,NSG3160/NSG 3160 Exam 2 | Health Assessment |
Galen College | 26/27 Updated (PDF)
1. A nurse is preparing to assess a patient's mental status. Which component is the priority to
evaluate first?
A) The patient's mood and affect
B) The patient's level of consciousness
C) The patient's remote memory
D) The patient's abstract reasoning abilities
Correct Answer: The patient's level of consciousness
Rationale: Level of consciousness (LOC) is the most fundamental indicator of neurologic function and
must be assessed before any other aspect of the mental status examination. An altered LOC affects
the patient's ability to participate in further cognitive testing, including mood, memory, or abstract
reasoning assessments.
2. In the A, B, C, T framework for mental status assessment, what does the "B" specifically represent?
A) Behavior
B) Breathing
C) Balance
D) Beliefs
Correct Answer: Behavior
Rationale: The A, B, C, T framework organizes the mental status examination into four domains:
Appearance, Behavior, Cognition, and Thought. Behavior encompasses the patient's consciousness,
alertness, and observable actions during the interview.
3. A nurse is assessing a patient's recent memory. Which question is most appropriate for this
evaluation?
,A) "What is your mother's maiden name?"
B) "What did you have for breakfast this morning?"
C) "Who is the current president of the United States?"
D) "Can you repeat these four words back to me now?"
Correct Answer: "What did you have for breakfast this morning?"
Rationale: Recent memory is assessed by asking the patient to recall events from the past 24 hours,
such as what they ate for breakfast. Asking about the president assesses orientation, mother's maiden
name tests remote memory, and immediate repetition tests immediate recall.
4. A patient scores a 12 on the PHQ-9 depression screening tool. The nurse correctly interprets this as
indicating which level of depressive symptoms?
A) Minimal
B) Mild
C) Moderate
D) Severe
Correct Answer: Moderate
Rationale: PHQ-9 scoring ranges are as follows: 0-4 indicates none/minimal, 5-9 mild, 10-14 moderate,
15-19 moderately severe, and 20-27 severe. A score of 12 falls within the moderate range, suggesting
clinically significant depressive symptoms that may warrant treatment.
5. A nurse is assessing a patient's attention span. Which technique is most appropriate for this
evaluation?
A) Asking the patient to interpret a proverb
B) Asking the patient to name the days of the week backward
C) Asking the patient to recall three unrelated words after 5 minutes
D) Asking the patient to describe the plot of a recent movie
, Correct Answer: Asking the patient to name the days of the week backward
Rationale: Attention span is evaluated by observing the patient's ability to focus and follow a
sequence. Asking the patient to name the days of the week backward or to repeat a series of digits
tests attention. Proverb interpretation assesses abstract reasoning, and delayed word recall tests
memory.
6. Which of the following is NOT classified as one of the four most common anxiety disorders?
A) Panic disorder
B) Posttraumatic stress disorder
C) Social anxiety disorder
D) Major depressive disorder
Correct Answer: Major depressive disorder
Rationale: Major depressive disorder is a mood disorder, not an anxiety disorder. The four most
common anxiety disorders include panic disorder, posttraumatic stress disorder (PTSD), social anxiety
disorder, and generalized anxiety disorder. Depression is characterized by persistent sadness and loss
of interest rather than excessive fear or worry.
7. A nurse is using the CAGE questionnaire to screen a patient for alcohol use disorder. What does the
"G" in CAGE represent?
A) Guilt
B) Gaze
C) Grief
D) Gesture
Correct Answer: Guilt
Rationale: The CAGE questionnaire is a screening tool for alcohol use disorder. It consists of four
questions: Have you ever felt you should Cut down on your drinking? Have people Annoyed you by
Galen College | 26/27 Updated (PDF)
1. A nurse is preparing to assess a patient's mental status. Which component is the priority to
evaluate first?
A) The patient's mood and affect
B) The patient's level of consciousness
C) The patient's remote memory
D) The patient's abstract reasoning abilities
Correct Answer: The patient's level of consciousness
Rationale: Level of consciousness (LOC) is the most fundamental indicator of neurologic function and
must be assessed before any other aspect of the mental status examination. An altered LOC affects
the patient's ability to participate in further cognitive testing, including mood, memory, or abstract
reasoning assessments.
2. In the A, B, C, T framework for mental status assessment, what does the "B" specifically represent?
A) Behavior
B) Breathing
C) Balance
D) Beliefs
Correct Answer: Behavior
Rationale: The A, B, C, T framework organizes the mental status examination into four domains:
Appearance, Behavior, Cognition, and Thought. Behavior encompasses the patient's consciousness,
alertness, and observable actions during the interview.
3. A nurse is assessing a patient's recent memory. Which question is most appropriate for this
evaluation?
,A) "What is your mother's maiden name?"
B) "What did you have for breakfast this morning?"
C) "Who is the current president of the United States?"
D) "Can you repeat these four words back to me now?"
Correct Answer: "What did you have for breakfast this morning?"
Rationale: Recent memory is assessed by asking the patient to recall events from the past 24 hours,
such as what they ate for breakfast. Asking about the president assesses orientation, mother's maiden
name tests remote memory, and immediate repetition tests immediate recall.
4. A patient scores a 12 on the PHQ-9 depression screening tool. The nurse correctly interprets this as
indicating which level of depressive symptoms?
A) Minimal
B) Mild
C) Moderate
D) Severe
Correct Answer: Moderate
Rationale: PHQ-9 scoring ranges are as follows: 0-4 indicates none/minimal, 5-9 mild, 10-14 moderate,
15-19 moderately severe, and 20-27 severe. A score of 12 falls within the moderate range, suggesting
clinically significant depressive symptoms that may warrant treatment.
5. A nurse is assessing a patient's attention span. Which technique is most appropriate for this
evaluation?
A) Asking the patient to interpret a proverb
B) Asking the patient to name the days of the week backward
C) Asking the patient to recall three unrelated words after 5 minutes
D) Asking the patient to describe the plot of a recent movie
, Correct Answer: Asking the patient to name the days of the week backward
Rationale: Attention span is evaluated by observing the patient's ability to focus and follow a
sequence. Asking the patient to name the days of the week backward or to repeat a series of digits
tests attention. Proverb interpretation assesses abstract reasoning, and delayed word recall tests
memory.
6. Which of the following is NOT classified as one of the four most common anxiety disorders?
A) Panic disorder
B) Posttraumatic stress disorder
C) Social anxiety disorder
D) Major depressive disorder
Correct Answer: Major depressive disorder
Rationale: Major depressive disorder is a mood disorder, not an anxiety disorder. The four most
common anxiety disorders include panic disorder, posttraumatic stress disorder (PTSD), social anxiety
disorder, and generalized anxiety disorder. Depression is characterized by persistent sadness and loss
of interest rather than excessive fear or worry.
7. A nurse is using the CAGE questionnaire to screen a patient for alcohol use disorder. What does the
"G" in CAGE represent?
A) Guilt
B) Gaze
C) Grief
D) Gesture
Correct Answer: Guilt
Rationale: The CAGE questionnaire is a screening tool for alcohol use disorder. It consists of four
questions: Have you ever felt you should Cut down on your drinking? Have people Annoyed you by
