Chapter 07: Mental Status

Multiple Choice

1. When is the mental status portion of the neurologic system examination performed?

a. During the history-taking process b. During assessment of cranial nerves and deep tendon reflexes c. During the time when questions related to memory are asked d. Continually, throughout the entire interaction with a patient

ANS: D

A mental status evaluation should be continually performed throughout the patient encounter. Assessing and validating clues to determine the individual s abilit to interact within the environment is a priority of the mental status evaluation.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

2. A 69-year-old truck driver presents with a sudden loss of the ability to understand spoken language. This indicates a lesion in the: a. temporal lobe. b. Broca area. c. frontal cortex. d. cerebellum.

ANS: A

The temporal lobe, specifically in the Wernicke speech area, is responsible for the comprehension of spoken and written language.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

3. The ability for abstract thinking normally develops during: a. infancy. b. early childhood. c. adolescence. d. adulthood.

ANS: C

Abstract thinking is an intellectual maturation that develops during adolescence.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

4. The Mini-Mental State Examination (MMSE) may be used to: a. estimate cognitive changes quantitatively. b. estimate personality disorders qualitatively. c. diagnose neurologic disorders. d. determine the cause of memory loss.

ANS: A

The MMSE is a standard tool that functions to estimate cognitive function quantitatively or to document cognitive changes serially.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

5. Assessing orientation to person, place, and time helps determine: a. ability to understand analogies. b. abstract reasoning. c. attention span. d. state of consciousness.

ANS: D

Orientation to person, place, and time are measures of states of consciousness and awareness.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Level of consciousness b. Abstract reasoning c. Emotional stability d. Memory

6. When you ask the patient to tell you the meaning of a proverb or metaphor, you are assessing which of the following?

ANS: B

Asking the patient to tell you the meaning of a proverb, metaphor, or fable assesses the patient s abilit to reason abstractl . Asking the patient to tell ou the meaning of a proverb or metaphor does not assess level of consciousness, emotional stability, or memory. The Mini-Mental State Examination tests memory.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

7. Impairment of arithmetic skills is often the result of: a. impaired execution of motor skills. b. impaired judgment. c. perceptual distortions. d. depression.

ANS: D

The patient with depression can display difficulty with simple arithmetic calculations.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

8. Peripheral neuropathy is most likely to be manifested by: a. impaired memory. b. impaired abstract reasoning. c. impaired writing ability. d. hallucinations.

ANS: C

Uncoordinated writing or drawing may indicate peripheral neuropathy, dementia, parietal lobe damage, or a cerebellar lesion.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

9. Recent memory may be tested by: a. asking the patient to name the past four presidents. b. asking the patient to listen to and repeat a series of numbers. c. showing the patient four items and asking him or her to list the items about 10 minutes later. d. asking the patient about verifiable information, such as his or her mother s maiden name.

ANS: C

Showing the patient four or five objects, saying you will ask about them in a few minutes, and then 10 minutes later asking the patient to list the objects is a technique to measure recent memory.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

10. Loss of immediate and recent memory with retention of remote memory suggests: a. attention-deficit/hyperactivity disorder (ADHD). b. impaired judgment. c. stupor. d. dementia.

ANS: D

Dementia is the loss of both immediate and recent memory while retaining remote memories. ADHD is associated with recent and remote memory impairment. Impaired judgment is a thought process dysfunction. Stupor is impaired consciousness.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

11. You ask the patient to follow a series of short commands to assess: a. judgment. b. attention span. c. arithmetic calculations. d. abstract reasoning.

ANS: B

Asking the patient to follow a series of short commands will test attention span.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Repeated failure to fulfill family obligations b. Forgetting famil members birth dates c. Going to church three times a week d. Planning for retirement in 20 years

12. Which observation would be most significant when assessing the condition of a patient who has judgment impairment?

ANS: A

Inadequately dealing with family and social affairs indicates impaired judgment, whereas the other choices do not.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

13. Appropriateness of logic, sequence, cohesion, and relevance to topics are markers for the assessment of: a. mood and feelings. b. attention span. c. thought process and content. d. abstract reasoning.

ANS: C

Thought process and content are e amined while observing the patient s patterns of thinking, especially appropriateness of sequence, logic, coherence, and relevance to the topics discussed.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Olfactory b. Visual c. Auditory d. Tactile

14. Which type of hallucination is most commonly associated with alcohol withdrawal?

ANS: D

Tactile hallucinations are most commonly associated with alcohol withdrawal.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

15. Flight of ideas or loosening of associations is associated with: a. aphasia. b. dysphonia. c. multiple sclerosis. d. psychiatric disorders.

ANS: D

Flight of ideas, loosening of associations, word salads, neologisms, clang associations, echolalia, and utterances of unusual sounds are all associated with psychiatric disorders.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

16. The Glasgow Coma Scale is used to: a. determine the cause of decreased consciousness. b. diagnose disorders that alter level of consciousness. c. quantify consciousness. d. predict response to stimulant medications.

ANS: C

The Glasgow Coma Scale is used when a patient has an altered level of consciousness and is used to quantify consciousness.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Delirium b. Dementia c. Depression d. Anxiety

17. Which condition is considered progressive rather than reversible?

ANS: B

Dementia is considered progressive and irreversible. Delirium has the potential for reversal. Depression and anxiety are reversible.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

18. A clinical syndrome of failing memory and impairment of other intellectual functions, usually related to obvious structural diseases of the brain, describes: a. delirium. b. dementia. c. depression. d. anxiety.

ANS: B

Dementia results from a chronic progressive deterioration of the brain that results in failing memory and impairment of other intellectual functioning.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. It occurs before 7 years of age. b. It is usually related to mental retardation. c. It is usually related to dementia. d. It is manifested by prolonged periods of catatonic behavior.

19. Mrs. Griffiths, a 28-year-old patient, presents to your office to discuss her attention-deficit/hyperactivity disorder (ADHD). Which statement is true in regard to ADHD?

ANS: A

ADHD occurs before 7 years of age. ADHD is not related to mental retardation, dementia, or prolonged periods of catatonic behavior.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

20. An aversion to touch or being held, along with delayed or absent language development, is characteristic of: a. attention-deficit/hyperactivity disorder. b. autism. c. dementia. d. mental retardation.

ANS: B

Autistic disorder involves a combination of behavioral traits (lack of awareness of others, aversion to touch or being held, odd or repetitive behaviors, or preoccupation with parts of objects) and communication deficits (usually echolalia [parrot speech]).

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

21. You are interviewing a 20-year-old patient with a new-onset psychotic disorder. The patient is apathetic and has disturbed thoughts and language patterns. The nurse recognizes this behavior pattern as consistent with a diagnosis of: a. depression. b. autistic disorder. c. mania. d. schizophrenia.

ANS: D

Schizophrenia manifests as a psychotic disorder of early adult onset, with disturbances in language and speech, emotions and social withdrawal, and apathy. Depression and mania do not have the language or speech component. Autistic disorders are not psychotic disorders, and they usually begin before 3 years of age.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

22. While interviewing a patient, ou ask him to e plain the Lion and the Mouse to assess: a. reading comprehension. b. attention span. c. mood and feeling. d. reasoning skills.

ANS: D

Having the patient explain fables or metaphors determines abstract reasoning skills.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

23. The Mini-Mental State Examination (MMSE) should be administered for the patient who: a. gets lost in her neighborhood. b. sleeps an excessive amount of time. c. has repetitive ritualistic behaviors. d. uses illegal hallucinogenic drugs.

ANS: A

The MMSE is a tool used to quantitatively estimate cognitive function or to serially document cognitive changes. Getting lost in a familiar territory is a sign of possible cognitive impairment.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

Multiple Response

1. Which clinical assessments test attention span?

a. Spell WORLD backward.

b. Draw a clock.

c. Say the days of the week.

d. Do arithmetic calculations.

e. E plain a stitch in time saves nine.

ANS: A, C, D

Clinical assessments to test attention span include spell WORLD backward, say th e days of the week, and do arithmetic calculations. Drawing a clock tests writing ability, and explaining a stitch in time saves nine tests abstract reasoning.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Aphasia b. Apathy c. Odd behaviors d. Disintegration of personality e. Lack of awareness of others

2. Which are signs and symptoms of dementia?

ANS: A, B, D

Aphasia, apathy, and disintegration of personality are all characteristics of dementia. Odd behaviors and lack of awareness of others are characteristics of autism.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

Completion

1. Under most conditions, adult patients should be able to repeat forward a series of _____________ numbers.

ANS: five to eight 5-8

Most adults should be able to immediately recall a series of five to eight numbers forward and a series of four to six numbers backward.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

2. The examiner should be concerned about neurologic competence if a social smile cannot be elicited by the time a child is _________ old.

ANS: 2 to 3 months

A social smile is expected in the 2- to 3-month-old infant. If it is difficult or impossible to elicit a social smile by 3 months, the infant may not be neurologically intact.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation