Jarvis: Physical Examination & Health Assessment, 6th Edition

Chapter 05: Mental Status Assessment

Test Bank

MULTIPLE CHOICE

1. During an examination, the nurse can assess mental status by which activity?
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
ANS: C
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.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF: Page: 71 MSC: Client Needs: Psychosocial Integrity

2. The nurse is assessing mental status of a child. Which of these statements about
children and mental status is true?
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.
ANS: A
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.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF: Page: 72 MSC: Client Needs: Psychosocial Integrity

3. The nurse is assessing a 75-year-old man. As the nurse begins the mental status
portion of the assessment, the nurse expects that this patient:
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.
ANS: C
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.

PTS: 1 DIF: Cognitive Level: Analyzing (Analysis)

REF: Page: 72 MSC: Client Needs: Psychosocial Integrity

4. When assessing aging adults, the nurse knows that one of the first things that
should be assessed before making judgments about their mental status is:
A) the presence of phobias.
B) their general intelligence.
C) the presence of irrational thinking patterns.
D) their sensory-perceptive abilities.
ANS: D
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.

PTS: 1 DIF: Cognitive Level: Analyzing (Analysis)

REF: Pages: 74-75 MSC: Client Needs: Psychosocial Integrity

5. The nurse is preparing to do a mental status examination. Which statement is true

regarding the mental status examination?
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 examina-
tion 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.
ANS: B
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.
PTS: 1 DIF: Cognitive Level: Applying (Application)
REF: Page: 73 MSC: Client Needs: Psychosocial Integrity

6. 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 deal of his memory of recent
events. Which statement reflects the nurse’s best course of action? The nurse should:
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.
ANS: A
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.

PTS: 1 DIF: Cognitive Level: Applying (Application)

REF: Pages: 72-73 MSC: Client Needs: Psychosocial Integrity

7. 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.
ANS: C
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.

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REF: Page: 73 MSC: Client Needs: Psychosocial Integrity

8. 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.
ANS: A
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.

PTS: 1 DIF: Cognitive Level: Analyzing (Analysis)

REF: Page: 73 MSC: Client Needs: Psychosocial Integrity

9. 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.
ANS: D
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.

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10. A patient has been in the intensive care unit for 10 days. He has just been moved
to the medical-surgical 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.
ANS: C
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.

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REF: Pages: 74-75 MSC: Client Needs: Psychosocial Integrity

11. 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?”
ANS: A
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.

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12. 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.
ANS: C
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.

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REF: Pages: 74-75 MSC: Client Needs: Psychosocial Integrity

13. A 45-year-old woman is at the clinic for a mental status assessment. In giving her
the Four Unrelated Words Test, the nurse would be concerned if she could not _____ four
unrelated words _____.
A) invent; within 5 minutes
B) invent; within 30 seconds
C) recall; after a 30-minute delay
D) recall; after a 60-minute delay
ANS: C
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.

PTS: 1 DIF: Cognitive Level: Analyzing (Analysis)

REF: Pages: 74-75 MSC: Client Needs: Psychosocial Integrity

14. 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) “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?”
ANS: B
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.

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REF: Pages: 76-77 MSC: Client Needs: Psychosocial Integrity

15. Which of these individuals would the nurse consider at highest risk for a suicide
attempt?
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
ANS: D
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.

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REF: Pages: 77-78 MSC: Client Needs: Psychosocial Integrity

16. The nurse is performing a mental status assessment on a 5-year-old girl. Her
parents are undergoing a bitter divorce and are worried about the effect it is having on their
daughter. Which action or statement might lead the nurse to be concerned about the girl’s mental
status?
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.
ANS: D
The mental status assessment of infants and children covers behavioral, cognitive, and psychoso-
cial 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 knowl-
edge 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).

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17. The nurse is planning to assess a child using the Behavioral Checklist. This tool is
most appropriate for a(n):
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.
ANS: A
For school-age children, ages 7 to 11 years, who have grown beyond the age when developmen-
tal 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.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF: Page: 80 MSC: Client Needs: Psychosocial Integrity

18. The nurse is assessing orientation in a 79-year-old patient. Which of these

responses would lead the nurse to conclude that this patient is oriented?
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.”
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 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.

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REF: Pages: 80-81 MSC: Client Needs: Psychosocial Integrity

19. The nurse is performing the Denver II screening test on a 12-month-old infant
during a routine well-child visit. The nurse should tell the infant’s 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 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.
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 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.

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20. A patient drifts off to sleep when she is not being stimulated. The nurse can
arouse her easily when calling her name, but she remains drowsy during the conversation. The
best description of this patient’s level of consciousness would be:
A) lethargic.
B) obtunded.
C) stuporous.
D) semialert.
ANS: A
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.

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21. A patient has had a cerebrovascular accident, or stroke. He is trying very hard to
communicate. He seems driven to speak and says, “I buy obie get spirding and take my train.”
What is the best description of this patient’s problem?
A) Global aphasia
B) Broca’s aphasia
C) Echolalia
D) Wernicke’s aphasia
ANS: D
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.

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22. A patient seems to repeatedly have difficulty coming up with a word. He says, “I
was on my way to work, and when I got there, the thing that you step into that goes up in the air
was so full that I decided to take the stairs.” The nurse will note on his chart that he is using or
experiencing:
A) blocking.
B) neologism.
C) circumlocution.
D) circumstantiality.
ANS: C
Circumlocution is a roundabout expression, substituting a phrase when one cannot think of the
name of the object.

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REF: Page: 86 MSC: Client Needs: Psychosocial Integrity

23. During an examination, the nurse notes that a patient is exhibiting flight of ideas.
Which statement by the patient is an example of flight of ideas?
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.”
ANS: C
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.

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REF: Page: 86 MSC: Client Needs: Psychosocial Integrity

24. A patient describes feeling an unreasonable, irrational fear of snakes. It is so

persistent that he can no longer comfortably even look at pictures of snakes and has made an
effort to identify all the places he might encounter a snake and avoids them. The nurse recog-
nizes that he:
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.
ANS: A
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.

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25. A patient has been diagnosed with schizophrenia. During a recent interview, he
shows the nurse a picture of a man holding a decapitated head. He describes this picture as
horrifying and laughs loudly at the content. This behavior is a display of:
A) confusion.
B) ambivalence.
C) depersonalization.
D) inappropriate affect.
ANS: D
An inappropriate affect is an affect clearly discordant with the content of the person’s speech.
The other terms are defined in Table 5-5.

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26. During report, the nurse hears that a patient is experiencing hallucinations. Which
is an example of a hallucination?
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.
ANS: A
Hallucinations are sensory perceptions for which there are no external stimuli. They may strike
any sense: visual, auditory, tactile, olfactory, or gustatory.

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REF: Page: 87 MSC: Client Needs: Psychosocial Integrity

27. A 20-year-old construction worker has been brought into the emergency depart-
ment with heat stroke. He has delirium as a result of the fluid and electrolyte imbalance. For the
mental status examination, the nurse should first assess the patient’s:
A) affect and mood.
B) memory and affect.
C) language abilities.
D) level of consciousness and cognitive abilities.
ANS: D
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.

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28. A patient states, “I feel so sad all of the time. I can’t feel happy even doing things
I used to like to do.” He also states that he is tired, sleeps poorly, and has no energy. To differen-
tiate between dysthymic disorder and a major depressive disorder, the nurse should ask which
question?
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?”
ANS: C
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.

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 29. A 26-year-old woman was robbed and beaten a month ago. She is returning to the
clinic today for a follow-up assessment. The nurse would want to be certain to ask her which of
these questions?
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?”
ANS: D
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.

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REF: Pages: 90-91 MSC: Client Needs: Psychosocial Integrity

30. The nurse is performing a mental status examination. Which statement is true
regarding the assessment of mental status?
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 behav-
iors.
D) Mental status can be assessed directly, just like other systems of the body (e.g.,
cardiac and breath sounds).
ANS: C
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.

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31. A 23-year-old patient in the clinic appears anxious. Her speech is rapid, and she is
fidgety and in constant motion. Which of these questions or statements would be most appropri-
ate for the nurse to use in this situation to assess attention span?
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.”
ANS: D
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.

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REF: Pages: 74-75 MSC: Client Needs: Psychosocial Integrity

32. The nurse is planning health teaching for a 65-year-old woman who has had a
cerebrovascular accident, or stroke, and is aphasic. Which of these questions is most important to
use when assessing mental status in this situation?
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?”
ANS: C
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).

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REF: Pages: 74-75 MSC: Client Needs: Psychosocial Integrity

33. A 30-year-old female patient is describing feelings of hopelessness and

depression. She has attempted self-mutilation and has a history of prior suicide attempts. She
describes difficulty sleeping at night and has lost 10 pounds in the past month. Which of these
statements or questions is the nurse’s best response in this situation?
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.”
ANS: C
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.

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REF: Pages: 77-78 MSC: Client Needs: Psychosocial Integrity

34. The nurse is providing instructions to newly hired graduates about the Mini-
Mental State Examination. Which statement best describes this examination?
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.
ANS: C
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.

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REF: Page: 78 MSC: Client Needs: Psychosocial Integrity

35. A 45-year-old woman is brought to the emergency department with a head injury
after her car hit a tree. A few months after recovering from her injuries, the nurse notes during an
examination that she is unable to learn new information or recall previously learned information.
This is an example of:
A) mania.
B) agnosia.
C) dementia.
D) amnestic disorder.
ANS: D
The development of a memory impairment (inability to learn new information or recall previous-
ly learned information) in the absence of other significant cognitive impairments may be due to a
pathology such as closed head trauma.

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36. The nurse discovers speech problems in a patient during an assessment. The
patient has spontaneous speech, but it is mostly absent or is reduced to a few stereotyped words
or sounds. This finding reflects which type of aphasia?
A) Global
B) Broca’s
C) Dysphonic
D) Wernicke’s
ANS: A
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.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF: Page: 84 MSC: Client Needs: Psychosocial Integrity
 37. A patient repeats, “I feel hot. Hot, cot, rot, tot, got. I’m a spot.” The nurse
documents this as an illustration of:
A) blocking.
B) clanging.
C) echolalia.
D) neologism.
ANS: B
Clanging is word choice based on sound, not meaning, and includes nonsense rhymes and puns.
The other terms are defined in Table 5-6.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF: Page: 86 MSC: Client Needs: Psychosocial Integrity

38. During an interview, the nurse notes that the patient gets up several times to wash
her hands even though they are not dirty. This is an example of:
A) social phobia.
B) compulsive disorder.
C) generalized anxiety disorder.
D) posttraumatic stress disorder.
ANS: B
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.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF: Page: 87 MSC: Client Needs: Psychosocial Integrity

39. The nurse is administering a Mini-Cog test to an elderly woman. When asked to
draw a clock showing the time of 10:45, the patient drew a clock with the numbers out of order
and with the time incorrect. This result indicates which finding?
A) Cognitive impairment
B) Amnesia
C) Delirium
D) Attention deficit disorder
ANS: A
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 impair-
ment.

PTS: 1 DIF: Cognitive Level: Analyzing (Analysis)

REF: Pages: 80-81 MSC: Client Needs: Psychosocial Integrity

40. During morning rounds, the nurse asks a patient, “How are you today?” The
patient responds, “You today, you today, you today!” and mumbles the words. This speech
pattern is an example of:
A) Echolalia
B) Clanging
C) Word salad
D) Perseveration
ANS: A
Echolalia occurs when a person imitates or repeats another’s words or phrases, often with a
mumbling, mocking, or mechanical tone.

PTS: 1 DIF: Cognitive Level: Applying (Application)

REF: Page: 86 MSC: Client Needs: Psychosocial Integrity

MULTIPLE RESPONSE

1. The nurse is assessing a patient who was admitted with possible delirium. Which
of these are manifestations of delirium? Select all that apply.
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
ANS: A, C, D
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.

PTS: 1 DIF: Cognitive Level: Applying (Application)

REF: Page: 87 MSC: Client Needs: Psychosocial Integrity