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1. During a mental status assessment, which question by the nurse would best
assess a person's judgment?
A "Do you feel that you are being watched, followed, or controlled?"
B "What would you do if you found a stamped, addressed envelope lying on the sidewalk?"
C "What does the statement, 'People in glass houses shouldn't throw stones,' mean to
you?"
D "Tell me what you plan to do once you are discharged from the hospital.": D
"Tell me what you plan to do once you are discharged from the hospital."
2. 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?
A "I have no health problems."
B "I never did too good in school."
C "I am not currently taking any medications."
D "I sleep like a baby.": B "I never did too good in school."
3. During an examination, the nurse can assess mental status by which activity?
A Observing the patient as he or she performs an intelligence quotient (IQ) test
B Examining the patient's response to a specific set of questions
C Observing the patient and inferring health or dysfunction
D Examining the patient's electroencephalogram: C Observing the patient and
inferring health or dysfunction
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4. When taking the health history on a patient with a seizure disorder, the nurse
assesses whether the patient has an aura. Which of these would be the best
question for obtaining this information?
A "After the seizure, do you spend a lot of time sleeping?"
B "Do you have any warning sign before your seizure starts?"
C "Do you experience any color change or incontinence during the seizure?"
D "Does your muscle tone seem tense or limp?": B "Do you have any warning sign
before your seizure starts?
5. During the assessment of an 80-year-old patient, the nurse notices that his
hands show tremors when he reaches for something and his head is always
nodding. No associated rigidity is observed with movement. Which of these
statements is most accurate?
A These findings are normal, resulting from aging.
B These findings could be r/t hyperthyroidism.
C These findings are the result of Parkinson disease.
D This patient should be evaluated for a cerebellar lesion.: A These findings are normal,
resulting from aging.
6. A man who was found wandering in a park at 2 AM has been brought to the
emergency department for an examination; he said he fell and hit his head.
During the examination, the nurse asks him to use his index finger to touch the
nurse's finger, then his own nose, then the nurse's finger again (which has been
moved to a different location). The patient is clumsy, unable to follow the
instructions, and overshoots the mark, missing the finger. What does the nurse
suspect?
A Cerebral injury
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B Peripheral neuropathy
C Cerebrovascular accident
D Acute alcohol intoxication: D Acute alcohol intoxication
7. When assessing the intensity of a patient's pain, which question by the nurse
is appropriate?
A "How does pain limit your activities?"
B "What does your pain feel like?"
C "How much pain do you have now?"
D "What makes your pain better or worse?": C "How much pain do you have now?"
8. The nurse is teaching a class on pain at a local retirement community. Which
statement about the pain experienced by older adults should the nurse include
in the instructions?
A "Pain is a normal process of aging and is to be expected."
B "Pain indicates a pathologic condition or an injury and is not a normal process of aging."
C "Older adults must learn to tolerate pain."
D "Older individuals perceive pain to a lesser degree than do younger individ-
uals.": B "Pain indicates a pathologic condition or an injury and is not a normal
process of aging."
9. The nurse is conducting an interview with an adult male patient. Which
statement made by the patient indicates an alcohol use disorder?
A "I usually stay out longer and drink more than I intended but I still make it into work on
time."
B "I've been late to work a few times so now I limit myself to 2 drinks/day and stick to it."
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C "I have a strong urge to drink and I've tried to stop drinking several times but it doesn't
last long."
D "I crave alcohol but have successfully cut down on my alcohol consumption."-
: C "I have a strong urge to drink and I've tried to stop drinking several times
but it doesn't last long."
10. The nurse has completed an assessment on a patient who came to the clinic
for a leg injury. As a result of the assessment, the nurse has determined that
the patient has at-risk alcohol use. Which action by the nurse is most
appropriate at this time?
A State, "You are drinking more than is medically safe. I strongly recommend that you quit
drinking, and I'm willing to help you."
B Give the patient information about a local rehabilitation clinic.
C Record the results of the assessment, and notify the physician on call.
D State, "It appears that you may have a drinking problem. Here is the telephone number
of our local Alcoholics Anonymous chapter.": A State, "You are drinking
more than is medically safe. I strongly recommend that you quit drinking, and
I'm willing to help you."
11. During a mental status examination, the nurse wants to assess a patient's
affect. Which question the nurse should ask?
A "Have these medications had any effect on your pain?"
B "Would you please repeat the following words?"
C "Has this pain affected your ability to get dressed by yourself?"
D "How do you feel today?": D "How do you feel today?"