NURS 301-P Health Assessment Exam Review 2 – Fall 2016 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 exa

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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 examina... tion  State the purpose of a mental status assessment  Complete a Mini-Mental state examination MULTIPLE CHOICE 1. During an examination, the nurse can assess mental status by which activity? a. Examining the patient’s electroencephalogram b. Observing the patient as he or she performs an intelligence quotient (IQ) test c. Observing the patient and inferring health or dysfunction d. 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 2. The nurse is assessing the mental status of a child. Which statement about children and mental status is true? a. All aspects of mental status in children are interdependent. b. Children are highly labile and unstable until the age of 2 years. c. Children’s mental status is largely a function of their parents’ level of functioning until the age of 7 years. d. 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 3. 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: a. Will have no decrease in any of his abilities, including response time. b. Will have difficulty on tests of remote memory because this ability typically decreases with age. c. May take a little longer to respond, but his general knowledge and abilities should not have declined. d. 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 4. 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: a. Presence of phobias b. General intelligence c. Presence of irrational thinking patterns d. Sensory-perceptive abilities Yeah I know bro, I just get sick and tired of the same promises 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 5. The nurse is preparing to conduct a mental status examination. Which statement is true regarding the mental status examination? a. A patient’s family is the best resource for information about the patient’s coping skills. b. Gathering mental status information during the health history interview is usually sufficient. c. Integrating the mental status examination into the health history interview takes an enormous amount of extra time. d. To get a good idea of the patient’s level of functioning, performing a complete mental status examination is usually necessary. ANS: B 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 6. 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? a. Perform a complete mental status examination. b. Refer him to a psychometrician. c. Plan to integrate the mental status examination into the history and physical examination. d. 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 (Applicatio [Show More]

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