1) A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great
... [Show More] deal of his memory of recent events. Which statement reflects the nurse’s best course of action?
a) The nurse should plan to perform a complete mental status examination.
b) The nurse should refer him to a psychometrician.
c) The nurse should plan to integrate the mental status examination into the history and physical examination.
d) The nurse should reassure his wife that memory loss after a physical shock is normal and will subside soon.
2) The nurse is conducting a patient interview. Which statement made by the patient should the nurse explore more fully during the interview? The patient states that he:
a) “Sleeps like a baby”
b) Has no health problems
c) “Never did too good in school”
d) Currently is not taking any medication
3) A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient's speech is dysarthric and that she is lethargic. The nurse’s best approach regarding this examination is to:
a) Plan to defer the rest of the mental status examination
b) Skip the language portion of the examination and go on to assess mood and affect
c) Do an in-depth speech evaluation and defer the mental status examination to another time
d) Go ahead and assess for suicidal thoughts because dysarthria is often accompanied by severe depression
4) A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. The nurse concludes:
a) She probably doesn’t have any problems at all.
b) She is just trying to shock people and her dress should be ignored.
c) She has manic syndrome because of her abnormal dress and grooming.
d) That more information should be gathered to decide whether her dress is appropriate.
5) A patient has been in the intensive care unit for 10 days. He has just been moved to the medicalsurgical unit, and the admitting nurse is planning to perform a mental status examination on him. During the tests of cognitive function the nurse would expect that he:
a) May display some disruption in thought content
b) Will state, “I am so relieved to be out of intensive care”
c) Will be oriented to place and person but may not be certain of the date
d) May show evidence of some clouding of his level of consciousness
6) During a mental status examination, the nurse wants to assess a patient’s affect. The nurse should ask the patient which question?
a) “How do you feel today?”
b) “Would you please repeat the following words?”
c) “Have these medications had any effect on your pain?”
d) “Has this pain affected your ability to get dressed by yourself?”
7) The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to:
a) Administer the FACT test.
b) Ask him to describe his first job.
c) Give him the Four Unrelated Words test.
d) Ask him to describe what television show he was watching before coming to the clinic.
8) A 29-year-old woman tells the nurse that she has “excruciating pain” in her back. Which would be an appropriate response by the nurse to the woman’s statement?
a) “How does your family react to your pain?”
b) “That must be terrible. You probably pinched a nerve.”
c) “I’ve had back pain myself, and it can be excruciating.”
d) “How would you say the pain affects your ability to do your daily activities?”
9) In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate?
a) Patient denies usual childhood illnesses.
b) Patient states he was a “very healthy” child.
c) Patient states sister had measles, but he didn’t.
d) Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.
10) A patient tells the nurse that he is allergic to penicillin. What would be the nurse’s best response tothis information?
a) “Are you allergic to any other drugs?”
b) “How often have you received penicillin?”
c) “I’ll write your allergy on your chart so you won’t receive any penicillin.”
d) “Please describe what happens to you when you take penicillin.”
11) The nurse is taking a family history. Important diseases or problems to ask the patient about specifically include:
a) Emphysema
b) Head trauma
c) Mental illness
d) Fractured bones
12) The review of systems provides the nurse with:
a) Physical findings related to each system
b) Information regarding health promotion practices
c) An opportunity to teach the patient medical terms
d) Information necessary for the nurse to diagnose the patient’s medical problem
HE
13) Which of these statements represents subjective data the nurse obtained from the patient regarding the patient’s skin?
a) Skin appears dry.
b) No obvious lesions.
c) Denies color change.
d) Lesion noted lateral aspect right arm.
14) In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking?
a) Note-taking may impede the nurse’s observation of the patient’s nonverbal behaviors.
b) Note-taking allows the patient to continue at his or her own pace as the nurse records what is said.
c) Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level.
d) Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort.
15) The nurse asks, “I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here.” This question is found at the phase of the interview process.
a) Summary
b) Closing
c) Body
d) Opening or introduction
... [Show Less]