NURS 2900 Final Exam Questions with Correct
Answers
Purpose of Mental Health Assessment Correct Answer ✓✓ Establish
rapport between pt. & nurse, Risk factors, Goals for treatment, Form
plan of care: consideration of cultural health care beliefs/practices/food,
safety for patient and others, (don't dismiss physical part of examination)
Mental Status Examination (MSE) Correct Answer ✓✓ Psychological
equivalent of a physical exam, Describes mental state & behaviors,
Objective observations of MD & subjective descriptions of pt., LOC,
Cognitive & intellectual abilities: orientation, memory, abstract thinking,
ability to calculate, rate/volume of speech, language quality
Level of Consciousness (Mental Status Examination) Correct Answer
✓✓ Alert, lethargic, stuporous, Comatose: abnormal posturing
Decorticate Correct Answer ✓✓ flexion-internal rotation of upper
extremity/joint/legs
decerebrate Correct Answer ✓✓ extension-neck/elbow extension
Physical Appearance: (Mental Status Examination) Correct Answer ✓✓
Note personal hygiene, grooming, & clothing choice; Mentally healthy
individual would be dressed/groomed appropriately for the environment
,Behavior (Mental Status Examination) Correct Answer ✓✓ Voluntary
& involuntary body movements/eye contact, Mood, affect: objective
expression of mood. Flat affect or lack of facial expression
Cognitive & intellectual abilities (Mental Status Examination) Correct
Answer ✓✓ -Orientation: time, place, person
-Memory: recent & remote
-Level of knowledge: what they know about current illness
-Ability to calculate: count backwards for 100 by 7
-Judgement based on hypothetical question: "What would you do if there
was fire?" Should provide logical answer
Standard Mental Health Screening Tools Correct Answer ✓✓ -Mini-
mental state examination (MMSE)
-Glasgow Coma Scale: Eye 4 levels, Verbal 5 levels, & Motor 6 levels.
Higher # is better
Mini-Mental State Examination (MMSE) Correct Answer ✓✓ -
Cognitive function can decline as a result of certain risk factors (HTN,
elevated cholesterol, cardiac arrhythmias) = adversely impacts
functioning and quality of life of older adults
-Assess pts., Cognitive status, orientation to time/place, Attention span,
Calculate by counting backward, Registration & recall of object,
language such as naming objects/following commands, Ability to write
,Lab tests for mental status Correct Answer ✓✓ Blood, urine, CBC,
BMP
Children & Adolescents Mental Health Assessment Correct Answer ✓✓
-Can have mental health problems as adults
-Mental health & developmental disorders not always easily diagnosed=
delays treatment/interventions
-Assess mood, anxiety, developmental, behavioral, & eating disorders
-At risk for self-injury (cutting) or suicide
Older Adults Assessment Correct Answer ✓✓ -Functional ability: how
independent are they, dressing, household tasks, use of stairs
-Standardized Assessments: Geriatric Depression Scale, Michigan
Alcoholism Screening Test
-MMSE, pain scales, pain assessment in advanced dementia (PAINAD)
When performing mental health assessment/interview: Correct Answer
✓✓ Quiet space, Introduce self & ask what pt. wants to be called, Sit or
stand at pts. level, Personal space, ask pt. before touching, medication
history, Questions r/t difficulty sleeping, falls/injuries, depression,
dizziness, lack of energy, Include family or significant others
Hamilton Anxiety Rating Scale (HAM-A) Correct Answer ✓✓ Rating
scale for anxiety (0-4)
, Diagnostic & Statistical Manual of Mental Health Disorders (DSM-5)
Correct Answer ✓✓ -Identifies diagnoses
-Diagnostic criteria to guide assessment
GCS (glasgow coma scale) Correct Answer ✓✓ BL assessment of LOC:
eye, verbal, and motor response (15-8): lower = coma
Counseling Correct Answer ✓✓ -Therapeutic communication skills
-Assist w/ problem solving & crisis intervention
Milieu Therapy Interventions Correct Answer ✓✓ -Orienting pt. to
physical setting
-Identify rules/boundaries
-Ensure safe environment
-Assist pt. to participate in activities
How does Milieu Therapy create a safe/therapeutic environment?
Correct Answer ✓✓ - Prevents self-destructive behavior
- Client is in therapeutic environment in which they learn tools necessary
to cope adaptively, interact more effectively and appropriately, and
strengthen relationship skills w/ others
- Nurse = manager of care, structure the aspects of therapeutic milieu,
each nurse is assigned a specific client = consistent approach to
interactions
Answers
Purpose of Mental Health Assessment Correct Answer ✓✓ Establish
rapport between pt. & nurse, Risk factors, Goals for treatment, Form
plan of care: consideration of cultural health care beliefs/practices/food,
safety for patient and others, (don't dismiss physical part of examination)
Mental Status Examination (MSE) Correct Answer ✓✓ Psychological
equivalent of a physical exam, Describes mental state & behaviors,
Objective observations of MD & subjective descriptions of pt., LOC,
Cognitive & intellectual abilities: orientation, memory, abstract thinking,
ability to calculate, rate/volume of speech, language quality
Level of Consciousness (Mental Status Examination) Correct Answer
✓✓ Alert, lethargic, stuporous, Comatose: abnormal posturing
Decorticate Correct Answer ✓✓ flexion-internal rotation of upper
extremity/joint/legs
decerebrate Correct Answer ✓✓ extension-neck/elbow extension
Physical Appearance: (Mental Status Examination) Correct Answer ✓✓
Note personal hygiene, grooming, & clothing choice; Mentally healthy
individual would be dressed/groomed appropriately for the environment
,Behavior (Mental Status Examination) Correct Answer ✓✓ Voluntary
& involuntary body movements/eye contact, Mood, affect: objective
expression of mood. Flat affect or lack of facial expression
Cognitive & intellectual abilities (Mental Status Examination) Correct
Answer ✓✓ -Orientation: time, place, person
-Memory: recent & remote
-Level of knowledge: what they know about current illness
-Ability to calculate: count backwards for 100 by 7
-Judgement based on hypothetical question: "What would you do if there
was fire?" Should provide logical answer
Standard Mental Health Screening Tools Correct Answer ✓✓ -Mini-
mental state examination (MMSE)
-Glasgow Coma Scale: Eye 4 levels, Verbal 5 levels, & Motor 6 levels.
Higher # is better
Mini-Mental State Examination (MMSE) Correct Answer ✓✓ -
Cognitive function can decline as a result of certain risk factors (HTN,
elevated cholesterol, cardiac arrhythmias) = adversely impacts
functioning and quality of life of older adults
-Assess pts., Cognitive status, orientation to time/place, Attention span,
Calculate by counting backward, Registration & recall of object,
language such as naming objects/following commands, Ability to write
,Lab tests for mental status Correct Answer ✓✓ Blood, urine, CBC,
BMP
Children & Adolescents Mental Health Assessment Correct Answer ✓✓
-Can have mental health problems as adults
-Mental health & developmental disorders not always easily diagnosed=
delays treatment/interventions
-Assess mood, anxiety, developmental, behavioral, & eating disorders
-At risk for self-injury (cutting) or suicide
Older Adults Assessment Correct Answer ✓✓ -Functional ability: how
independent are they, dressing, household tasks, use of stairs
-Standardized Assessments: Geriatric Depression Scale, Michigan
Alcoholism Screening Test
-MMSE, pain scales, pain assessment in advanced dementia (PAINAD)
When performing mental health assessment/interview: Correct Answer
✓✓ Quiet space, Introduce self & ask what pt. wants to be called, Sit or
stand at pts. level, Personal space, ask pt. before touching, medication
history, Questions r/t difficulty sleeping, falls/injuries, depression,
dizziness, lack of energy, Include family or significant others
Hamilton Anxiety Rating Scale (HAM-A) Correct Answer ✓✓ Rating
scale for anxiety (0-4)
, Diagnostic & Statistical Manual of Mental Health Disorders (DSM-5)
Correct Answer ✓✓ -Identifies diagnoses
-Diagnostic criteria to guide assessment
GCS (glasgow coma scale) Correct Answer ✓✓ BL assessment of LOC:
eye, verbal, and motor response (15-8): lower = coma
Counseling Correct Answer ✓✓ -Therapeutic communication skills
-Assist w/ problem solving & crisis intervention
Milieu Therapy Interventions Correct Answer ✓✓ -Orienting pt. to
physical setting
-Identify rules/boundaries
-Ensure safe environment
-Assist pt. to participate in activities
How does Milieu Therapy create a safe/therapeutic environment?
Correct Answer ✓✓ - Prevents self-destructive behavior
- Client is in therapeutic environment in which they learn tools necessary
to cope adaptively, interact more effectively and appropriately, and
strengthen relationship skills w/ others
- Nurse = manager of care, structure the aspects of therapeutic milieu,
each nurse is assigned a specific client = consistent approach to
interactions
