C HAPTER 5: B EHAVIOR AND M ENTAL S TATUS
MULTIPLE CHOICE
1. The nurse is assessing orientation in a 79 -year-old patient. Wh ich of these
responses would lead the nurse to conclude that this patient is oriented?
a. I know m y name is John. I couldn’t tell you where I am. I think it is
2010, though.
b. I know m y name is John, but to tell you the truth, I get kind of
confused about the date.
c. I know m y name is John; I guess Im at the hospital in Spokane. No,
I don’t know the date.
d. I know m y name is John. I am at the hospital in Spokane. I couldn’t
tell you what date it is, but I know that it is February of a new
year2010.
ANS: D
Many aging persons experience social isolation, loss of structure
without a job, a change in residence, or some short -term memory loss.
These factors affect orientation, and the person may not provide the
precise date or complete name of the agency. You may consider aging
persons oriented if they generall y know where they are and the present
period. They should be considered oriented to time if the year and
month are correctl y stated. Orientation to place is accepted with the
correct identification of the t yp e of setting (e.g., hospital) and the
name of the town.
, PTS: 1 DIF: Cognitive Level: Appl ying (Application) REF: p.
76 MSC: Client Needs: Psychosocial Integrity
2. The nurse is performing the Denver II screening test on a 12 -month-old
infant during a routin e well-child visit. The nurse should tell the infants
parents that the Denver II:
a. Tests three areas of development: cognitive, physical, and
psychological
b. Will indicate whether the child has a speech disorder so that
treatment can begin.
c. Is a screenin g instrument designed to detect children who are slow
in development.
d. Is a test to determine intellectual abilit y and may indicate whether
problems will develop later in school.
ANS: C
The Denver II is a screening instrument designed to detect
developmental delays in infants and preschoolers. It tests four
functions: gross motor, language, fine motor -adaptive, and
personalsocial. The Denver II is not an intelligence test; it does not
predict current or future intellectual ability. It is not diagnostic; it does
not suggest treatment regimens.
PTS: 1 DIF: Cognitive Level: Appl ying (Application) REF: p.
75 MSC: Client Needs: Psychosocial Integrity
3. A patient drifts off to sleep when she is not being stimulated. The nurse
can easil y arouse her by calling he r name, but the patient remains drowsy
, during the conversation. The best description of this patients level of
consciousness would be:
a. Lethargic
b. Obtunded
c. Stuporous
d. Semialert
ANS: A
Lethargic (or somnolent) is when the person is not full y alert, drifts off
to sleep when not stimulated, and can be aroused when called by name
in a normal voice but looks drowsy. He or she appropriatel y responds
to questions or commands, but thinking seems slow and fuzzy. He or
she is inattentive and loses the train of thou ght. Spontaneous
movements are decreased. (See Table 5 -3 for the definitions of the
other terms.)
PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)
REF: p. 79 MSC: Client Needs: Psychosocial Integrity
4. A patient has had a cerebrovascular accident ( stroke). He is trying very
hard to communicate. He seems driven to speak and says, I buy obie get
spirding and take m y train. What is the best description of this patients
problem?
a. Global aphasia
b. Brocas aphasia
c. Echolalia
d. Wernickes aphasia
ANS: D
MULTIPLE CHOICE
1. The nurse is assessing orientation in a 79 -year-old patient. Wh ich of these
responses would lead the nurse to conclude that this patient is oriented?
a. I know m y name is John. I couldn’t tell you where I am. I think it is
2010, though.
b. I know m y name is John, but to tell you the truth, I get kind of
confused about the date.
c. I know m y name is John; I guess Im at the hospital in Spokane. No,
I don’t know the date.
d. I know m y name is John. I am at the hospital in Spokane. I couldn’t
tell you what date it is, but I know that it is February of a new
year2010.
ANS: D
Many aging persons experience social isolation, loss of structure
without a job, a change in residence, or some short -term memory loss.
These factors affect orientation, and the person may not provide the
precise date or complete name of the agency. You may consider aging
persons oriented if they generall y know where they are and the present
period. They should be considered oriented to time if the year and
month are correctl y stated. Orientation to place is accepted with the
correct identification of the t yp e of setting (e.g., hospital) and the
name of the town.
, PTS: 1 DIF: Cognitive Level: Appl ying (Application) REF: p.
76 MSC: Client Needs: Psychosocial Integrity
2. The nurse is performing the Denver II screening test on a 12 -month-old
infant during a routin e well-child visit. The nurse should tell the infants
parents that the Denver II:
a. Tests three areas of development: cognitive, physical, and
psychological
b. Will indicate whether the child has a speech disorder so that
treatment can begin.
c. Is a screenin g instrument designed to detect children who are slow
in development.
d. Is a test to determine intellectual abilit y and may indicate whether
problems will develop later in school.
ANS: C
The Denver II is a screening instrument designed to detect
developmental delays in infants and preschoolers. It tests four
functions: gross motor, language, fine motor -adaptive, and
personalsocial. The Denver II is not an intelligence test; it does not
predict current or future intellectual ability. It is not diagnostic; it does
not suggest treatment regimens.
PTS: 1 DIF: Cognitive Level: Appl ying (Application) REF: p.
75 MSC: Client Needs: Psychosocial Integrity
3. A patient drifts off to sleep when she is not being stimulated. The nurse
can easil y arouse her by calling he r name, but the patient remains drowsy
, during the conversation. The best description of this patients level of
consciousness would be:
a. Lethargic
b. Obtunded
c. Stuporous
d. Semialert
ANS: A
Lethargic (or somnolent) is when the person is not full y alert, drifts off
to sleep when not stimulated, and can be aroused when called by name
in a normal voice but looks drowsy. He or she appropriatel y responds
to questions or commands, but thinking seems slow and fuzzy. He or
she is inattentive and loses the train of thou ght. Spontaneous
movements are decreased. (See Table 5 -3 for the definitions of the
other terms.)
PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)
REF: p. 79 MSC: Client Needs: Psychosocial Integrity
4. A patient has had a cerebrovascular accident ( stroke). He is trying very
hard to communicate. He seems driven to speak and says, I buy obie get
spirding and take m y train. What is the best description of this patients
problem?
a. Global aphasia
b. Brocas aphasia
c. Echolalia
d. Wernickes aphasia
ANS: D
