Chapter 05: Mental Status Assessment

Chapter 05: Mental Status Assessment When examining a patient, the nurse can assess mental status by: 1.examining the patient's electroencephalogram. 2.observing the patient as he or she performs an IQ test. 3.obse ...

Chapter 05: Mental Status Assessment When examining a patient, the nurse can assess mental status by: 1.examining the patient's electroencephalogram. 2.observing the patient as he or she performs an IQ test. 3.observing the patient and inferring health or dysfunction. 4.examining the patient's response to a specific set of questions. ans: ANS: 3 Mental status cannot be scrutinized directly like the characteristics of skin or heart sounds. Its functioning is inferred through assessment of an individual's behavior. The nurse is assessing mental status in children. Which of the following statements is true? 1.All aspects of mental status in children are interrelated. 2.Children are highly labile and unstable until the age of 2 years. 3.Children's mental status is largely a function of their parents' level of functioning until the age of 7 years. 4.Children's mental status is impossible to assess until the child develops the ability to concentrate. ans: ANS: 1 It is difficult to separate and trace the development of just one aspect of mental status. All aspects are interdependent. For example, consciousness is rudimentary at birth because the cerebral cortex is not yet developed. The infant cannot distinguish the self from the mother's body. The nurse is assessing a 75-year-old man. As the nurse beings the mental status portion of the assessment, the nurse expects that this patient: 1.will have no decrease in any of his abilities, including response time. 2.will have difficulty on tests of remote memory because this typically decreases with age. 3.may take a little longer to respond, but his general knowledge and abilities should not have declined. 4.will have had a decrease in his response time because of language loss and a decrease in general knowledge. ans: ANS: 3 The aging process leaves the parameters of mental status mostly intact. There is no decrease in general knowledge and little or no loss in vocabulary. Response time is slower than in youth. It takes a bit longer for the brain to process information and react to it. When assessing aging adults, the nurse knows that one of the first things that should be assessed before making judgments about their mental status is: 1.the presence of phobias. 2.their general intelligence. 3.the presence of irrational thinking patterns. 4.their sensory-perceptive abilities. ans: ANS: 4 Age-related changes in sensory perception can affect mental status. For example, vision loss (as detailed in Chapter 14) may result in apathy, social isolation, and depression. Hearing changes are common in older adults. This problem produces frustration, suspicion, and social isolation and makes the person look confused. Which of the following statements is true regarding the mental status examination? 1.A patient's family is the best resource for information about the patient's coping skills. 2.It is usually sufficient to gather mental status information during the health history interview. 3.It takes an enormous amount of extra time to integrate the mental status examina- tion into the health history interview. 4.It is usually necessary to perform a complete mental status examination to get a good idea of the patient's level of functioning. ans: ANS: 2 The full mental status examination is a systematic check of emotional and cognitive functioning. The steps described here, though, rarely need to be taken in their entirety. Usually, one can assess mental status through the context of the health history interview. A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse's best course of action? 1.The nurse should plan to perform a complete mental status examination. 2.It would be most appropriate to refer him to a psychometrician. 3.The nurse should plan to integrate the mental status examination into the history and physical examination. 4.The nurse should reassure his wife that memory loss after a physical shock is normal and will subside soon. ans: ANS: 1 It is necessary to perform a full mental status examination when any abnormality in affect or behavior is discovered and in the following situation: family members are concerned about a person's behavioral changes (e.g., memory loss, inappropriate social interaction). In an interview with a patient, it will be important for the nurse to ascertain some basic history information. Which of the following statements should be explored more fully during an interview? The patient states that he: 1."sleeps like a baby." 2.has no health problems. 3."never did too good in school." 4.is currently not taking any medication. ans: ANS: 3 In every mental status examination, note these factors from the health history that could affect the findings: any known illnesses or health problems, such as alcoholism or chronic renal disease; current medications, the side effects of which may cause confusion or depression; the usual educational and behavioral level—note that factor as the normal baseline and do not expect performance on the mental status examination to exceed it; and responses to personal history questions, indicating current stress, social interaction patterns, and sleep habits. A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient's speech is dysarthric and that she is lethargic. The nurse's best approach regarding this examination is to: 1.plan to defer the rest of the mental status examination. 2.skip the language portion of the examination and go on to assess mood and affect. 3.do an in-depth speech evaluation and defer the mental status examination to another time.