HEATH ASSESSMENT COMPLETE | Questions and Answers 2024
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Nursing \\OBGYN
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Nursing \\OBGYN
HEATH ASSESSMENT COMPLETE | Questions and Answers 2024
The nurse is administering a Mini-Cog test to an older adult woman. When asked to draw a clock showing the time of 10:45, the patient drew a clock with the numbers out of order and with an incorrect time. This result indicates which finding?...
HEATH ASSESSMENT COMPLETE | Questions and
Answers 2024
The nurse is administering a Mini-Cog test to an older adult woman. When asked to
draw a clock showing the time of 10:45, the patient drew a clock with the numbers out of
order and with an incorrect time. This result indicates which finding?
*Amnesia
*Delirium
*Cognitive impairment
*Attention-deficit disorder. ** Answ** Cognitive impairment
During morning rounds, the nurse asks a patient, "How are you today?" The patient
responds, "You today, you today, you today!" and mumbles the words. This is an
example of which speech pattern?
*Echolalia
*Clanging
*Word salad
*Perseveration ** Answ** Echolalia
The nurse is assessing a patient who is admitted with possible delirium. Which of these
are manifestations of delirium? (Select all that apply.)
*Person experiences agnosia
*Person demonstrates apraxia
*Develops over a short period,
*Person exhibits memory impairment or deficits
* Occurs as a result of a medical condition, such as systemic infection ** Answ**
*Develops over a short period
*Person exhibits memory impairment or deficits
*Occurs as a result of a medical condition, such as systemic infection
A woman has come to the clinic to seek help with a substance-abuse problem. She
admits to using cocaine just before arriving.Which of these assessment findings would
the nurse expect to find when examining this woman?
*Dilated pupils,pacing and psychomotor agitation
*Dilated pupils,unsteady gait, and aggressiveness ** Answ** * Dilated pupils,
pacing, and psychomotor agitation
Pupil constriction, lethargy, apathy, and dysphoria During an examination, the nurse can
assess mental status by which activity?
*Examining the patient's electroencephalogram,
*Observing the patient as he or she performs an intelligence quotient (IQ) test,
*Observing the patient and inferring health or dysfunction,
,*Examining the patient's response to a specific set of questions ** Answ**
*Observing the patient and inferring health or dysfunction
The nurse is assessing the mental status of a child. Which statement about children and
mental status is true?
*All aspects of mental status in children are interdependent.
*Children are highly labile and unstable until the age of 2 years.
*A child's mental status is impossible to assess until the child develops the ability to
concentrate.
*Children's mental status is largely a function of their parents' level of functioning until
the age of 7 years. ** Answ** *All aspects of mental status in children are
interdependent.
The nurse is assessing a 75-year-old man. What should the nurse expect when
performing the mental status portion of the assessment? *Will have no decrease in any
of his abilities, including response time.
*Will have difficulty on tests of remote memory because this ability typically decreases
with age.
*May take a little longer to respond, but his general knowledge and abilities should not
have declined.
*Will exhibit a decrease in his response time because of the loss of language and a
decrease in general knowledge. ** Answ** *May take a little longer to respond, but
his general knowledge and abilities should not have declined
When assessing aging adults, what is one of the first things the nurse should assess
before making judgments about the aging person's mental status? *Presence of phobias
*General intelligence
*Sensory-perceptive abilities
*Presence of irrational thinking patterns ** Answ** *Sensory-perceptive abilities
The nurse is preparing to conduct a mental status examination. Which statement is true
regarding the mental status examination?
*A patient's family is the best resource for information about the patient's coping skills.
*Gathering mental status information during the health history interview is usually
sufficient.
*Integrating the mental status examination into the health history interview takes an
enormous amount of extra time.
*To get a good idea of the patient's level of functioning, performing a complete mental
status examination is usually necessary. ** Answ** *Gathering mental status
information during the health history interview is usually sufficient.
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?
*Perform a complete mental status examination.
*Refer him to a psychometrician.
,* Plan to integrate the mental status examination into the history and physical
examination.
*Reassure his wife that memory loss after a physical shock is normal and will soon
subside. ** Answ** *Perform a complete mental status examination.
The nurse is conducting a patient interview. Which statement made by the patient
should the nurse more fully explore to assess the mental status during the interview?
*"I sleep like a baby."
*"I have no health problems."
*"I never did too good in school."
* "I am not currently taking any medications." ** Answ** *"I never did too good in
school."
A patient is admitted to the unit after an automobile accident. The nurse begins the
mental status examination and finds that the patient has dysarthric speech and is
lethargic. How should the nurse proceed?
*Defer the rest of the mental status examination.
*Skip the language portion of the examination and proceed onto assessing mood and
affect.
*Conduct an in-depth speech evaluation and defer the mental status examination to
another time.
*Proceed with the examination and assess the patient for suicidal thoughts ** Answ**
*Defer the rest of the mental status examination.
A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing
black combat boots and a black lace nightgown over the top of her other clothes. Her
hair is dyed pink with black streaks throughout. She has several pierced holes in her
nares and ears and is wearing an earring through her eyebrow and heavy black
makeup. Which is an appropriate conclusion for the nurse draw?
*She probably does not have any problems.
*She is only trying to shock people and that her dress should be ignored.
* She has a manic syndrome because of her abnormal dress and grooming.
* More information should be gathered to decide whether her dress is appropriate. **
Answ** *More information should be gathered to decide whether her dress is
appropriate.
A patient has been in the intensive care unit for 10 days. He has just been moved to the
medical-surgical unit, and the admitting nurse is planning to perform a mental status
examination. What should the nurse expect during this patient's tests of cognitive
function?
*May display some disruption in thought content.
* Will state, "I am so relieved to be out of intensive care."
* Will be oriented to place and person, but the patient may not be certain of the date.
*May show evidence of some clouding of his level of consciousness. ** Answ** *Will
be oriented to place and person, but the patient may not be certain of the date.
, During a mental status examination, the nurse wants to assess a patient's affect. Which
question the nurse should ask?
*"How do you feel today?"
*"Would you please repeat the following words?"
*"Have these medications had any effect on your pain?"
*"Has this pain affected your ability to get dressed by yourself?" ** Answ** *"How do
you feel today?"
The nurse is planning to assess new memory with a patient. Which is the best way for
the nurse to do this?
*Administer the FACT test.
*Ask him to describe his first job
* Give him the Four Unrelated Words Test.
*Ask him to describe what television show he was watching before coming to the clinic.
** Answ** *Give him the Four Unrelated Words Test.
A 45-year-old woman is at the clinic for a mental status assessment. Which describes
the expecting findings on the Four Unrelated Words Test?
*Invents four unrelated words within 5 minutes
* Invents four unrelated words within 30 seconds,
*Recalls four unrelated words after a 30-minute delay,
*Recalls four unrelated words after a 60-minute delay ** Answ** *Recalls four
unrelated words after a 30-minute delay
During a mental status assessment, which question by the nurse would best assess a
person's judgment?
*"Do you feel that you are being watched, followed, or controlled?"
*Tell me what you plan to do once you are discharged from the hospital." *"What does
the statement, 'People in glass houses shouldn't throw stones,' mean to you?"
*"What would you do if you found a stamped, addressed envelope lying on the
sidewalk?" ** Answ** * "Tell me what you plan to do once you are discharged from
the hospital."
Which of these individuals would the nurse consider at highest risk for a suicide
attempt?
*Man who jokes about death, Woman who, during a past episode of major depression,
attempted suicide
* Adolescent who just broke up with her boyfriend and states that she would like to kill
herself
*Older adult man who tells the nurse that he is going to "join his wife in heaven"
tomorrow and plans to use a gun ** Answ** *Older adult man who tells the nurse
that he is going to "join his wife in heaven" tomorrow and plans to use a gun
The nurse is assessing orientation in a 79-year-old patient. Which of these responses
would lead the nurse to conclude that this patient is oriented?
*"I know my name is John. I couldn't tell you where I am. I think it is 2010, though."
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