NURSING HEALTH ASSESSMENT
TEST BANK QUESTIONS - CHAPTER 5
EXAM QUESTIONS AND ANSWERS
A - Answer-A 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. A snake phobia
b. A hypochondriac
c. An obsession with snakes
d. A delusion that snakes are harmful stemming from an early traumatic incident
involving snakes
D - Answer-During a recent interview, a patient diagnosed with schizophrenia shows
the nurse a picture of a man holding a decapitated head.
He describes this picture as horrifying but then laughs loudly at the content. What is
the best description of this behavior?
a. Confusion
b. Ambivalence
c. Depersonalization
d. Inappropriate affect
A - Answer-During change of shift report, the nurse hears that a patient is
experiencing hallucinations. Which is an example of a hallucination?
a. Man believes that his dead wife is talking to him.
b. Woman hears the doorbell ring and goes to answer it, but no one is there.
c. Child sees a man standing in his closet. When the lights are turned on, it is only a
dry cleaning bag.
d. Man believes that the dog has curled up on the bed, but when he gets closer he
sees that it is a blanket.
D - Answer-A 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?
a. Affect and mood
b. Memory and affect
c. Cognitive abilities
d. Level of consciousness
D - Answer-A 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?
a. "How are things going with the trial?"
, b. "How are things going with your job?"
c. "Tell me about your recent engagement!"
d. "Are you having any disturbing dreams?"
C - Answer-The nurse is performing a mental status examination. Which statement is
true regarding the assessment of mental status?
a. Mental status assessment diagnoses specific psychiatric disorders.
b. Mental disorders occur in response to everyday life stressors.
c. Mental status functioning is inferred through the assessment of an individual's
behaviors.
d. Mental status can be directly assessed, similar to other systems of the body (e.g.,
heart sounds, breath sounds).
D - Answer-A 23-year-old patient in the clinic appears anxious. Her speech is rapid,
and she is fidgety and in constant motion. Which of these
questions or statements would be most appropriate for the nurse to use in this
situation?
a. "How do you usually feel? Is this normal behavior for you?"
b. "I am going to say four words. In a few minutes, I will ask you to recall them."
c. "Describe the meaning of the phrase, 'Looking through rose-colored glasses.'"
d. "Pick up the pencil in your left hand, move it to your right hand, and place it on
the table."
C - Answer-The 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?
a. "Please count backward from 100 by 7."
b. "I will name three items and ask you to repeat them in a few minutes."
c. "Please point to articles in the room and parts of the body as I name them."
d. "What would you do if you found a stamped, addressed envelope on the
sidewalk?"
C - Answer-A 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?
a. "Do you have a weapon?"
b. "How do other people treat you?"
c. "Are you feeling so hopeless that you feel like hurting yourself now?"
d. "People often feel hopeless, but the feelings resolve within a few weeks."
C - Answer-The nurse is providing instructions to newly hired graduates for the mini-
mental state examination (MMSE). Which statement best
describes this examination?
a. Scores below 30 indicate cognitive impairment.
b. The MMSE is a good tool to evaluate mood and thought processes.
c. This examination is a good tool to detect delirium and dementia and to
differentiate these from psychiatric mental illness.
TEST BANK QUESTIONS - CHAPTER 5
EXAM QUESTIONS AND ANSWERS
A - Answer-A 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. A snake phobia
b. A hypochondriac
c. An obsession with snakes
d. A delusion that snakes are harmful stemming from an early traumatic incident
involving snakes
D - Answer-During a recent interview, a patient diagnosed with schizophrenia shows
the nurse a picture of a man holding a decapitated head.
He describes this picture as horrifying but then laughs loudly at the content. What is
the best description of this behavior?
a. Confusion
b. Ambivalence
c. Depersonalization
d. Inappropriate affect
A - Answer-During change of shift report, the nurse hears that a patient is
experiencing hallucinations. Which is an example of a hallucination?
a. Man believes that his dead wife is talking to him.
b. Woman hears the doorbell ring and goes to answer it, but no one is there.
c. Child sees a man standing in his closet. When the lights are turned on, it is only a
dry cleaning bag.
d. Man believes that the dog has curled up on the bed, but when he gets closer he
sees that it is a blanket.
D - Answer-A 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?
a. Affect and mood
b. Memory and affect
c. Cognitive abilities
d. Level of consciousness
D - Answer-A 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?
a. "How are things going with the trial?"
, b. "How are things going with your job?"
c. "Tell me about your recent engagement!"
d. "Are you having any disturbing dreams?"
C - Answer-The nurse is performing a mental status examination. Which statement is
true regarding the assessment of mental status?
a. Mental status assessment diagnoses specific psychiatric disorders.
b. Mental disorders occur in response to everyday life stressors.
c. Mental status functioning is inferred through the assessment of an individual's
behaviors.
d. Mental status can be directly assessed, similar to other systems of the body (e.g.,
heart sounds, breath sounds).
D - Answer-A 23-year-old patient in the clinic appears anxious. Her speech is rapid,
and she is fidgety and in constant motion. Which of these
questions or statements would be most appropriate for the nurse to use in this
situation?
a. "How do you usually feel? Is this normal behavior for you?"
b. "I am going to say four words. In a few minutes, I will ask you to recall them."
c. "Describe the meaning of the phrase, 'Looking through rose-colored glasses.'"
d. "Pick up the pencil in your left hand, move it to your right hand, and place it on
the table."
C - Answer-The 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?
a. "Please count backward from 100 by 7."
b. "I will name three items and ask you to repeat them in a few minutes."
c. "Please point to articles in the room and parts of the body as I name them."
d. "What would you do if you found a stamped, addressed envelope on the
sidewalk?"
C - Answer-A 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?
a. "Do you have a weapon?"
b. "How do other people treat you?"
c. "Are you feeling so hopeless that you feel like hurting yourself now?"
d. "People often feel hopeless, but the feelings resolve within a few weeks."
C - Answer-The nurse is providing instructions to newly hired graduates for the mini-
mental state examination (MMSE). Which statement best
describes this examination?
a. Scores below 30 indicate cognitive impairment.
b. The MMSE is a good tool to evaluate mood and thought processes.
c. This examination is a good tool to detect delirium and dementia and to
differentiate these from psychiatric mental illness.
