
“Please point to articles in the room and parts of the body as I name them.”
“What would you do if you found a stamped, addressed envelope on the sidewalk?”
Question 4During an interview, the nurse notes that the patient gets up several times to wash her hands even though they are not dirty. This is an example of what behavior?
Social phobia
Compulsive disorder
Generalized anxiety disorder
Posttraumatic stress disorder
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. When conducting the mental status examination for this patient, what should the nurse assess first?
Affect and mood
Memory and affect
Cognitive abilities
Level of consciousness
Question 6A 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 of these questions?
“How are things going with the trial?”
“How are things going with your job?”
“Tell me about your recent engagement!”
“Are you having any disturbing dreams?”
Question 7The nurse is assessing a patient who is admitted with possible delirium. Which of these are manifestations of delirium? (Select all that apply.)
Person experiences agnosia.
Person demonstrates apraxia.
Develops over a short period
Person exhibits memory impairment or deficits.
Occurs as a result of a medical condition, such as systemic infection
Question 8A patient describes feeling an unreasonable, irrational fear of snakes. His fear is so persistent that he can no longer comfortably look at even pictures of snakes and has made an effort to identify all the places he might encounter a snake and avoids them. What is the best description of this patient’s condition?
A snake phobia
A hypochondriac
An obsession with snakes
A delusion that snakes are harmful stemming from an early traumatic incident involving snakes
Question 9A 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?
“Do you have a weapon?”
“How do other people treat you?”
“Are you feeling so hopeless that you feel like hurting yourself now?”
“People often feel hopeless, but the feelings resolve within a few weeks.”
Question 10A 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. How should the nurse proceed?
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.
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