CH 5 Mental Status Assessment PDF

Preview

Summary

Download CH 5 Mental Status Assessment PDF

Description

PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK

TestBank-PhysicalExaminationandHealthAssessment8e(byJarvis)

64

Chapter05:MentalStatusAssessment MULTIPLECHOICE 1.Duringanexamination,thenursecanassessmentalstatusbywhichactivity? a.

Examiningthepatients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patients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individualsbehaviors,suchasconsciousness,language,moodandaffect, andotheraspects. PTS:1DIF:CognitiveLevel:Understanding(Comprehension) 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.

Childrensmentalstatusislargelyafunctionoftheirparentsleveloffunctioninguntiltheageof7 years.

d.

Achildsmentalstatusisimpossibletoassessuntilthechilddevelopstheabilitytoconcentrate.

NURSINGTB.COM

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mothersbody.Theotherstatementsarenottrue. PTS:1DIF:CognitiveLevel:Understanding(Comprehension) 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

NURSINGTB.COM

PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK TestBank-PhysicalExaminationandHealthAssessment8e(byJarvis)

65

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) 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 NURSINGTB.COM

ANS:D Age-relatedchangesinsensoryperceptioncanaffectmentalstatus.Forexample,visionloss(asdetailedin Chapter15)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) 5.Thenurseispreparingtoconductamentalstatusexamination.Whichstatementistrueregardingthemental statusexamination? a.

Apatientsfamilyisthebestresourceforinformationaboutthepatients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patients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

NURSINGTB.COM

PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK TestBank-PhysicalExaminationandHealthAssessment8e(byJarvis)

66

contextofthehealthhistoryinterview. PTS:1DIF:CognitiveLevel:Applying(Application) 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 nurses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personsbehavioralchanges(e.g.,memoryloss, inappropriatesocialinteraction)oraftertrauma,suchasaheadinjury. PTS:1DIF:CognitiveLevel:Applying(Application) 7.Thenurseisconductingapatientinterview.Whichstatementmadebythepatientshouldthenursemore fullyexploreduringtheinterview? NURSINGTB.COM

a.

Isleeplikeababy.

b.

Ihavenohealthproblems.

c.

Ineverdidtoogoodinschool.

d.

Iamnotcurrentlytakinganymedications.

ANS:C Ineverymentalstatusexamination,thefollowingfactorsfromthehealthhistorythatcouldaffectthefindings shouldbenoted:anyknownillnessesorhealthproblems,suchasalcoholismorchronicrenaldisease;current medications,thesideeffectsofwhichmaycauseconfusionordepression;theusualeducationalandbehaviora level,notingthislevelasthepatientsnormalbaselineandnotexpectingalevelofperformanceonthemental statusexaminationtoexceedit;andresponsestopersonalhistoryquestions,indicatingcurrentstress,social interactionpatterns,andsleephabits. PTS:1DIF:CognitiveLevel:Analyzing(Analysis) 8.A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.Thenursesbestapproach regardingthisexaminationisto: a.

Plantodefertherestofthementalstatusexamination.

NURSINGTB.COM

PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK TestBank-PhysicalExaminationandHealthAssessment8e(byJarvis)

67

b.

Skipthelanguageportionoftheexamination,andproceedontoassessingmoodandaffect.

c.

Conductanin-depthspeechevaluation,anddeferthementalstatusexaminationtoanothertime.

d.

Proceedwiththeexamination,andassessthepatientforsuicidalthoughtsbecausedysarthriais oftenaccompaniedbyseveredepression.

ANS:A 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. PTS:1DIF:CognitiveLevel:Analyzing(Analysis) 9.A19-year-oldwomancomestotheclinicattheinsistenceofherbrother.Sheiswearingblackcombatboots andablacklacenightgownoverthetopofherotherclothes.Herhairisdyedpinkwithblackstreaks throughout.Shehasseveralpiercedholesinhernaresandearsandiswearinganearringthroughhereyebrow andheavyblackmakeup.Thenurseconcludesthat: a.

Sheprobablydoesnothaveanyproblems.

b.

Sheisonlytryingtoshockpeopleandthatherdressshouldbeignored. NURSINGTB.COM

c.

Shehasamanicsyndromebecauseofherabnormaldressandgrooming.

d.

Moreinformationshouldbegatheredtodecidewhetherherdressisappropriate.

ANS:D Groomingandhygieneshouldbenotedthepersoniscleanandwellgroomed,hairisneatandclean,women havemoderateornomakeup,andmenareshavedortheirbeardsormoustachesarewellgroomed.Careshould betakenwheninterpretingclothingthatisdisheveled,bizarre,orinpoorrepairbecausethesesometimes reflectthepersonseconomicstatusoradeliberatefashiontrend. PTS:1DIF:CognitiveLevel:Applying(Application) 10.Apatienthasbeenintheintensivecareunitfor10days.Hehasjustbeenmovedtothemedical-surgical unit,andtheadmittingnurseisplanningtoperformamentalstatusexamination.Duringthetestsofcognitive function,thenursewouldexpectthathe: a.

Maydisplaysomedisruptioninthoughtcontent.

b.

Willstate,Iamsorelievedtobeoutofintensivecare.

c.

Willbeorientedtoplaceandperson,butthepatientmaynotbecertainofthedate.

NURSINGTB.COM

PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK TestBank-PhysicalExaminationandHealthAssessment8e(byJarvis)

d.

68

Mayshowevidenceofsomecloudingofhislevelofconsciousness.

ANS:C Thenursecandiscerntheorientationofcognitivefunctionthroughthecourseoftheintervieworcandirectly andtactfullyask,Somepeoplehavetroublekeepingupwiththedateswhileinthehospital.Doyouknow todaysdate?Manyhospitalizedpeoplehavetroublewiththeexactdatebutarefullyorientedontheremaining items. PTS:1DIF:CognitiveLevel:Analyzing(Analysis) 11.Duringamentalstatusexamination,thenursewantstoassessapatientsaffect.Thenurseshouldaskthe patientwhichquestion? a.

Howdoyoufeeltoday?

b.

Wouldyoupleaserepeatthefollowingwords?

c.

Havethesemedicationshadanyeffectonyourpain?

d.

Hasthispainaffectedyourabilitytogetdressedbyyourself?

ANS:A Judgemoodandaffectbybodylanguageandfacialexpressionandbydirectlyasking,Howdoyoufeeltoday? NURSINGTB.COM orHowdoyouusuallyfeel?Themoodshouldbeappropriatetothepersonsplaceandconditionandshould appropriatelychangewiththetopics. PTS:1DIF:CognitiveLevel:Applying(Application) 12.Thenurseisplanningtoassessnewmemorywithapatient.Thebestwayforthenursetodothiswouldbe to: a.

AdministertheFACTtest.

b.

Askhimtodescribehisfirstjob.

c.

GivehimtheFourUnrelatedWordsTest.

d.

Askhimtodescribewhattelevisionshowhewaswatchingbeforecomingtotheclinic.

ANS:C Askquestionsthatcanbecorroborated,whichscreensfortheoccasionalpersonwhoconfabulatesormakesup answerstofillinthegapsofmemoryloss.TheFourUnrelatedWordsTestteststhepersonsabilitytolaydown newmemoriesandisahighlysensitiveandvalidmemorytest. PTS:1DIF:CognitiveLevel:Applying(Application) 13.A45-year-oldwomanisattheclinicforamentalstatusassessment.IngivinghertheFourUnrelated WordsTest,thenursewouldbeconcernedifshecouldnot____fourunrelatedwords____.

NURSINGTB.COM

PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK TestBank-PhysicalExaminationandHealthAssessment8e(byJarvis)

a.

Invent;within5minutes

b.

Invent;within30seconds

c.

Recall;aftera30-minutedelay

d.

Recall;aftera60-minutedelay

69

ANS:C TheFourUnrelatedWordsTestteststhepersonsabilitytolaydownnewmemories.Itisahighlysensitiveand validmemorytest.Itrequiresmoreeffortthantherecallofpersonalorhistoricevents.Tothepersonsay,Iam goingtosayfourwords.Iwantyoutorememberthem.InafewminutesIwillaskyoutorecallthem.After5 minutes,askforthefourwords.Thenormalresponseforpersonsunder60yearsisanaccuratethree-orfourwordrecallaftera5-,10-,and30-minutedelay. PTS:1DIF:CognitiveLevel:Analyzing(Analysis) 14.Duringamentalstatusassessment,whichquestionbythenursewouldbestassessapersonsjudgment? a.

Doyoufeelthatyouarebeingwatched,followed,orcontrolled?

b.

Tellmewhatyouplantodoonceyouaredischargedfromthehospital.

c.

Whatdoesthestatement,Peopleinglasshousesshouldntthrowstones,meantoyou?

d.

Whatwouldyoudoifyoufoundastamped,addressedenvelopelyingonthesidewalk?

NURSINGTB.COM

ANS:B Apersonexercisesjudgmentwhenheorshecancompareandevaluatethealternativesinasituationandreach anappropriatecourseofaction.Ratherthantestingthepersonsresponsetoahypotheticalsituation(as illustratedintheoptionwiththeenvelope),thenurseshouldbemoreinterestedinthepersonsjudgmentabout dailyorlong-termgoals,thelikelihoodofactinginresponsetodelusionsorhallucinations,andthecapacityfo violentorsuicidalbehavior. PTS:1DIF:CognitiveLevel:Applying(Application) 15.Whichoftheseindividualswouldthenurseconsiderathighestriskforasuicideattempt? a.

Manwhojokesaboutdeath

b.

Womanwho,duringapastepisodeofmajordepression,attemptedsuicide

c.

Adolescentwhojustbrokeupwithherboyfriendandstatesthatshewouldliketokillherself

d.

Olderadultmanwhotellsthenursethatheisgoingtojoinhiswifeinheaventomorrowandplans touseagun

NURSINGTB.COM

PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK TestBank-PhysicalExaminationandHealthAssessment8e(byJarvis)

70

ANS:D Whenthepersonexpressesfeelingsofsadness,hopelessness,despair,orgrief,assessinganypossibleriskof 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. PTS:1DIF:CognitiveLevel:Applying(Application) 16.Thenurseisperformingamentalstatusassessmentona5-year-oldgirl.Herparentsareundergoingabitter divorceandareworriedabouttheeffectitishavingontheirdaughter.Whichactionorstatementmightlead thenursetobeconcernedaboutthegirlsmentalstatus? a.

Sheclingstohermotherwheneverthenurseisintheroom.

b.

Sheappearsangryandwillnotmakeeyecontactwiththenurse.

c.

Hermotherstatesthatshehasbeguntorideatricyclearoundtheiryard.

d.

Hermotherstatesthatherdaughterpreferstoplaywithtoddlersinsteadofkidsherownagewhile indaycare.

ANS:D Thementalstatusassessmentofinfantsandchildrencoversbehavioral,cognitive,andpsychosocial developmentandexamineshowthechildiscopingwithhisorherenvironment.Essentially,thenurseshould NURSINGTB.COM followthesameAssociationforBehavioralandCognitiveTherapies(ABCT)guidelinesasthosefortheadult, withspecialconsiderationfordevelopmentalmilestones.Thebestexaminationtechniquearisesfroma thoroughknowledgeofthedevelopmentalmilestones(describedinChapter2).Abnormalitiesareoften problemsofomission(e.g.,thechilddoesnotachieveamilestoneasexpected). PTS:1DIF:CognitiveLevel:Applying(Application) 17.Thenurseisassessingorientationina79-year-oldpatient.Whichoftheseresponseswouldleadthenurse toconcludethatthispatientisoriented? a.

IknowmynameisJohn.IcouldnttellyouwhereIam.Ithinkitis2010,though.

b.

IknowmynameisJohn,buttotellyouthetruth,Igetkindofconfusedaboutthedate.

c.

IknowmynameisJohn;IguessImatthehospitalinSpokane.No,Idontknowthedate.

d.

IknowmynameisJohn.IamatthehospitalinSpokane.Icouldnttellyouwhatdateitis,butI knowthatitisFebruaryofanewyear2010.

ANS:D Manyagingpersonsexperiencesocialisolation,lossofstructurewithoutajob,achangeinresidence,orsome short-termmemoryloss.Thesefactorsaffectorientation,andthepersonmaynotprovidetheprecisedateor completenameoftheagency.Youmayconsideragingpersonsorientediftheygenerallyknowwheretheyare andthepresentperiod.Theyshouldbeconsideredorientedtotimeiftheyearandmontharecorrectlystated. Orientationtoplaceisacceptedwiththecorrectidentificationofthetypeofsetting(e.g.,hospital)andthe

NURSINGTB.COM

PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK TestBank-PhysicalExaminationandHealthAssessment8e(byJarvis)

71

nameofthetown. PTS:1DIF:CognitiveLevel:Applying(Application) 18.ThenurseisperformingtheDenverIIscreeningtestona12-month-oldinfantduringaroutinewell-child visit.ThenurseshouldtelltheinfantsparentsthattheDenverII: a.

Teststhreeareasofdevelopment:cognitive,physical,andpsychological

b.

Willindicatewhetherthechildhasaspeechdisordersothattreatmentcanbegin.

c.

Isascreeninginstrumentdesignedtodetectchildrenwhoareslowindevelopment.

d.

Isatesttodetermineintellectualabilityandmayindicatewhetherproblemswilldeveloplaterin school.

ANS:C TheDenverIIisascreeninginstrumentdesignedtodetectdevelopmentaldelaysininfantsandpreschoolers.It testsfourfunctions:grossmotor,language,finemotor-adaptive,andpersonal-social.TheDenverIIisnotan intelligencetest;itdoesnotpredictcurrentorfutureintellectualability.Itisnotdiagnostic;itdoesnotsuggest treatmentregimens. PTS:1DIF:CognitiveLevel:Applying(Application) 19.Apatientdriftsofftosleepwhensheisnotbeingstimulated.Thenursecaneasilyarouseherbycallingher NURSINGTB.COM name,butthepatientremainsdrowsyduringtheconversation.Thebestdescriptionofthispatientslevelof consciousnesswouldbe: a.