Unit 5 - Mental Status Assessment

Question 1

Mental Health

Answer 1

A balance in emotional and cognitive abilities that allow a person to manage life’s stressors

Question 2

Mental status

Answer 2

a component of mental health that includes emotional and cognitive functioning

Question 3

Mental illness:

Answer 3

Any disorder that affects the mind

Dx based on DSM-V criteria

Question 4

Mental Health Assessment

Answer 4

Reflects your observations and impressions, is an evaluation of the individual’s current state.

Question 5

4 Components of Mental Status Examination

Answer 5

A. Appearance
B. Behaviour
C. Cognition
T. Thought processes

Question 6

Indications for a Full Mental Status Exam

Answer 6

Affect or behaviour changes
Brain lesions
Aphasia
Symptoms of mental illness

Question 7

Health history can reveal

Answer 7

Other illnesses
Medications /w side effects
Educational and behavioural level
Personal history

Question 8

2 components of mental status exam

Answer 8

1. Emotional
   Appearance
   Behaviour
2. Cognitive
   Cognitive functions
   Thought processes

Question 9

Appearance - assess:

Answer 9

Posture
Body movements
Dress
Grooming and hygiene

Question 10

Behavioural - Assess:

Answer 10

Level of consciousness
Facial expression
Speech
Mood and affect

Question 11

Mood

Answer 11

a sustained and durable emotion that can noticeably affect the person’s worldview
Ex: Season

Question 12

Affect

Answer 12

the capacity of an individual to vary emotional expression

Ex: Cold day

Question 13

Cognition

Answer 13

The mental process of how we acquire knowledge

Question 14

Cognitive functions – assess:

Answer 14

Orientation 
Attention span 
Recent memory 
Remote memory 
New learning 
Further assess: Aspasia
judgement

Question 15

Thought processes – assess:

Answer 15

Thought process
Thought content
Perceptions

Question 16

Risk Assessment

Answer 16

Suicidal thoughts
Assaultive/homicidal ideation
Elopement risk

Question 17

To assess affect, the nurse should ask the patient:
A. “How do you feel today?”
B. “Would you please repeat the following words?”
C. “How did you arrive at the hospital?”
D. “Has this pain affected your ability to dress yourself?”

Answer 17

A. “How do you feel today?”

Question 18

Obtunded

Answer 18

b/t lethargy & stupor

Question 19

Elation

Answer 19

Joy, optimism, over confidence

Question 20

Euphoria

Answer 20

Excessive well-being

Question 21

Ambivalence

Answer 21

opposing emotions toward person, object, idea

Question 22

Lability

Answer 22

Rapid shift of emotions

Question 23

Inappropriate affect

Answer 23

Affect discordant with content of pt’s speech

Question 24

A full mental status examination should be completed if the patient:
A. has a change in behaviour and the family is concerned.
B. develops dysphagia.
C. is newly diagnosed with type 2 diabetes mellitus.
D. complains of insomnia.

Answer 24

A. has a change in behaviour and the family is concerned.

Question 25

Aphasia is best described as:
A. a language disturbance in speaking, writing, or understanding.
B. the impaired ability to carry out motor activities despite intact motor function.
C. the impaired ability to recognize or identify objects despite intact sensory function.
D. a disturbance in executive functioning (planning, organizing, sequencing, abstracting).

Answer 25

A. a language disturbance in speaking, writing, or understanding.

Question 26

A patient who was recently diagnosed with a seizure disorder plans to continue a career as a pilot. At this time in the interview, the nurse begins to question the patient’s:
A.  thought process.
B.  judgement.
C.  perception.
D.  intellect.

Answer 26

B. judgement.

Question 27

A major characteristic of dementia is:
A. impaired short-term and long-term memory.
B. hallucinations.
C. sudden onset of symptoms.
D. cognitive deficits that are substance-induced.

Answer 27

A. impaired short-term and long-term memory.

Question 28

Mental status assessment documents:
A. emotional and cognitive functioning.
B. intelligence and educational level.
C. artistic or writing ability in the mentally ill person.
D. schizophrenia and other mental health disorders.

Answer 28

A. emotional and cognitive functioning.

Question 29

Although a full mental status examination may not be required for every patient, the health care provider must address the four main components during a health history and physical examination. The four components are:
A. memory, attention, thought content, and perceptions.
B. language, orientation, attention, and abstract reasoning.
C. appearance, behaviour, cognition, and thought processes.
D. mood, affect, consciousness, and orientation.

Answer 29

C. appearance, behaviour, cognition, and thought processes.

Question 30

An older adult:
A. experiences a 10-point decrease in intelligence.
B. has diminished recent and remote memory recall.
C. has a slower response time.
D. has difficulty with problem solving.

Answer 30

C. has a slower response time.

Question 31

Which of the following would cause the nurse to consider screening a patient for suicidal thoughts?
A. The patient does not have off-unit privileges and is restricted to the unit.
B. The patient reveals that he or she has detailed plans to harm another individual.
C. The patient demonstrates grief and despair during the interview.
D. The patient cannot identify the season and is unable to name his or her family members.

Answer 31

C. The patient demonstrates grief and despair during the interview.

Question 32

Which of the following best illustrates an abnormality of thought process?
A.  Lability
B.  Blocking
C.  Compulsion
D.  Aphasia

Answer 32

B. Blocking

Question 33

The mental status examination:
A. should be completed at the end of the physical examination.
B. will not be affected if the patient has a language impairment.
C. is usually not assessed in children younger than 2 years of age.
D. assesses mental health strengths and coping skills, and screens for any dysfunction.

Answer 33

D. assesses mental health strengths and coping skills, and screens for any dysfunction.