Health Assessment Chapter 5 Mental Status Assessment, Jarvis: Physical Examination and Health Assessment Chapter 4, Jarvis: Physical Examination and Health Assessment Chapter 3, Jarvis: Physical Examination and Health Assessment Chapter 2, Jarvis: Questio

Health Assessment Chapter 5 Mental Status Assessment, Jarvis: Physical Examination and Health Assessment Chapter 4, Jarvis: Physical Examination and Health Assessment Chapter 3, Jarvis: Physical Examination and Health Assessment Chapter 2, Jarvis: Questions ad answers. Accurate Document Content and Description Below Health Assessment Chapter 5 Mental Status Assessment, Jarvis: Physical Examination and Health Assessment Chapter 4, Jarvis: Physical Examination and Health Assessment Chapter 3, Jarvis: Physical Exami nation and Health Assessment Chapter 2, Jarvis: Questions ad answers. Accurate What is the maximum score given to a patient in the Mini-Mental State Examination (MMSE)? 1. 5 2. 20 3. 25 4. 30 - ☑☑4 The nurse is caring for a child with posttraumatic stress disorder (PTSD). Which other condition is the patient susceptible to develop as a result of the PTSD? 1 Anxiety 2 Delirium 3 Dementia 4 Alzheimer disease - ☑☑1 A patient asks, "Where is that thing I use to read the newspaper?" and the nurse figures out that the patient wants glasses. Which thought process abnormality is this an example of? 1 Perseveration 2 Confabulation 3 Circumlocution 4 Circumstantiality - ☑☑3 When should an infant be tested for language development skills using a one-word sentence? 1. 1 year 2. 2 years 3. 4 weeks 4. 6 weeks - ☑☑1 While assessing a patient in the intensive care unit, the nurse observes that the patient is responding to touch only on persistent and vigorous shaking. The nurse also notices that the patient withdraws both hands when pressure is applied to the nail beds. What does the nurse conclude from these findings? 1 The patient is in a coma. 2 The patient is lethargic. 3 The patient is in a semi-coma. 4 The patient is in an acute confusional state. - ☑☑3 Which findings of a mental status examination of an adolescent patient are considered normal? Select all that apply. 1 The patient has darting, watchful eyes. 2 The patient has a flat, masklike facial expression. 3 The patient has a moderate pace of conversation. 4 The patient has tattoos and piercings on the body. 5 The patient has worn jeans that are torn at the knees. - ☑☑3, 4, 5 Which mental disorder is associated with agnosia? 1 Anxiety 2 Hallucinations 3 Dementia 4 Depression - ☑☑3 The nurse is assessing a patient with anxiety and depression using the Generalized Anxiety Disorder (GAD) scale. After assessment, the nurse concludes that the patient has moderate levels of anxiety. What was the patient's score on the GAD scale? 1. 0 2. 5 3. 10 4. 15 - ☑☑3 Which emotional characteristics are common in a patient with clinical depression? Select all that apply. 1 Irritability 2 Aggression 3 Rapid mood swings 4 Hallucinations 5 Extreme sadness - ☑☑1, 5 The nurse is performing a mental status assessment using the Mini-Cog tests in an older adult patient. The nurse observes that the patient is able to recall all three words that were stated to the patient as a part of the test. The patient, however, draws an abnormal clock with misplaced numbers, and presents the hour hand and minute hand in the wrong position. What does the nurse conclude from these findings? 1 The patient has dementia. 2 The patient has depression. 3 The patient has confusion. 4 The patient has cognitive impairment. - ☑☑4 What characteristic abnormality can be observed in a child with oppositional defiant disorder (ODD)? 1 Elation 2 Lability 3 Euphoria 4 Irritability - ☑☑4 Which disability will be seen in a patient with organic dementia? 1 The patient recalls events only from his or her childhood. 2 The patient remembers only most recent events. 3 The patient demonstrates unilateral neglect. 4 The patient has expressive and receptive aphasia. - ☑☑1 The patient visits the hospital for a routine health checkup, claims to be extremely sick, and expresses the desire to be admitted to the hospital. The test results of the patient are all normal. Which mental disorder does the nurse expect to find in the patient? 1 Hallucination 2 Perseveration 3 Circumlocution 4 Hypochondriasis - ☑☑4 During a conversation, the nurse finds that a 9-year-old child has incomprehensible and jumbled language. The nurse also observes that the child uses new words that have no real meaning. Which thought process abnormality does the child exhibit? 1 Word salad 2 Confabulation 3 Circumstantiality 4 Loosening associations - ☑☑1 What does the nurse infer if a patient scores a 12 on the Patient Health Questionnaire-9 (PHQ-9)? 1 Minor depression 2 Chronic depression 3 Major depression, severe 4 Major depression, moderately severe - ☑☑1 The nurse is planning to assess a preschool child's mental status. Which assessment tool should the nurse use to determine if the child has a developmental delay? 1 The Mini-Cog test 2 Denver II screening test 3 Patient Health Questionnaire-9 (PHQ-9) 4 Mini-Mental State Examination (MMSE) - ☑☑2 The nurse is caring for a patient who has difficulty understanding language. Which condition does the nurse expect in the patient? 1 Dysphonia 2 Dysarthria 3 Receptive aphasia 4 Expressive aphasia - ☑☑3 What are the different organic mental disorders? Select all that apply. 1 Anxiety 2 Delirium 3 Schizophrenia 4 Alcohol intoxication 5 Drug intoxication - ☑☑2, 4, 5 During a mental status assessment, the nurse asks about the patient's first job. What is the nurse trying to test? 1 Orientation 2 Attention span 3 Recent memory 4 Remote memory - ☑☑4 A patient is diagnosed with agoraphobia. Which characteristic behavior would the nurse observe in the patient? 1 The patient feels reluctant to leave home. 2 The patient has difficulty in making decisions. 3 The patient washes his or her hands every 15 minutes. 4 The patient has a debilitating fear of enclosed spaces - ☑☑1 The nurse observes that a patient's caregiver wears bizarre makeup and eccentric clothing during every visit to the hospital. The patient also talks loudly and continuously, and the speech is too fast to be comprehended. Which mental disorder might the nurse expect in the caregiver? 1 Depression 2 Manic syndrome 3 Alzheimer disease 4 Organic brain syndrome - ☑☑2 During an interview, the nurse asks an older adult patient to describe childhood teachers, first job, and important dates in life. Which cognitive function is the nurse assessing in the patient? 1 Orientation 2 Attention span 3 Recent memory 4 Remote memory - ☑☑4 The nurse is using the Patient Health Questionnaire-9 (PHQ-9) to screen a patient who has depression. The patient scores 13 on the test. What does the nurse infer from the test result? 1 The patient has minor depression. 2 The patient has chronic depression. 3 The patient has severe major depression. 4 The patient has moderately severe major depression. - ☑☑1 After performing the Four Unrelated Words Test for a patient, the nurse concludes that the patient has Alzheimer dementia. What must be the word recall score of this patient? Select all that apply. 1. 0 2. 1 3. 2 4. 3 5. 4 - ☑☑1, 2 During an assessment, the nurse finds that an adolescent patient's body mass index is 18.4. The patient's caregiver states that the patient is extremely afraid of weight gain and barely eats for 4 days a week. Which disorder does the nurse suspect in the patient? 1 Bulimia nervosa 2 Anorexia nervosa 3 Autism spectrum disorder 4 Oppositional defiant disorder - ☑☑2 The nurse is caring for a patient who is at a moderate stage of Alzheimer disease. The nurse determines that the patient has impaired memory and abstract thinking ability. Which other assessment findings will the nurse expect in this patient? Select all that apply. 1 Agnosia 2 Agitation 3 Aggression 4 Paranoid ideation 5 Unaltered level of consciousness - ☑☑1, 2, 5 The nurse is caring for a patient with generalized anxiety disorder. Which associated physiologic complications does the nurse expect in the patient? Select all that apply. 1 Diarrhea 2 Tachypnea 3 Nausea 4 Sweating 5 Sleep disturbance - ☑☑1, 2 , 5 A patient tells the nurse, "My favorite activity is to asteldish. And then sometimes I take my oddley and schmake with it." Which abnormality does the patient exhibit? 1 Echolalia 2 Neologism 3 Perseveration 4 Circumstantiality - ☑☑2 While assessing a child, the nurse finds that the child is unable to follow directions and has trouble staying alert. The child's parents report that the child also talks excessively. Which disorder does the nurse suspect? 1 Eating disorder 2 Autism spectrum disorder 3 Oppositional defiant disorder 4 Attention deficit hyperactivity disorder - ☑☑4 The nurse is caring for a patient who has stage IV cancer and is undergoing chemotherapy. The prognosis is terminal, and the patient is being transferred to hospice care. This patient has no history of mood disorders. While communicating with the nurse, the patient says, "I am on top of the world and feel so free and happy." Which mood and affect abnormality does the nurse suspect in this patient? 1 Anxiety 2 Lability 3 Euphoria 4 Depersonalization - ☑☑3 Which disorder is characterized by intrusive thoughts and ritualistic behaviors? 1 Social anxiety disorder 2 Generalized anxiety disorder 3 Posttraumatic stress disorder 4 Obsessive-compulsive disorder - ☑☑4 The nurse performing a cognitive assessment asks the patient about the date and time. What does the nurse intend to assess in the patient? 1 Orientation 2 Thought process 3 Thought content 4 Remote memory - ☑☑1 A husband tells the nurse that his wife worries excessively about dirt, germs, and chemicals in food and clothes. He explains that she also washes her hands every 10 minutes to prevent contracting any infection. What does the nurse infer about the wife? 1 The patient has delusions. 2 The patient has an obsession. 3 The patient has a compulsion. 4 The patient has hypochondriasis. - ☑☑2 What information should the nurse obtain from the patient's health history while assessing the cognitive status of that patient? Select all that apply. 1 Dietary habits 2 Exercise habits 3 Educational levels 4 Current medication 5 Current health problems - ☑☑3, 4, 5 While collecting the medical history of a patient with cancer, the nurse finds that the patient is laughing for no evident reason. What mood and affect disorder does this behavior indicate? 1 Elation 2 Euphoria 3 Depersonalization 4 Inappropriate affect - ☑☑4 A patient tells the nurse about being extremely fearful of dogs. The patient has stopped going to the park to take walks because of this. What does the nurse conclude from this finding? 1 The patient has agoraphobia. 2 The patient has a specific phobia. 3 The patient has a generalized anxiety disorder. 4 The patient has obsessive-compulsive disorder. - ☑☑2 The patient tells the nurse, "I often hear my dead grandfather's voice." What does the nurse infer from the patient's statement? 1 The patient has illusions. 2 The patient has delusions. 3 The patient has flight of ideas. 4 The patient has hallucinations. - ☑☑4 What does the nurse infer if a patient scores a 12 on the Patient Health Questionnaire-9 (PHQ-9)? 1 Minor depression 2 Chronic depression 3 Major depression, severe 4 Major depression, moderately severe - ☑☑1 Which condition is seen in a patient with aphasia? 1 Inability to smell any fragrances, odors, or aromas 2 Inability to comprehend or express verbal language 3 An inappropriate attention span and impulsiveness 4 Inability to perform a purposeful act on command - ☑☑2 The nurse is assessing a patient who sustained a leg injury due to a motor vehicle accident. When asked about the mechanism of injury, the patient said, "I was crossing the street, then met my friend. Then my leg started bleeding profusely." The patient's caregiver explains that the patient was hit by a car while crossing the road, and never met the friend. Which though process abnormality does the patient exhibit? 1 Flight of ideas 2 Confabulation 3 Circumstantiality 4 Loosening associations - ☑☑2 During an assessment, the nurse finds that a 5-year-old child has distorted speech. The child misuses certain words and omits other words while speaking. Which disorder does the nurse expect in the child? 1 Echolalia 2 Dysarthria 3 Dysphonia 4 Neologism - ☑☑2 Which mental disorders are observed in children? Select all that apply. 1 Delusions 2 Dementia 3 Alzheimer disease 4 Autism spectrum disorder 5 Attention-deficit hyperactivity disorder (ADHD) - ☑☑4, 5 The nurse tells the patient, "You should turn off the lights and sleep now." The patient mockingly mumbles, "Turn off the lights and sleep now. Turn off the lights and sleep now." What does the nurse infer from this behavior? 1 The patient exhibits echolalia. 2 The patient exhibits neologism. 3 The patient exhibits perseveration. 4 The patient exhibits circumstantiality. - ☑☑1 Which mental disorder causes a gradual decrease in the patient's cognitive functioning? 1 Delirium 2 Dementia 3 Depression 4 Anxiety disorder - ☑☑2 Which assessment tool does the nurse use to assess the level of consciousness of an older adult with confusion? 1 The Mini-Cog test 2 Denver II screening test 3 The Glasgow Coma Scale 4 Generalized Anxiety Disorder (GAD) scale - ☑☑3 The nurse is assessing the cognitive functioning of a patient using the Mini-Mental State Examination (MMSE). The patient scores 27 on the examination. What does the nurse infer from the score? 1 The patient has a normal mental status. 2 The patient has mild cognitive impairment. 3 The patient has severe cognitive impairment. 4 The patient has moderate cognitive impairment. - ☑☑1 The nurse is performing the Mini-Mental State Examination (MMSE) in a patient and confirms that the patient has mild cognitive impairment. What must be the score given to this patient? 1. 7 2. 22 3. 25 4. 27 - ☑☑2 What is the nurse assessing when using the Glasgow Coma Scale? 1 Memory, computation, and level of consciousness 2 Reading, writing, and knowing factual information 3 Level of consciousness and involuntary movement 4 Eye opening, verbal response, and motor response - ☑☑4 While assessing a preschool child, the nurse finds that the child shows strict adherence to routines. Which other findings would confirm that the child has autism spectrum disorder? Select all that apply. 1 Irritable mood 2 Poor eye contact 3 Repetitive speech 4 Aggressive behaviors 5 Short attention span - ☑☑2, 3 A patient reports having difficulty sleeping and concentrating. During the interview, the nurse finds out that the patient's father died suddenly in an accident that the patient witnessed a few days earlier. The nurse observes that the patient gets startled even at the sound of knock on the door. Which condition does the nurse suspect in this patient? 1 Panic attack 2 Specific phobia 3 Generalized anxiety disorder 4 Posttraumatic stress disorder (PTSD) - ☑☑4 The patient tells the nurse, "I am the almighty and your creator. You all must do as I say; I am your ruler." Which thought content abnormality does the patient exhibit? 1 Delusions 2 Obsessions 3 Compulsions 4 Hypochondriasis - ☑☑1 The nurse is assessing a patient with schizophrenia. The nurse finds that the patient starts communicating and abruptly stops speaking in the middle of a conversation. Which thought process abnormality does the patient exhibit? 1 Blocking 2 Echolalia 3 Flight of ideas 4 Circumlocution - ☑☑1 The nurse is assessing an elderly patient for a possible fractured tibia after a fall. The nurse asks when the fall occurred, and the patient responds with a discussion about how much it snowed last night, where the patient went, what the patient was wearing, and how much the meal cost. What does this response indicate? 1 Blocking 2 Delusions 3 Neologisms 4 Confabulation - ☑☑4 The nurse uses the Mini-Cog instrument to test the cognitive ability of a patient and declares that the patient has dementia. How many words did the patient recall? 1 One word 2 Two words 3 Zero words 4 Three words - ☑☑3 What are the common consequences of age-related hearing loss in an older adult patient? Select all that apply. 1 The patient may develop anxiety. 2 The patient may be frustrated. 3 The patient may become aggressive. 4 The patient may become socially isolated. 5 The patient may develop suspicious behavior. - ☑☑2, 4, 5 What are the characteristic features of a patient with Parkinson's disease? Select all that apply. 1 Loud talking 2 Pressurized talking 3 Masklike expression 4 Monotonous speech 5 Failure in word search - ☑☑3, 4, 5 Which factors may cause delirium? Select all that apply. 1 Crises 2 Loneliness 3 Hypoglycemia 4 Hypotension 5 Head injury - ☑☑3, 4, 5 The nurse is caring for a patient with a brain tumor and observes that the patient is reviewing the scan report every 10 minutes. What might be the reason for this behavior? 1 Phobia 2 Obsession 3 Compulsion 4 Hypochondriasis - ☑☑3 A full mental status examination should be completed if the patient: A. has a change in behavior and the family is concerned. B. develops dysphagia. C. has a new diagnosis of type 2 diabetes mellitus. D. complains of insomnia. - ☑☑A Aphasia is best described as: A. a language disturbance in speaking, writing, or understanding. B. the impaired ability to carry out motor activities despite intact motor function. C. the impaired ability to recognize or identify objects despite intact sensory function. D. a disturbance in executive functioning (planning, organizing, sequencing, abstracting). - ☑☑A A patient in whom a seizure disorder was recently diagnosed plans to continue a career as a pilot. At this time in the interview, the nurse begins to question the patient's: A. thought process. B. judgment. C. perception. D. intellect. - ☑☑B A major characteristic of dementia is: A. impaired short-term and long-term memory. B. hallucinations. C. sudden onset of symptoms. D. cognitive deficits that are substance-induced. - ☑☑A Mental status assessment documents: A. emotional and cognitive functioning. B. intelligence and educational level. C. artistic or writing ability in the mentally ill person. D. schizophrenia and other mental health disorders. - ☑☑A Although a full mental status examination may not be required for every patient, the health care provider must address the four main components during a health history and physical examination. The four components are: A. memory, attention, thought content, and perceptions. B. language, orientation, attention, and abstract reasoning. C. appearance, behavior, cognition, and thought processes. D. mood, affect, consciousness, and orientation. - ☑☑C An older adult: A. experiences a 10-point decrease in intelligence. B. has diminished recent and remote memory recall. C. has a slower response time. D. has difficulty with problem solving. - ☑☑C Which of the following statements about mental status testing of children is correct? A. The results of the Denver II screening test are valid for white, middle-class children only. B. The behavioral checklist is useful to assess children who are 3 to 5 years old. C. Abnormal findings are usually related to not achieving an expected developmental milestone. D. Input from parents and caretakers is discouraged when assessing psychosocial development. - ☑☑C Which of the following best illustrates an abnormality of thought process? A. Lability B. Blocking C. Compulsion D. Aphasia - ☑☑B The mental status examination: A. should be completed at the end of the physical examination. B. will not be affected if the patient has a language impairment. C. is usually not assessed in children younger than 2 years of age. D. assesses mental health strengths and coping skills and screens for any dysfunction. - ☑☑D D - ☑☑The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history? a. To provide an opportunity for interaction between the patient and the nurse b. To provide a form for obtaining the patients biographic information c. To document the normal and abnormal findings of a physical assessment d. To provide a database of subjective information about the patients past and current health B - ☑☑Wh