Mental Status Exam Questions Answered Correctly Latest 2025
When assessing the mental status of a 67-year-old woman, the nurse detects some difficulty with free-
flow of thought and following directions. What would the nurse do first? - Answers Assess vision and
hearing, because these can impact the patient's deficits
What scale is used if depression is suspected? - Answers A Geriatric Depression Scale would be used if
depression was suspected
Wernicke's aphasia - Answers client can speak effortlessly and fluently, but his words often make no
sense. Words can be malformed or completely invented.
Speaks rapidly and uses words that make no sense or communicate any clear meaning
Found on the temporal lobes.
SLUM Values for MCI - Answers High school education: 20-27
Less than high school education: 14-19
SLUM Values for Dementia - Answers High school education: 1-19 i
Less than high school education: 1-14
How can a nurse assess the visual, perceptual, and constructional ability of a client? - Answers Have the
client draw the face of a clock
Confusion Assessment Method (CAM) assesses for - Answers Delirium
A gerontologic nurse is assessing the speech of an older adult client. Which of the following would the
nurse characterize as an expected assessment finding? - Answers Moderate pace
Slow, repetitive speech is characteristic of ___. - Answers Depression or Parkinson's Disease
A nurse in the emergency department is utilizing the SAD PERSONAS assessment guide during the
mental status assessment of a client. What is the most likely rationale for the nurse's choice of this
assessment tool? - Answers SAD PERSONAS
Glasgow of 3 = ____ - Answers deep coma
Glasgow of 7 = ____ - Answers coma
The nurse uses the Mini-Mental State Examination to assess a client. For which reason is this assessment
tool most likely used? - Answers Dementia
, The nurse observes a client's entire body posture to be somewhat stiff, with his shoulders elevated
upward toward the ears. The nurse would interpret this to indicate that the client is experiencing which
of the following? - Answers Anxiety
Broca's Aphasia - Answers Slow and difficult speech
Nouns, verbs, and important adjectives are usually present
Lateral portion of frontal lobe
The patient is able to draw a clock correctly but is unable to recall the three words given at the
beginning of the assessment. What do the results suggest to the nurse? - Answers Dementia
How can the nurse differentiate the cause of the client's slow speech? - Answers Have the client read a
few sentences out loud
Speech is influenced by experience, education level, and culture.
The nurse documents findings from the client's Mini-Mental State Examination. The following
information will be documented as a result of this test. - Answers Orientation, memory, and cognitive
function.
Glasgow = 15 - Answers no impairments
dysarthria - Answers difficult or unclear articulation of speech that is otherwise linguistically normal.
caused by muscle weakness
remote vs recent memory - Answers remote is years ago and recent is within days
CAGE Questions - Answers C =
A=
G = Guilt
E=
The client has been admitted for depression. What should the nurse include in the admission mental
status assessment? - Answers related to loss
change in physiological status, including history of a stroke.
The nurse learns during handoff communication during end-of-shift that a client has delirium. What
should the nurse expect to assess in this client? - Answers Vacillates between lucidity and confusion
Experiences visual and auditory hallucinations
When assessing the mental status of a 67-year-old woman, the nurse detects some difficulty with free-
flow of thought and following directions. What would the nurse do first? - Answers Assess vision and
hearing, because these can impact the patient's deficits
What scale is used if depression is suspected? - Answers A Geriatric Depression Scale would be used if
depression was suspected
Wernicke's aphasia - Answers client can speak effortlessly and fluently, but his words often make no
sense. Words can be malformed or completely invented.
Speaks rapidly and uses words that make no sense or communicate any clear meaning
Found on the temporal lobes.
SLUM Values for MCI - Answers High school education: 20-27
Less than high school education: 14-19
SLUM Values for Dementia - Answers High school education: 1-19 i
Less than high school education: 1-14
How can a nurse assess the visual, perceptual, and constructional ability of a client? - Answers Have the
client draw the face of a clock
Confusion Assessment Method (CAM) assesses for - Answers Delirium
A gerontologic nurse is assessing the speech of an older adult client. Which of the following would the
nurse characterize as an expected assessment finding? - Answers Moderate pace
Slow, repetitive speech is characteristic of ___. - Answers Depression or Parkinson's Disease
A nurse in the emergency department is utilizing the SAD PERSONAS assessment guide during the
mental status assessment of a client. What is the most likely rationale for the nurse's choice of this
assessment tool? - Answers SAD PERSONAS
Glasgow of 3 = ____ - Answers deep coma
Glasgow of 7 = ____ - Answers coma
The nurse uses the Mini-Mental State Examination to assess a client. For which reason is this assessment
tool most likely used? - Answers Dementia
, The nurse observes a client's entire body posture to be somewhat stiff, with his shoulders elevated
upward toward the ears. The nurse would interpret this to indicate that the client is experiencing which
of the following? - Answers Anxiety
Broca's Aphasia - Answers Slow and difficult speech
Nouns, verbs, and important adjectives are usually present
Lateral portion of frontal lobe
The patient is able to draw a clock correctly but is unable to recall the three words given at the
beginning of the assessment. What do the results suggest to the nurse? - Answers Dementia
How can the nurse differentiate the cause of the client's slow speech? - Answers Have the client read a
few sentences out loud
Speech is influenced by experience, education level, and culture.
The nurse documents findings from the client's Mini-Mental State Examination. The following
information will be documented as a result of this test. - Answers Orientation, memory, and cognitive
function.
Glasgow = 15 - Answers no impairments
dysarthria - Answers difficult or unclear articulation of speech that is otherwise linguistically normal.
caused by muscle weakness
remote vs recent memory - Answers remote is years ago and recent is within days
CAGE Questions - Answers C =
A=
G = Guilt
E=
The client has been admitted for depression. What should the nurse include in the admission mental
status assessment? - Answers related to loss
change in physiological status, including history of a stroke.
The nurse learns during handoff communication during end-of-shift that a client has delirium. What
should the nurse expect to assess in this client? - Answers Vacillates between lucidity and confusion
Experiences visual and auditory hallucinations
