Test chapter 5 2019, questions and answers PDF

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Chapter 05: Mental Status Test Bank—Nursing MULTIPLE CHOICE 1. When is the mental status portion of the neurologic system examination performed? a. During the history-taking process b. During assessment of cranial nerves and deep tendon reflexes c. During the time when questions related to memory are asked d. Continually, throughout the entire interaction with a patient ANS: D

A mental status evaluation should be continually performed throughout the patient encounter. Assessing and validating clues to determine the individual’s ability to interact within the environment is a priority of the mental status evaluation. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 64 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. A 69-year-old truck driver presents with a sudden loss of the ability to understand spoken

language. This indicates a lesion in the: a. temporal lobe. b. Broca area. c. frontal cortex. d. cerebellum. ANS: A

The temporal lobe, specifically in the Wernicke speech area, is responsible for the comprehension of spoken and written language. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 64 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. Mr. DeLaurentis is a 58-year-old man who presents to your office with slumped posture and a

lack of facial expression, which may indicate depression or: a. Parkinson disease. b. anxiety. c. loss of abstract reasoning. d. attention-deficit/hyperactivity disorder. ANS: A

A slumped posture and lack of facial expression may be clues to more than depression; they are also defining characteristics of Parkinson disease. DIF: Cognitive Level: Applying (Application) REF: p. 64 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 4. The ability for abstract thinking normally develops during: a. infancy. b. early childhood. c. adolescence.

d. adulthood. ANS: C

Abstract thinking is an intellectual maturation that develops during adolescence. DIF: Cognitive Level: Remembering (Knowledge) REF: pp. 64-65 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 5. The Mini-Mental State Examination (MMSE) may be used to: a. estimate cognitive changes quantitatively. b. estimate personality disorders qualitatively. c. diagnose neurologic disorders. d. determine the cause of memory loss. ANS: A

The MMSE is a standard tool that functions to estimate cognitive function quantitatively or to document cognitive changes serially. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 67 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 6. Assessing orientation to person, place, and time helps determine: a. ability to understand analogies. b. abstract reasoning. c. attention span. d. state of consciousness. ANS: D

Orientation to person, place, and time are measures of states of consciousness and awareness. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 66 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 7. When you ask the patient to tell you the meaning of a proverb or metaphor, you are assessing

which of the following? a. Level of consciousness b. Abstract reasoning c. Emotional stability d. Memory ANS: B

Asking the patient to tell you the meaning of a proverb, metaphor, or fable assesses the patient’s ability to reason abstractly. Asking the patient to tell you the meaning of a proverb or metaphor does not assess level of consciousness, emotional stability, or memory. The Mini-Mental State Examination tests memory. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 69 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 8. Impairment of arithmetic skills is often the result of: a. impaired execution of motor skills. b. impaired judgment.

c. perceptual distortions. d. depression. ANS: D

The patient with depression can display difficulty with simple arithmetic calculations. DIF: Cognitive Level: Applying (Application) REF: p. 70 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 9. Peripheral neuropathy is most likely to be manifested by: a. impaired memory. b. impaired abstract reasoning. c. impaired writing ability. d. hallucinations. ANS: C

Uncoordinated writing or drawing may indicate peripheral neuropathy, dementia, parietal lobe damage, or a cerebellar lesion. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 70 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 10. Recent memory may be tested by: a. asking the patient to name the past four presidents. b. asking the patient to listen to and repeat a series of numbers. c. showing the patient four items and asking him or her to list the items about 10

minutes later. d. asking the patient about verifiable information, such as his or her mother’s maiden

name. ANS: C

Showing the patient four or five objects, saying you will ask about them in a few minutes, and then 10 minutes later asking the patient to list the objects is a technique to measure recent memory. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 70 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 11. Loss of immediate and recent memory with retention of remote memory suggests: a. attention-deficit/hyperactivity disorder (ADHD). b. impaired judgment. c. stupor. d. dementia. ANS: D

Dementia is the loss of both immediate and recent memory while retaining remote memories. ADHD is associated with recent and remote memory impairment. Impaired judgment is a thought process dysfunction. Stupor is impaired consciousness. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 70 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

12. You ask the patient to follow a series of short commands to assess: a. judgment. b. attention span. c. arithmetic calculations. d. abstract reasoning. ANS: B

Asking the patient to follow a series of short commands will test attention span. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 70 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 13. Which of these observations would be most significant when assessing the condition of a

patient who has judgment impairment? a. Repeated failure to complete work obligations b. Forgetting family members’ birth dates c. Going to church three times a week d. Planning for retirement in 20 years ANS: A

Inadequately dealing with business affairs indicates impaired judgment, whereas the other choices do not. DIF: Cognitive Level: Applying (Application) REF: p. 70 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 14. Appropriateness of logic, sequence, cohesion, and relevance to topics are markers for the

assessment of: a. mood and feelings. b. attention span. c. thought process and content. d. abstract reasoning. ANS: C

Thought process and content are examined while observing the patient’s patterns of thinking, especially appropriateness of sequence, logic, coherence, and relevance to the topics discussed. DIF: Cognitive Level: Understanding (Comprehension) REF: pp. 71-72 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 15. Which type of hallucination is most commonly associated with alcohol withdrawal? a. Olfactory b. Visual c. Auditory d. Tactile ANS: D

Tactile hallucinations are most commonly associated with alcohol withdrawal. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 72 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

16. Flight of ideas or loosening of associations is associated with: a. aphasia. b. dysphonia. c. multiple sclerosis. d. psychiatric disorders. ANS: D

Flight of ideas, loosening of associations, word salads, neologisms, clang associations, echolalia, and utterances of unusual sounds are all associated with psychiatric disorders. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 71 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 17. Facial muscle or tongue weakness may result in: a. aphasia. b. impaired comprehension. c. neologisms. d. echolalia. ANS: A

Aphasia can result from facial muscle or tongue weakness or from neurologic damage to the speech and language regions of the brain. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 71 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 18. The Glasgow Coma Scale is used to: a. determine the cause of decreased consciousness. b. diagnose disorders that alter level of consciousness. c. quantify consciousness. d. predict response to stimulant medications. ANS: C

The Glasgow Coma Scale is used when a patient has an altered level of consciousness and is used to quantify consciousness. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 67 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 19. The Denver II is a tool used to determine: a. a child’s IQ. b. a child’s mood. c. whether a child is educable. d. whether a child is developing as expected. ANS: D

Denver II is a tool used to determine whether the child is developing fine and gross motor, language, personal, and social skills as expected according to the child’s age. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 73 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

20. When the Goodenough-Harris Drawing Test is administered to a child, the evaluator

principally observes the: a. presence and form of body parts. b. gender and race of the person drawn. c. approximate age and posture of the person drawn. d. length of time needed to draw a stick man. ANS: A

The presence and form of body parts provide a clue about the child’s development when following the scoring criteria of the Goodenough-Harris Drawing Test. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 73 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 21. An older adult is administered the Set Test and scores a 14. The nurse interprets this score as

indicative of: depression. cognitive impairment. delirium. dementia.

a. b. c. d.

ANS: D

Scores of less than 15 on this mental function test indicate dementia. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 74 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 22. Which condition is considered progressive rather than reversible? a. Delirium b. Dementia c. Depression d. Anxiety ANS: B

Dementia is considered progressive and irreversible. Delirium has the potential for reversal. Depression and anxiety are reversible. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 76 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 23. A clinical syndrome of failing memory and impairment of other intellectual functions, usually

related to obvious structural diseases of the brain, describes: a. delirium. b. dementia. c. depression. d. anxiety. ANS: B

Dementia results from a chronic progressive deterioration of the brain that results in failing memory and impairment of other intellectual functioning.

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 76 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 24. Mrs. Griffiths, a 28-year-old patient, presents to your office to discuss her

attention-deficit/hyperactivity disorder (ADHD). Which statement is true in regard to ADHD? a. It occurs before 7 years of age. b. It is usually related to mental retardation. c. It is usually related to dementia. d. It is manifested by prolonged periods of catatonic behavior. ANS: A

ADHD occurs before 7 years of age. ADHD is not related to mental retardation, dementia, or prolonged periods of catatonic behavior. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 77 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 25. An aversion to touch or being held, along with delayed or absent language development, is

characteristic of: a. attention-deficit/hyperactivity disorder. b. autism. c. dementia. d. mental retardation. ANS: B

Autistic disorder involves a combination of behavioral traits (lack of awareness of others, aversion to touch or being held, odd or repetitive behaviors, or preoccupation with parts of objects) and communication deficits (usually echolalia [parrot speech]). DIF: Cognitive Level: Understanding (Comprehension) REF: p. 78 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 26. You are interviewing a 20-year-old patient with a new-onset psychotic disorder. The patient is

apathetic and has disturbed thoughts and language patterns. The nurse recognizes this behavior pattern as consistent with a diagnosis of: a. depression. b. autistic disorder. c. mania. d. schizophrenia. ANS: D

Schizophrenia manifests as a psychotic disorder of early adult onset, with disturbances in language and speech, emotions and social withdrawal, and apathy. Depression and mania do not have the language or speech component. Autistic disorders are not psychotic disorders, and they usually begin before 3 years of age. DIF: Cognitive Level: Applying (Application) REF: p. 77 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 27. The patient who is delirious usually maintains orientation to: a. time. b. place.

c. person. d. circumstance. ANS: C

The person with delirium is unable to orient to time, place, or circumstance, but remains oriented to person. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 76 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 28. While interviewing a patient, you ask him to explain the “Lion and the Mouse” to assess: a. reading comprehension. b. attention span. c. mood and feeling. d. reasoning skills. ANS: D

Having the patient explain fables or metaphors determines abstract reasoning skills. DIF: Cognitive Level: Applying (Application) REF: p. 69 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 29. The Mini-Mental State Examination (MMSE) should be administered for the patient who: a. gets lost in her neighborhood. b. sleeps an excessive amount of time. c. has repetitive ritualistic behaviors. d. uses illegal hallucinogenic drugs. ANS: A

The MMSE is a tool used to quantitatively estimate cognitive function or to serially document cognitive changes. Getting lost in a familiar territory is a sign of possible cognitive impairment. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 67 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation COMPLETION 1. Under most conditions, adult patients should be able to repeat a series of _____________

numbers. ANS:

five to eight Most adults should be able to immediately recall a series of five to eight numbers forward and a series of four to six numbers backward. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 70 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. The examiner should be concerned about neurologic competence if a social smile cannot be

elicited by the time a child is _________ old.

ANS:

3 months A social smile is expected in the 2- to 3-month-old infant. If it is difficult or impossible to elicit a social smile by 3 months, the infant may not be neurologically intact. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 72 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation MULTIPLE RESPONSE 1. Which of the following clinical assessments will test attention span? a. Spell WORLD backward. b. Draw a clock. c. Say the days of the week. d. Do arithmetic calculations. e. Explain “a stitch in time saves nine.” ANS: A, C, D

Clinical assessments to test attention span include spell WORLD backward, say the days of the week, and do arithmetic calculations. Drawing a clock tests writing ability, and explaining a “stitch in time saves nine” tests abstract reasoning. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 70 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. Which of the following are signs and symptoms of dementia? a. Aphasia b. Apathy c. Odd behaviors d. Disintegration of personality e. Lack of awareness of others ANS: A, B, D

Aphasia, apathy, and disintegration of personality are all characteristics of dementia. Odd behaviors and lack of awareness of others are characteristics of autism. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 78 OBJ: Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation...