A. Examining the patient’s electroencephalogram
B. Observing the patient as he or she performs an IQ test
C. Observing the patient and inferring health or dysfunction
D. Examining the patient’s response to a specific set of questions
Mental status cannot be scrutinized directly like the characteristics of skin or heart sounds. Its functioning is inferred through assessment of an individual’s behaviors, such as consciousness, language, mood and affect, and other aspects.
A. All aspects of mental status in children are interdependent.
B. Children are highly labile and unstable until the age of 2 years.
C. Children’s mental status is largely a function of their parents’ level of functioning until the age of 7 years.
D. A child’s mental status is impossible to assess until the child develops the ability to concentrate
It is difficult to separate and trace the development of just one aspect of mental status. All aspects are interdependent. For example, consciousness is rudimentary at birth because the cerebral cortex is not yet developed. The infant cannot distinguish the self from the mother’s body. The other statements are not true.
A. Will have no decrease in any of his abilities, including response time
B. Will have difficulty on tests of remote memory because this typically decreases with age.
C. May take a little longer to respond, but his general knowledge and abilities should not have declined.
D. Will have had a decrease in his response time because of language loss and a decrease in general knowledge.
The aging process leaves the parameters of mental status mostly intact. There is no decrease in general knowledge and little or no loss in vocabulary. Response time is slower than in youth. It takes a bit longer for the brain to process information and to react to it. Recent memory, which requires some processing is somewhat decreased with aging, but remote memory is not affected.
A. The presence of phobias.
B. Their general intelligence.
C. The presence of irrational thinking patterns.
D. Their sensory-perceptive abilities.
Age-related changes in sensory perception can affect mental status. For example, vision loss (as detailed in Chapter 14) may result in apathy, social isolation, and depression. Hearing changes are common in older adults. This problem produces frustration, suspicion, and social isolation and makes the person look confused.
A. A patient’s family is the best resource for information about the patient’s coping skills.
B. It is usually sufficient to gather mental status information during the health history interview.
C. It takes an enormous amount of extra time to integrate the mental status examination into the health history interview.
D. It is usually necessary to perform a complete mental status examination to get a good idea of the patient’s level of functioning.
The full mental status examination is a systematic check of emotional and cognitive functioning. The steps described here, though, rarely need to be taken in their entirety. Usually, one can assess mental status through the context of the health history interview.
A. Plan to perform a complete mental status examination.
B. Refer him to a psychometrician.
C. Plan to integrate the mental status examination into the history and physical examination.
D. Reassure his wife that memory loss after a physical shock is normal and will subside soon
It is necessary to perform a complete mental status examination when any abnormality in affect or behavior is discovered and when family members are concerned about a person’s behavioral changes (e.g., memory loss, inappropriate social interaction) or after trauma, such as a head injury.
A. “Sleeps like a baby.”
B. Has no health problems.
C. “Never did too good in school.”
D. Currently is not taking any medication
In every mental status examination, note these factors from the health history that could affect the findings: any known illnesses or health problems, such as alcoholism or chronic renal disease; current medications, the side effects of which may cause confusion or depression; the usual educational and behavioral level—note that factor as the normal baseline and do not expect performance on the mental status examination to exceed it; and responses to personal history questions, indicating current stress, social interaction patterns, and sleep habits.
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
In the mental status examination the sequence of steps forms a hierarchy in which the most basic functions (consciousness, language) are assessed first. The first steps must be accurately assessed to ensure validity for the steps to follow. That is, if consciousness is clouded, then the person cannot be expected to have full attention and to cooperate with new learning. If language is impaired, then subsequent assessment of new learning or abstract reasoning (anything that requires language functioning) can give erroneous conclusions.
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.
Grooming and hygiene should be noted. The person is clean and well groomed, hair is neat and clean, women have moderate or no makeup, men are shaved or their beards or moustaches are well groomed. Use care in interpreting clothing that is disheveled, bizarre, or in poor repair because these sometimes reflect the person’s economic status or a deliberate fashion trend.
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
The nurse can discern the orientation of cognitive function through the course of the interview or can tactfully ask directly. “Some people have trouble keeping up with the dates while in the hospital. Do you know today’s date?” Many hospitalized people normally have trouble with the exact date but are fully oriented on the remaining items.
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?”
Judge mood and affect by body language and facial expression and by asking directly, “How do you feel today?” or “How do you usually feel?” The mood should be appropriate to the person’s place and condition and should change appropriately with topics.
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
Ask questions that can be corroborated. This screens for the occasional person who confabulates or makes up answers to fill in the gaps of memory loss. The Four Unrelated Words Test tests the person’s ability to lay down new memories. It is a highly sensitive and valid memory test.
A. Invent; within 5 minutes
B. Invent; within 30 seconds
C. Recall; after a 30-minute delay
D. Recall; after a 60-minute delay
The Four Unrelated Words Test tests the person’s ability to lay down new memories. It is a highly sensitive and valid memory test. It requires more effort than does the recall of personal or historic events. To the person, say, “I am going to say four words. I want you to remember them. In a few minutes I will ask you to recall them.” After 5 minutes, ask for the four words. The normal response for persons under 60 years is an accurate three- or four-word recall after a 5-, 10-, and 30-minute delay.
A. “Do you feel that you are being watched, followed, or controlled?”
B. “Tell me about what you plan to do once you are discharged from the hospital.”
C. “What does the statement, ‘People in glass houses shouldn’t throw stones,’ mean to you?”
D. “What would you do if you found a stamped, addressed envelope lying on the sidewalk?
A person exercises judgment when he or she can compare and evaluate the alternatives in a situation and reach an appropriate course of action. Rather than testing the person’s response to a hypothetical situation (as illustrated in the option with the envelope), the nurse should be more interested in the person’s judgment about daily or long-term goals, the likelihood of acting in response to delusions or hallucinations and the capacity for violent or suicidal behavior.
A. Man who jokes about death
B. Woman who, during a past episode of major depression, attempted suicide
C. Adolescent who has just broken up with her boyfriend and states that she would like to kill herself
D. Elderly man who tells the nurse that he is going to “join his wife in heaven” tomorrow and plans to use a gun
When the person expresses feelings of sadness, hopelessness, despair, or grief, it is important to assess any possible risk of physical harm to himself or herself. Begin with more general questions. If the nurse hears affirmative answers, then he or she should continue with more specific questions. A precise suicide plan to take place in the next 24 to 48 hours with use of a lethal method constitutes high risk.
A. She clings to her mother whenever the nurse is in the room.
B. She appears angry and will not make eye contact with the nurse.
C. Her mother states that she has begun to ride a tricycle around their yard.
D. Her mother states that her daughter prefers to play with toddlers instead of kids her own age while in daycare.
The mental status assessment of infants and children covers behavioral, cognitive, and psychosocial development and examines how the child is coping with his or her environment. Essentially, the nurse should follow the same A-B-C-T guidelines as for the adult, with special consideration for developmental milestones. The best examination “technique” arises from thorough knowledge of developmental milestones as described in Chapter 2. Abnormalities are often problems of omission (e.g., the child does not achieve a milestone as expected).
A. 8-year-old child.
B. 16-year-old child.
C. 5-year-old child, just before kindergarten.
D. Child having difficulty with gross motor skills
For school-age children, ages 7 to 11 years, who have grown beyond the age when developmental milestones are very useful, the Behavioral Checklist is an additional tool that can be given to the parent(s) along with the history questionnaire. The tool is not appropriate for the other examples listed.
A. “I know that my name is John. I couldn’t tell you where I am. I think it is 2010, though.”
B. “I know that my name is John, but to tell you the truth, I get kind of confused about the date.”
C. “I know that my name is John; I guess I’m at the hospital in Spokane. No, I don’t know the date.”
D. “I know that my 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 year—2010.”
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 know generally where they are and the present period. That is, consider them oriented to time if the year and month are correctly stated. Orientation to place is accepted with the correct identification of the type of setting (e.g., the hospital) and the name of the town.
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 screening instrument designed to detect children who are slow in development.
D. Is a test to determine intellectual ability and may indicate whether there will be problems later in school
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 personal-social. 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.
Lethargic (or somnolent) is when the person is not fully 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 responds appropriately to questions or commands, but thinking seems slow and fuzzy. He or she is inattentive and loses the train of thought. Spontaneous movements are decreased. See Table 5-3 for definitions of the other terms.
A. Global aphasia
B. Broca’s aphasia
D. Wernicke’s aphasia
This illustrates Wernicke’s, or receptive aphasia. The person can hear sounds and words but cannot relate them to previous experiences. Speech is fluent, effortless, and well articulated, but it has many paraphasias (word substitutions that are malformed or wrong) and neologisms (made-up words) and often lacks substantive words. Speech can be totally incomprehensible. Often, there is a great urge to speak. Repetition, reading, and writing also are impaired. Echolalia is imitation or repetition of another person’s words or phrases. See Table 5-4 for definitions of the other disorders.
Circumlocution is a roundabout expression, substituting a phrase when one cannot think of the name of the object.
A. “My stomach hurts. Hurts, spurts, burts.”
B. “Kiss, wood, reading, ducks, onto, maybe.”
C. “Take this pill? The pill is red. I see red. Red velvet is soft, soft as a baby’s bottom.”
D. “I wash my hands, wash them, wash them. I usually go to the sink and wash my hands.
Flight of ideas is demonstrated by an abrupt change, rapid skipping from topic to topic, and practically continuous flow of accelerated speech. Topics usually have recognizable associations or are plays on words.
A. Has a snake phobia.
B. Is a hypochondriac; snakes are usually harmless.
C. Has an obsession with snakes.
D. Has a delusion that snakes are harmful, and it must stem from an early traumatic incident involving snakes.
A phobia is a strong, persistent, irrational fear of an object or situation; the person feels driven to avoid it. The other terms are defined in Table 5-7.
D. Inappropriate affect.
An inappropriate affect is an effect clearly discordant with the content of the person’s speech. The other terms are defined in Table 5-5.
A. A man believes that his dead wife is talking to him.
B. A woman hears the doorbell ring and goes to answer it, but no one is there.
C. A child sees a man standing in his closet. When the lights are turned on, it is only a dry cleaning bag.
D. A man believes that the dog has curled up on the bed, but when he gets closer he sees that it is a blanket.
Hallucinations are sensory perceptions for which there are no external stimuli. They may strike any sense: visual, auditory, tactile, olfactory, or gustatory.
A. Affect and mood.
B. Memory and affect.
C. Language abilities.
D. Level of consciousness and cognitive abilities.
Delirium is a disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention. It is not an alteration in mood, affect, or language abilities.
A. “Have you had any weight changes?”
B. “Are you having any thoughts of suicide?”
C. “How long have you been feeling this way?”
D. “Are you having feelings of worthlessness?”
Major depressive disorder is characterized by one or more major depressive episodes (i.e., at least 2 weeks of depressed mood or loss of interest accompanied by at least four additional symptoms of depression). Dysthymic disorder is characterized by at least 2 years of depressed mood for more days than not, accompanied by additional depressive symptoms.
A. “How are things going with the trial?”
B. “How are things going with your job?”
C. “Tell me about your recent engagement!”
D. “Are you having any disturbing dreams?”
In posttraumatic stress disorder the person has been exposed to a traumatic event. The traumatic event is persistently reexperienced by recurrent and intrusive, distressing recollections of the event, including images, thoughts, or perceptions; recurrent distressing dreams of the event; and acting or feeling as if the traumatic event were recurring.
A. Mental status assessment diagnoses specific psychiatric disorders.
B. Mental disorders occur in response to everyday life stressors.
C. Mental status functioning is inferred through assessment of an individual’s behaviors.
D. Mental status can be assessed directly, just like other systems of the body (e.g, cardiac and breath sounds)
Mental status functioning is inferred through assessment of an individual’s behaviors. It cannot be assessed directly like characteristics of the skin or heart sounds.
A. “How do you usually feel? Is this normal behavior for you?”
B. “I am going to say four words. In a few minutes, I will ask you to recall them.”
C. “Please describe the meaning of the phrase, ‘Looking through rose-colored glasses.'”
D. “Please pick up the pencil in your left hand, move it to your right hand, and place it on the table.”
Attention span is evaluated by assessing the individual’s ability to concentrate and complete a thought or task without wandering. Giving a series of directions to follow is one method used to assess attention span.
A. “Please count back from 100 by seven.”
B. “I will name three items and ask you to repeat them in a few minutes.”
C. “Please point to articles in the room and parts of the body as I name them.”
D. “What would you do if you found a stamped, addressed envelope on the sidewalk?”
Additional tests for persons with aphasia include word comprehension (asking the individual to point to articles in the room or parts of the body), reading (asking the person to read available print), and writing (asking the person to make up and write a sentence).
A. “Do you have a weapon?”
B. “How do other people treat you?”
C. “Are you feeling so hopeless that you feel like hurting yourself now?”
D. “Oftentimes people feel hopeless, but the feelings resolve within a few weeks.”
When the person expresses feelings of hopelessness, despair, or grief, it is important to assess for risk of physical harm to himself or herself. Begin this process with more general questions. If the answers are affirmative, then continue with more specific questions.
A. Scores below 30 indicate cognitive impairment.
B. It is a good tool to evaluate mood and thought processes.
C. It is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness.
D. It is useful for an initial evaluation of mental status. Additional tools are needed to evaluate cognition changes over time.
The Mini-Mental State Examination is a quick, easy test of 11 questions. It is used for initial and serial evaluations and can demonstrate worsening or improvement of cognition over time and with treatment. It evaluates cognitive functioning, not mood or thought processes. It is a good screening tool to detect dementia and delirium and to differentiate these from psychiatric mental illness.
D. Amnestic disorder
The development of a memory impairment (inability to learn new information or recall previously learned information) in the absence of other significant cognitive impairments may be due to a pathology such as closed head trauma.
Global aphasia is the most common and severe form of aphasia. Spontaneous speech is absent or reduced to a few stereotyped words or sounds, and prognosis for language recovery is poor. Broca’s and Wernicke’s aphasias are described in Table 5-4. Dysphonic aphasia is not a valid condition.
Clanging is word choice based on sound, not meaning, and includes nonsense rhymes and puns. The other terms are defined in Table 5-6.
A. Social phobia.
B. Compulsive disorder.
C. Generalized anxiety disorder.
D. Posttraumatic stress disorder
Repetitive behaviors, such as handwashing, are behaviors that the person feels driven to perform in response to an obsession. The behaviors are aimed at preventing or reducing distress or preventing some dreaded event or situation.
A. Cognitive impairment
D. Attention deficit disorder
The Mini-Cog is a newer instrument that screens for cognitive impairment, often found with dementia. The result of an abnormal drawing of a clock and time indicates a cognitive impairment.
C. Word salad
Echolalia occurs when a person imitates or repeats another’s words or phrases, often with a mumbling, mocking, or mechanical tone.
A. Develops over a short period of time
B. Person is experiencing apraxia
C. Memory impairment or deficits
D. Occurs as a result of a medical condition, such as systemic infection
E. Person is experiencing agnosia
Delirium is a disturbance of consciousness that develops over a short period of time and may be due to a medical condition. Memory deficits may also occur. Apraxia and agnosia occur with dementia.