Chapter 07: Mental Health Assessment
Wilson: Health Assessment for Nursing Practice, 6th Edition
MULTIPLE CHOICE
1. What function do neurotransmitters have in mental health disorders?
a. Dopamine levels are increased in schizophrenia.
b. Increased levels of gamma aminobutyric acid (GABA) contribute to anxiety.
c. Serotonin is decreased in a state of anxiety.
d. Norepinephrine is increased in depression.
ANS: A
Dopamine levels are increased in schizophrenia. Insufficient GABA may contribute to anxiety.
GABA is an inhibitory neurotransmitter. Serotonin is increased in anxiety states.
Norepinephrine is decreased in depression.
m
DIF: Cognitive Level: Remember REF: p. 66 in Table 9-2
er as
TOP: Nursing Process: Assessment
co
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
eH w
2. A 24-year-old male patient tells the nurse he has had no energy for 2 weeks. He has no trouble
o.
rs e
falling asleep; in fact, he sleeps deeply about 12 hours every night. He states that he has
ou urc
gained 10 lb in the past 2 months and has no friends. The nurse associates these
manifestations with which mental health disorder?
a. Depression
o
b. Schizophrenia
aC s
c. Bipolar disorder
vi y re
d. Anxiety disorder
ANS: A
These are symptoms of depression. Clinical manifestations of schizophrenia include apathy
ed d
and confusion, delusions and hallucinations, and rambling or stylized patterns of speech.
ar stu
Characteristics of the manic phase are excessive emotional displays, excitement, euphoria, and
hyperactivity. In contrast, characteristics of the depressive phase are marked apathy and
feelings of profound sadness, loneliness, guilt, and lowered self-esteem. Anxiety is a feeling
of uneasiness or discomfort experienced in varying degrees, from mild anxiety to panic. The
is
energy that anxiety provides may mobilize a person to take constructive action such as solving
Th
a major problem or filling an unmet need.
DIF: Cognitive Level: Apply REF: p. 68 |p. 75
TOP: Nursing Process: Assessment
sh
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
3. A female patient states that she has had problems with depression in the past and thinks she is
depressed again. Which response by the nurse is most appropriate?
a. “What do you think is causing your depression this time?”
b. “What therapies have worked for you in the past?”
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, c. “Did you stop taking your medication?”
d. “Do you think this is a situational depression?”
ANS: B
Question B is a therapeutic response to determine if the same or similar therapy can be used
again for this depression. It is an open-ended question to collect more data. Also treatment is
information collected in a symptom analysis that is useful in this situation. Question A
provides information but does not direct the patient toward identifying a treatment. Question
C sounds accusatory, and the nurse is guessing the cause of this episode of depression without
collecting data from the patient. This is a closed-ended question asking for a “yes” or “no”
response. Question D is a closed-ended question and does not collect data to determine if the
patient has depression again.
DIF: Cognitive Level: Apply REF: p. 68
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
m
4. Which patient may be experiencing severe anxiety?
er as
a. A woman who tells the nurse she is terrified of cats
co
b. A man who tells the nurse he feels worthless and is always tired
eH w
c. A woman who reports that she is sleeping very lightly each night because her child
o.
has an ear infection
rs e
d. A man who phones the nurse five times asking for instructions about how to take
ou urc
his new medication
ANS: D
A man who phones the nurse five times asking for instructions about how to take his new
o
medication shows characteristics of anxiety, which includes forgetfulness and difficulty
aC s
concentrating or making decisions. Being terrified of cats describes fear or a phobia rather
vi y re
than anxiety. Unlike fear, which is a response to an actual object or event, anxiety is a
response to no specific source or actual object. Although fatigue is a characteristic of anxiety,
in this case, the patient also verbalizes feelings of worthlessness, which suggests depression
ed d
rather than anxiety. Although problems falling and staying asleep are characteristics of
ar stu
anxiety, in this example the patient can identify the cause of the sleeplessness—her ill child—
thus anxiety is not the cause of the sleep disturbance.
DIF: Cognitive Level: Apply REF: p. 69
is
TOP: Nursing Process: Assessment
Th
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
5. While assessing a man during a physical examination for work, the nurse suspects alcohol
use. Which assessment tool is appropriate in this situation?
sh
a. AUDIT screening tool
b. Rapid eye test
c. Mental status examination
d. HITS screening tool
ANS: A
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Wilson: Health Assessment for Nursing Practice, 6th Edition
MULTIPLE CHOICE
1. What function do neurotransmitters have in mental health disorders?
a. Dopamine levels are increased in schizophrenia.
b. Increased levels of gamma aminobutyric acid (GABA) contribute to anxiety.
c. Serotonin is decreased in a state of anxiety.
d. Norepinephrine is increased in depression.
ANS: A
Dopamine levels are increased in schizophrenia. Insufficient GABA may contribute to anxiety.
GABA is an inhibitory neurotransmitter. Serotonin is increased in anxiety states.
Norepinephrine is decreased in depression.
m
DIF: Cognitive Level: Remember REF: p. 66 in Table 9-2
er as
TOP: Nursing Process: Assessment
co
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
eH w
2. A 24-year-old male patient tells the nurse he has had no energy for 2 weeks. He has no trouble
o.
rs e
falling asleep; in fact, he sleeps deeply about 12 hours every night. He states that he has
ou urc
gained 10 lb in the past 2 months and has no friends. The nurse associates these
manifestations with which mental health disorder?
a. Depression
o
b. Schizophrenia
aC s
c. Bipolar disorder
vi y re
d. Anxiety disorder
ANS: A
These are symptoms of depression. Clinical manifestations of schizophrenia include apathy
ed d
and confusion, delusions and hallucinations, and rambling or stylized patterns of speech.
ar stu
Characteristics of the manic phase are excessive emotional displays, excitement, euphoria, and
hyperactivity. In contrast, characteristics of the depressive phase are marked apathy and
feelings of profound sadness, loneliness, guilt, and lowered self-esteem. Anxiety is a feeling
of uneasiness or discomfort experienced in varying degrees, from mild anxiety to panic. The
is
energy that anxiety provides may mobilize a person to take constructive action such as solving
Th
a major problem or filling an unmet need.
DIF: Cognitive Level: Apply REF: p. 68 |p. 75
TOP: Nursing Process: Assessment
sh
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
3. A female patient states that she has had problems with depression in the past and thinks she is
depressed again. Which response by the nurse is most appropriate?
a. “What do you think is causing your depression this time?”
b. “What therapies have worked for you in the past?”
TestBankWorld.org
This study source was downloaded by 100000827280193 from CourseHero.com on 06-05-2021 01:48:15 GMT -05:00
https://www.coursehero.com/file/40969953/c7doc/
, c. “Did you stop taking your medication?”
d. “Do you think this is a situational depression?”
ANS: B
Question B is a therapeutic response to determine if the same or similar therapy can be used
again for this depression. It is an open-ended question to collect more data. Also treatment is
information collected in a symptom analysis that is useful in this situation. Question A
provides information but does not direct the patient toward identifying a treatment. Question
C sounds accusatory, and the nurse is guessing the cause of this episode of depression without
collecting data from the patient. This is a closed-ended question asking for a “yes” or “no”
response. Question D is a closed-ended question and does not collect data to determine if the
patient has depression again.
DIF: Cognitive Level: Apply REF: p. 68
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
m
4. Which patient may be experiencing severe anxiety?
er as
a. A woman who tells the nurse she is terrified of cats
co
b. A man who tells the nurse he feels worthless and is always tired
eH w
c. A woman who reports that she is sleeping very lightly each night because her child
o.
has an ear infection
rs e
d. A man who phones the nurse five times asking for instructions about how to take
ou urc
his new medication
ANS: D
A man who phones the nurse five times asking for instructions about how to take his new
o
medication shows characteristics of anxiety, which includes forgetfulness and difficulty
aC s
concentrating or making decisions. Being terrified of cats describes fear or a phobia rather
vi y re
than anxiety. Unlike fear, which is a response to an actual object or event, anxiety is a
response to no specific source or actual object. Although fatigue is a characteristic of anxiety,
in this case, the patient also verbalizes feelings of worthlessness, which suggests depression
ed d
rather than anxiety. Although problems falling and staying asleep are characteristics of
ar stu
anxiety, in this example the patient can identify the cause of the sleeplessness—her ill child—
thus anxiety is not the cause of the sleep disturbance.
DIF: Cognitive Level: Apply REF: p. 69
is
TOP: Nursing Process: Assessment
Th
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts
5. While assessing a man during a physical examination for work, the nurse suspects alcohol
use. Which assessment tool is appropriate in this situation?
sh
a. AUDIT screening tool
b. Rapid eye test
c. Mental status examination
d. HITS screening tool
ANS: A
TestBankWorld.org
This study source was downloaded by 100000827280193 from CourseHero.com on 06-05-2021 01:48:15 GMT -05:00
https://www.coursehero.com/file/40969953/c7doc/
