Bates Chapter 9 All Answers Correct

Bates Chapter 9 All Answers Correct 1. When assessing mental status, which activity is a nurse likely to use? A) Examining the patient's electroencephalogram (EEG) B) Observing the patient's response to a set of questions C) Inquiring about the patient's intelligence quotient (IQ) D) Observing the patient's behaviors Correct answer: D) Observing the patient's behaviors 2. What is a true statement about children and mental status? A) Children's mental status is largely a function of their parents' level of functioning until age 7. B) Children are highly labile and unstable until age 2. C) Children's mental status is impossible to assess until they develop the ability to concentrate. D) All aspects of mental status in children are interdependent. Correct answer: D) All aspects of mental status in children are interdependent. 3. What can a nurse expect when assessing the mental status of a 75-year-old man? A) He will have difficulty on tests of remote memory. B) He will have a decrease in his response time due to loss of language and decline in general knowledge. C) He may take a little longer to respond, but his general knowledge and abilities should not have declined. D) He will have no decrease in any of his abilities, including response time. Correct answer: C) He may take a little longer to respond, but his general knowledge and abilities should not have declined. 4. What should a nurse assess first when evaluating an aging adult's mental status? A) Presence of phobias B) General intelligence C) Presence of irrational thinking patterns D) Sensory-perceptive abilities Correct answer: D) Sensory-perceptive abilitiesAge-related changes in sensory perception can affect mental status. For example, vision loss 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. 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 context of the health history interview. 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. The nurse is conducting a patient interview. Which statement made by the patient should the nurse more fully explore during the interview? 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 behavioral 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. 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. 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. 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: