1. A nurse is performing a mental status examination (MSE) on a patient. Which of the following components should the nurse assess first?
A) Mood
B) Appearance
C) Speech
D) Thought process
Answer: B) Appearance
Rationale: The first component of the mental status examination is assessing the p...
1. A nurse is performing a mental status examination (MSE) on a patient. Which of the
following components should the nurse assess first?
A) Mood
B) Appearance
C) Speech
D) Thought process
Answer: B) Appearance
Rationale: The first component of the mental status examination is assessing the patient’s
appearance, as it provides important clues about their overall functioning and mental health.
2. When assessing a patient’s thought process, which of the following findings would the
nurse consider abnormal?
A) Logical and goal-directed thoughts
B) Flight of ideas
C) Coherent speech
D) Organized thinking
Answer: B) Flight of ideas
Rationale: Flight of ideas is characterized by rapidly shifting thoughts and topics, indicating a
disorganized thought process often seen in manic episodes.
3. The nurse is evaluating a patient for suicidal ideation. Which question is most
appropriate for the nurse to ask?
A) "Do you have any thoughts about hurting yourself?"
B) "Are you feeling sad today?"
C) "Do you think life is worth living?"
D) "What are your plans for the future?"
Answer: A) "Do you have any thoughts about hurting yourself?"
Rationale: This question directly addresses suicidal ideation, allowing the nurse to assess the
patient’s safety and need for further intervention.
,4. A patient presents with anhedonia and lack of interest in daily activities. Which
assessment finding would be most consistent with depression?
A) Increased energy levels
B) Weight gain
C) Difficulty concentrating
D) Euphoric mood
Answer: C) Difficulty concentrating
Rationale: Difficulty concentrating is a common symptom of depression, alongside anhedonia
and lack of interest in activities.
5. During a psychiatric assessment, the nurse notes the patient is exhibiting paranoid
delusions. What should the nurse prioritize in this situation?
A) Building rapport
B) Establishing safety
C) Providing education
D) Encouraging social interaction
Answer: B) Establishing safety
Rationale: In cases of paranoid delusions, it is crucial to ensure the patient’s safety, as they may
perceive threats in their environment.
6. Which of the following should be included in the assessment of a patient’s psychosocial
history?
A) Family history of mental illness
B) Current medications
C) Physical health status
D) Employment history
Answer: A) Family history of mental illness
Rationale: Understanding family history helps in identifying potential genetic factors that may
influence the patient’s mental health.
7. A nurse is assessing a patient’s insight into their illness. Which statement by the patient
indicates poor insight?
, A) "I know my depression is affecting my life."
B) "I just have a bad attitude."
C) "I’m trying to understand why I feel this way."
D) "I realize I need help."
Answer: B) "I just have a bad attitude."
Rationale: This statement reflects a lack of understanding of the illness and its impact on the
patient’s life, indicating poor insight.
8. When assessing a patient for anxiety, which physical symptom might the nurse expect to
find?
A) Bradycardia
B) Hypertension
C) Hypotension
D) Bradypnea
Answer: B) Hypertension
Rationale: Anxiety often leads to increased sympathetic nervous system activity, resulting in
elevated blood pressure and heart rate.
9. The nurse is assessing a child’s mental health. Which of the following behaviors would be
considered typical for a child in the preoperational stage of development?
A) Logical reasoning
B) Egocentrism
C) Abstract thinking
D) Conservation
Answer: B) Egocentrism
Rationale: Egocentrism is a characteristic of the preoperational stage (ages 2-7), where children
have difficulty seeing perspectives other than their own.
10. Which statement by the patient indicates a potential for substance abuse?
A) "I enjoy a drink occasionally."
B) "I only drink when I’m with friends."
C) "I need a drink to relax after work."
D) "I don’t drink at all."
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