NSG3160 HEALTH ASSESSMENT EXAM 2
PRACTICE QUESTIONS & ANSWERS
1. During a mental status assessment, which question by the nurse would best assess a person's
judgment?
A. "Do you feel that you are being watched, followed, or controlled?"
B. "What would you do if you found a stamped, addressed envelope lying on the sidewalk?"
C. "What does the statement, 'People in glass houses shouldn't throw stones,' mean to you?"
D. "Tell me what you plan to do once you are discharged from the hospital." ✅
Rationale: Judgment is assessed by evaluating a person’s ability to make reasonable plans for the future.
Asking about discharge plans provides insight into decision-making and judgment.
2. The nurse is conducting a patient interview. Which statement made by the patient should the nurse
more fully explore to assess mental status?
A. "I have no health problems."
B. "I never did too good in school." ✅
C. "I am not currently taking any medications."
D. "I sleep like a baby."
Rationale: Saying "I never did too good in school" may reveal underlying cognitive, learning, or
developmental issues that affect mental status and should be explored further.
3. During an examination, the nurse can best assess mental status by which activity?
A. Observing the patient as he or she performs an intelligence quotient (IQ) test
B. Examining the patient's response to a specific set of questions
C. Observing the patient and inferring health or dysfunction ✅
D. Examining the patient's electroencephalogram
Rationale: Mental status is primarily assessed by observation and inference of behavior, mood, affect,
and thought processes during the interview—not solely by formal testing.
,4. When taking the health history on a patient with a seizure disorder, the nurse assesses whether the
patient has an aura. Which is the best question?
A. "After the seizure, do you spend a lot of time sleeping?"
B. "Do you have any warning sign before your seizure starts?" ✅
C. "Do you experience any color change or incontinence during the seizure?"
D. "Does your muscle tone seem tense or limp?"
Rationale: An aura is a warning sign or sensory experience before a seizure begins, so the best question
is whether the patient notices one.
5. During the assessment of an 80-year-old patient, the nurse notices tremors when reaching and
constant head nodding. No rigidity is observed. Which interpretation is most accurate?
A. These findings are normal, resulting from aging. ✅
B. These findings could be related to hyperthyroidism.
C. These findings are the result of Parkinson’s disease.
D. This patient should be evaluated for a cerebellar lesion.
Rationale: In the elderly, benign tremors and head nodding are normal aging findings, unlike
Parkinson’s disease, which would show rigidity and bradykinesia.
6. A man brought to the ED after wandering is asked to touch the nurse’s finger, then his nose, then
the nurse’s finger again. He is clumsy, overshoots, and misses the finger. The nurse suspects:
A. Cerebral injury
B. Peripheral neuropathy
C. Cerebrovascular accident
D. Acute alcohol intoxication ✅
Rationale: Overshooting during coordination testing (dysmetria) is a common finding in acute alcohol
intoxication due to cerebellar impairment.
7. When assessing the intensity of a patient’s pain, which question is most appropriate?
A. "How does pain limit your activities?"
B. "What does your pain feel like?"
C. "How much pain do you have now?" ✅
D. "What makes your pain better or worse?"
,Rationale: The most direct way to assess intensity is asking the patient to rate pain at the present
moment (e.g., 0–10 scale).
8. The nurse is teaching about pain in older adults. Which statement is correct?
A. "Pain is a normal process of aging and is to be expected."
B. "Pain indicates a pathologic condition or injury and is not a normal process of aging." ✅
C. "Older adults must learn to tolerate pain."
D. "Older individuals perceive pain to a lesser degree than younger adults."
Rationale: Pain in older adults always indicates pathology—it is not a normal part of aging.
9. The nurse interviews a patient. Which statement indicates an alcohol use disorder?
A. "I usually stay out longer and drink more than I intended but I still make it into work on time."
B. "I've been late to work a few times so now I limit myself to 2 drinks/day and stick to it."
C. "I have a strong urge to drink and I've tried to stop drinking several times but it doesn't last long." ✅
D. "I crave alcohol but have successfully cut down on my alcohol consumption."
Rationale: Repeated unsuccessful attempts to stop, despite desire to quit, indicate alcohol use disorder.
10. The nurse assesses a patient with at-risk alcohol use. Which action is most appropriate?
A. "You are drinking more than is medically safe. I strongly recommend that you quit drinking, and I'm
willing to help you." ✅
B. Give the patient information about a local rehabilitation clinic.
C. Record the results and notify the physician.
D. Provide the phone number for Alcoholics Anonymous.
Rationale: The best nursing action is to provide clear, nonjudgmental feedback and offer support to
reduce risky drinking.
11. During a mental status examination, the nurse wants to assess affect. Which question should be
asked?
A. "Have these medications had any effect on your pain?"
B. "Would you please repeat the following words?"
C. "Has this pain affected your ability to get dressed by yourself?"
D. "How do you feel today?" ✅
, Rationale: Asking "How do you feel today?" elicits the patient’s affect and mood, key elements of
mental status.
12. A woman reports her husband has lost memory of recent events after a fall. What should the
nurse do?
A. Integrate mental status exam into physical exam.
B. Reassure wife memory loss is normal after shock.
C. Perform a complete mental status examination. ✅
D. Refer to a psychometrician.
Rationale: Significant memory loss after trauma requires a complete mental status exam for accurate
assessment.
13. The Mini-Mental State Exam (MMSE) is best described as:
A. A useful tool for initial evaluation of mental status, but needs other tools for changes over time.
B. A good tool to evaluate mood and thought processes.
C. A tool to detect delirium and dementia, differentiating from psychiatric illness. ✅
D. Any score below 30 indicates impairment.
Rationale: The MMSE is widely used to screen for cognitive disorders (dementia/delirium) and is not
intended for psychiatric evaluation.
14. An elderly man drinks daily and reports tremors. Which question should the nurse ask first?
A. "Does the tremor change when you drink alcohol?" ✅
B. "We’ll do some tests to see what is causing the tremor."
C. "You shouldn’t drink so much alcohol; it may cause your tremor."
D. "Does your family know you are drinking every day?"
Rationale: Alcohol-related tremors often improve when drinking resumes, suggesting alcohol
dependence.
15. The most reliable indicator of pain is:
A. Patient’s vital signs
B. Subjective report ✅
PRACTICE QUESTIONS & ANSWERS
1. During a mental status assessment, which question by the nurse would best assess a person's
judgment?
A. "Do you feel that you are being watched, followed, or controlled?"
B. "What would you do if you found a stamped, addressed envelope lying on the sidewalk?"
C. "What does the statement, 'People in glass houses shouldn't throw stones,' mean to you?"
D. "Tell me what you plan to do once you are discharged from the hospital." ✅
Rationale: Judgment is assessed by evaluating a person’s ability to make reasonable plans for the future.
Asking about discharge plans provides insight into decision-making and judgment.
2. The nurse is conducting a patient interview. Which statement made by the patient should the nurse
more fully explore to assess mental status?
A. "I have no health problems."
B. "I never did too good in school." ✅
C. "I am not currently taking any medications."
D. "I sleep like a baby."
Rationale: Saying "I never did too good in school" may reveal underlying cognitive, learning, or
developmental issues that affect mental status and should be explored further.
3. During an examination, the nurse can best assess mental status by which activity?
A. Observing the patient as he or she performs an intelligence quotient (IQ) test
B. Examining the patient's response to a specific set of questions
C. Observing the patient and inferring health or dysfunction ✅
D. Examining the patient's electroencephalogram
Rationale: Mental status is primarily assessed by observation and inference of behavior, mood, affect,
and thought processes during the interview—not solely by formal testing.
,4. When taking the health history on a patient with a seizure disorder, the nurse assesses whether the
patient has an aura. Which is the best question?
A. "After the seizure, do you spend a lot of time sleeping?"
B. "Do you have any warning sign before your seizure starts?" ✅
C. "Do you experience any color change or incontinence during the seizure?"
D. "Does your muscle tone seem tense or limp?"
Rationale: An aura is a warning sign or sensory experience before a seizure begins, so the best question
is whether the patient notices one.
5. During the assessment of an 80-year-old patient, the nurse notices tremors when reaching and
constant head nodding. No rigidity is observed. Which interpretation is most accurate?
A. These findings are normal, resulting from aging. ✅
B. These findings could be related to hyperthyroidism.
C. These findings are the result of Parkinson’s disease.
D. This patient should be evaluated for a cerebellar lesion.
Rationale: In the elderly, benign tremors and head nodding are normal aging findings, unlike
Parkinson’s disease, which would show rigidity and bradykinesia.
6. A man brought to the ED after wandering is asked to touch the nurse’s finger, then his nose, then
the nurse’s finger again. He is clumsy, overshoots, and misses the finger. The nurse suspects:
A. Cerebral injury
B. Peripheral neuropathy
C. Cerebrovascular accident
D. Acute alcohol intoxication ✅
Rationale: Overshooting during coordination testing (dysmetria) is a common finding in acute alcohol
intoxication due to cerebellar impairment.
7. When assessing the intensity of a patient’s pain, which question is most appropriate?
A. "How does pain limit your activities?"
B. "What does your pain feel like?"
C. "How much pain do you have now?" ✅
D. "What makes your pain better or worse?"
,Rationale: The most direct way to assess intensity is asking the patient to rate pain at the present
moment (e.g., 0–10 scale).
8. The nurse is teaching about pain in older adults. Which statement is correct?
A. "Pain is a normal process of aging and is to be expected."
B. "Pain indicates a pathologic condition or injury and is not a normal process of aging." ✅
C. "Older adults must learn to tolerate pain."
D. "Older individuals perceive pain to a lesser degree than younger adults."
Rationale: Pain in older adults always indicates pathology—it is not a normal part of aging.
9. The nurse interviews a patient. Which statement indicates an alcohol use disorder?
A. "I usually stay out longer and drink more than I intended but I still make it into work on time."
B. "I've been late to work a few times so now I limit myself to 2 drinks/day and stick to it."
C. "I have a strong urge to drink and I've tried to stop drinking several times but it doesn't last long." ✅
D. "I crave alcohol but have successfully cut down on my alcohol consumption."
Rationale: Repeated unsuccessful attempts to stop, despite desire to quit, indicate alcohol use disorder.
10. The nurse assesses a patient with at-risk alcohol use. Which action is most appropriate?
A. "You are drinking more than is medically safe. I strongly recommend that you quit drinking, and I'm
willing to help you." ✅
B. Give the patient information about a local rehabilitation clinic.
C. Record the results and notify the physician.
D. Provide the phone number for Alcoholics Anonymous.
Rationale: The best nursing action is to provide clear, nonjudgmental feedback and offer support to
reduce risky drinking.
11. During a mental status examination, the nurse wants to assess affect. Which question should be
asked?
A. "Have these medications had any effect on your pain?"
B. "Would you please repeat the following words?"
C. "Has this pain affected your ability to get dressed by yourself?"
D. "How do you feel today?" ✅
, Rationale: Asking "How do you feel today?" elicits the patient’s affect and mood, key elements of
mental status.
12. A woman reports her husband has lost memory of recent events after a fall. What should the
nurse do?
A. Integrate mental status exam into physical exam.
B. Reassure wife memory loss is normal after shock.
C. Perform a complete mental status examination. ✅
D. Refer to a psychometrician.
Rationale: Significant memory loss after trauma requires a complete mental status exam for accurate
assessment.
13. The Mini-Mental State Exam (MMSE) is best described as:
A. A useful tool for initial evaluation of mental status, but needs other tools for changes over time.
B. A good tool to evaluate mood and thought processes.
C. A tool to detect delirium and dementia, differentiating from psychiatric illness. ✅
D. Any score below 30 indicates impairment.
Rationale: The MMSE is widely used to screen for cognitive disorders (dementia/delirium) and is not
intended for psychiatric evaluation.
14. An elderly man drinks daily and reports tremors. Which question should the nurse ask first?
A. "Does the tremor change when you drink alcohol?" ✅
B. "We’ll do some tests to see what is causing the tremor."
C. "You shouldn’t drink so much alcohol; it may cause your tremor."
D. "Does your family know you are drinking every day?"
Rationale: Alcohol-related tremors often improve when drinking resumes, suggesting alcohol
dependence.
15. The most reliable indicator of pain is:
A. Patient’s vital signs
B. Subjective report ✅
