Mental Status Examination and Substance Abuse Assessment, Exams of Nursing

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Mental status is defined as A.) A pt's emotional & cognitive function B.) The pt's conscious, mood, and affect C.) General Intelligence D.) Pt's perception - - CORRECT ANSWER- - A.) A pt's emotional & cognitive function A mental disorder is best defined as A.) Presence of phobia B.) A lack of rational thought and abstract researching C.) Extreme behavior that is usually associated with stress D.) Remote memory from years ago may be impacted - - CORRECT ANSWER- - C.) Extreme behavior that is usually associated with stress The A, B, C, and T of the mental health assessment is A.) Attitude, behavior, cleanliness, talk/speech B.) Appearance, behavior, cognition, and thought C.) Airway, breathing, circulation D.) Ability, beliefs, culture, traditions - - CORRECT ANSWER- - B.) Appearance, behavior, cognition, and thought

Which of the following best describes a pt's appearance? A.) Posture is erect and body movement is voluntary B.) Pt is oriented x C.) Pt is awake, alert, and aware and responds appropriately D.) GAD score > 3 - - CORRECT ANSWER- - A.) Posture is erect and body movement is voluntary One method a nurse can use to assess recent memory A.) Assess a pt's ability to complete a thought without wandering B.) Ask pt for a 24 hour diet recall C.) Ask about pt's first job D.) Perform 4 unrelated words test - - CORRECT ANSWER- - B.) Ask pt for a 24 hour diet recall Recent memory deficit can occur with delirium and dementia A.) True B.) False - - CORRECT ANSWER- - A.) True A nurse can assess a pt's attention span by giving a series of directions to follow and note correct sequence performed A.) True B.) False - - CORRECT ANSWER- - A.) True

To assess for new learning using 4 unrelated words, after 5 minutes, ask for the recall of A.) 5 words B.) 10 words C.) 4 words D.) 8 words - - CORRECT ANSWER- - C.) 4 words To test the duration of memory using the new learning 4 unrelated words test, ask for a recall at A.) 10 and 30 minutes B.) 5 and 10 minutes C.) 15 and 60 minutes D.) 1 and 2 hours - - CORRECT ANSWER- - A.) 10 and 30 minutes Which of the following is not one of the 4 most common anxiety disorders? A.) Panic disorder B.) Posttraumatic stress disorder C.) Social anxiety disorder D.) Depression - - CORRECT ANSWER- - D.) Depression The PH-Q depression screening tool defines minimal symptoms in what score range? A.) > 20 B.) 10- 14

C.) 1- 5

D.) 5- 9 - - CORRECT ANSWER- - D.) 5- 9

Obtunded means A.) Drifts off to sleep when not stimulated B.) Responds only to persistent shaking or pain C.) Will wake with loud shouting or vigorous shake D.) No response to pain or any external stimuli - - CORRECT ANSWER- - C.) Will wake with loud shouting or vigorous shake Expressive aphasia is also known as A.) Broca aphasia B.) Global aphasia C.) Wernicke aphasia D.) Receptive aphasia - - CORRECT ANSWER- - A.) Broca aphasia Delirium is a chronic progressive loss of cognitive and intellectual functions A.) True B.) False - - CORRECT ANSWER- - B.) False Hypochondriasis means A.) Person believes they are God

B.) Person feels "They are out to get me" C.) Morbid fear of their lack of health or a fear of having cancer D.) Irrational fear of an object - - CORRECT ANSWER- - C.) Morbid fear of their lack of health or a fear of having cancer Which substance displays signs of intoxication of reddened eyes, relaxation, suspicious A.) Cocaine B.) Nicotine C.) Cannabis D.) Opiates - - CORRECT ANSWER- - C.) Cannabis Which substance displays signs of intoxication of pinpoint pupils, decreased pulse, and BP A.) Cocaine B.) Nicotine C.) Cannabis D.) Opitaes - - CORRECT ANSWER- - D.) Opitaes Which substance displays signs of intoxication of pupillary dilation, chills, and nausea A.) Cocaine B.) Nicotine C.) Cannabis D.) Opiates - - CORRECT ANSWER- - A.) Cocaine

Which areas on the body are lymph nodes NOT easily palpated? A.) Head, neck, inguinal B.) Breast and neck C.) Axillae and arm D.) Popliteal and inguinal - - CORRECT ANSWER- - B.) Breast and neck The corneal light reflex is also called A.) Convergence test B.) Accomodation test C.) PEARRLA D.) Hirschberg test - - CORRECT ANSWER- - D.) Hirschberg test As people age, the skin begins to "sag" NOT due to A.) Reduced subcutaneous fat B.) Decreased moisturizer C.) Decreased elasticity D.) Decreased protein and fats in diet - - CORRECT ANSWER- - D.) Decreased protein and fats in diet With the older adult, nurses must remain aware of lingering effects if medications and drugs due to A.) Increased liver and kidney functioning B.) Decreased cardiac functioning

C.) Decreased liver and kidney functioning D.) Decreased subcutaneous fat - - CORRECT ANSWER- - C.) Decreased liver and kidney functioning If the patellar joint is able to articulate, it is able to A.) Have range of motion B.) Become dislocated C.) Remain rigid D.) Withstand a higher BMI - - CORRECT ANSWER- - A.) Have range of motion A cluster headache A.) May be caused by alcohol and napping B.) Are described as throbbing C.) Can occur several times a month D.) Is usually retro-orbital - - CORRECT ANSWER- - A.) May be caused by alcohol and napping Is non-tenderness or tenderness an indication of malignancy? A.) Non-tenderness B.) Tenderness - - CORRECT ANSWER- - A.) Non-tenderness What does the Whisper Voice Test detect? A.) High frequency or high tone loss

B.) Ear formation development C.) Memory recall D.) Amount of cerumen in the ear canal - - CORRECT ANSWER- - A.) High frequency or high tone loss Which of the following is NOT true of the external ear? A.) Called Pinna B.) Terminates at the eardrum C.) Consists of movable cartilage D.) Tunnels through temporal bone - - CORRECT ANSWER- - D.) Tunnels through temporal bone Which of the following is NOT true of cerumen? A.) Wax forms sticky barrier B.) Is part of the middle ear C.) Helps keep foreign bodies from entering tympanic membrane D.) Migrates out with chewing and talking - - CORRECT ANSWER- - B.) Is part of the middle ear What color is the normal color of the tympanic membrane? A.) White B.) Pale yellow C.) Pearly gray D.) Pink - - CORRECT ANSWER- - C.) Pearly gray

Lymphatic drainage of the external ear flows to A.) Parotid, mastoid, superficial cervical B.) Submental submandibular C.) Postauricular, eustachian tube D.) Mastoid, preauricular, deep cervical chain - - CORRECT ANSWER- - A.) Parotid, mastoid, superficial cervical Which is NOT true of the middle ear? A.) It is a tiny air-filled cavity B.) Protected by the tympanic membrane C.) Contains 3 ossicles or 3 bones D.) Contains the cochlea - - CORRECT ANSWER- - D.) Contains the cochlea The sounds amplitude means A.) The pitch B.) The vibration C.) The loudness D.) The fibers - - CORRECT ANSWER- - C.) The loudness Normal pathway of hearing is A.) Air conduction

B.) Water conduction C.) Bone conduction - - CORRECT ANSWER- - A.) Air conduction What causes presbycusis? A.) Nerve degeneration that occurs with aging B.) Too much cerumen in the ear canal C.) Bright light D.) The room is spinning - - CORRECT ANSWER- - A.) Nerve degeneration that occurs with aging While completing health hx, to evaluate pt's mental status, the nurse must observe A.) Appearance, behavior, cognition, thought process B.) Ask pt's family about coping skills C.) The presence of phobias D.) Perform an IQ test - - CORRECT ANSWER- - A.) Appearance, behavior, cognition, thought process Older adults tend to report pain... A.) Is dull due to neuropathy B.) Describing it as walking on pins and needles C.) Infrequently D.) Heightened due to loss of fat - - CORRECT ANSWER- - C.) Infrequently What specialized nerve endings detect painful sensations in the peripheral system?

A.) Noxious stimuli B.) Nociceptors C.) Modulation D.) Opioid receptors - - CORRECT ANSWER- - B.) Nociceptors Neuropathic pain is often due to... A.) Lesion or disease in somatosensory nervous system B.) Responding when touching a hot stove C.) Poorly controlled chronic nociceptive pain D.) Typically predictable - - CORRECT ANSWER- - A.) Lesion or disease in somatosensory nervous system The pain scale is used to measure the pain's... A.) Length B.) Quality C.) Location D.) Severity - - CORRECT ANSWER- - D.) Severity Which area are lymph rarely palpable? A.) Arms B.) Neck C.) Inguinal

D.) Breast - - CORRECT ANSWER- - D.) Breast Which part of the stethoscope is used to listen for abnormal sounds? A.) Diaphragm B.) Earbuds C.) Bell - - CORRECT ANSWER- - C.) Bell The diaphragm of the stethoscope is used to detect A.) Bruit sound B.) Normal S1 and S2 sounds C.) Murmur sound D.) Whooshing sound - - CORRECT ANSWER- - B.) Normal S1 and S2 sounds When using a snellen chart, what does 20/10 mean? A.) Pt reads at 20 feet when normal person reads at 10 feets B.) Normal person reads 20 feet and pt reads at 10 feet C.) Pt reads at 10 feet when normal person reads at 20 feet D.) Pt is legally blind - - CORRECT ANSWER- - A.) Pt reads at 20 feet when normal person reads at 10 feets Approximate means A.) Line up close to equally

B.) Distal C.) Opposite D.) Lateral - - CORRECT ANSWER- - A.) Line up close to equally Bilateral - - CORRECT ANSWER- - Occurs on both sides of the body Ipsilateral - - CORRECT ANSWER- - Occurs more than once on the same side of the body Unilateral - - CORRECT ANSWER- - Occurs on one side of the body Contralateral - - CORRECT ANSWER- - Occurs more than once on opposite side of the body ABC or T? Level of Consciousness - - CORRECT ANSWER- - B - Behavior ABC or T? Mood and Affect - - CORRECT ANSWER- - B - Behavior ABC or T? Body Movement - - CORRECT ANSWER- - A - Appearance ABC or T? Pupils - - CORRECT ANSWER- - A - Appearance ABC or T? Dress - - CORRECT ANSWER- - A - Appearance

ABC or T? Posture - - CORRECT ANSWER- - A - Appearance ABC or T? Remote Memory - - CORRECT ANSWER- - C - Cognitive ABC or T? Screen for suicidal thoughts - - CORRECT ANSWER- - T - Thought process ABC or T? Thought content - - CORRECT ANSWER- - T - Thought process ABC or T? Grooming - - CORRECT ANSWER- - A - Appearance ABC or T? Hygiene - - CORRECT ANSWER- - A - Appearance ABC or T? Judgment - - CORRECT ANSWER- - C - Cognitive ABC or T? Perception - - CORRECT ANSWER- - T - Thought Process ABC or T?

Speech - - CORRECT ANSWER- - B - Behavior ABC or T? Recent Memory - - CORRECT ANSWER- - C - Cognitive ABC or T? Facial Expression - - CORRECT ANSWER- - B - Behavior ABC or T? Attention Span - - CORRECT ANSWER- - C - Cognitive ABC or T? Orientation - - CORRECT ANSWER- - C - Cognitive ABC or T? New learning - - CORRECT ANSWER- - C - Cognitive Which answer below does not describe a patch?

• Solely a color change
• Larger than 1 cm
• Pruritic
• Examples include mongolian spot, chloasma - - CORRECT ANSWER- - Pruritic Which of the following describes a papule?
• Something you can feel, smaller than 1 cm
• Something you can feel, larger than 1 cm

• Examples include psoriasis and mosquito bite
• Soft nodule - - CORRECT ANSWER- -- Something you can feel, smaller than 1 cm Which of the statements is true for a nodule?
• Flat, shallow, smaller than 1 cm
• Elevated, soft, smaller than 1 cm
• Solid, elevated, soft, larger than 1 cm
• Solid, flat, shallow, larger than 1 cm - - CORRECT ANSWER- -- Solid, elevated, soft, larger than 1 cm T/F Purpura is a confluent patch of petechiae and ecchymoses - - CORRECT ANSWER- - True T/F A papule is solid and elevated, caused by superficial thickening - - CORRECT ANSWER-
• True T/F A wheal is superficial, raised, and erythematous - - CORRECT ANSWER- - True T/F A pustule contains pus like acne - - CORRECT ANSWER- - True T/F Petechiae is tiny punctate hemorrhages, > 3mm - - CORRECT ANSWER- - False Which of the following is incorrect in regards to petechiae?
• Tiny hemorrhages
• Dark red, purple, or brown in color

• 3mm

• 1 - 3 mm - - CORRECT ANSWER- - > 3mm

Cannabis intoxication - - CORRECT ANSWER- - Red eyes, dry mouth, increased appetite, slowed judgment Alcohol intoxication - - CORRECT ANSWER- - Slurred speech, impaired memory, depression Moderate drinking for men - - CORRECT ANSWER- - 2 or less per day Moderate drinking for women - - CORRECT ANSWER- - 1 or less per day Heavy drinking for men - - CORRECT ANSWER- - 15 or more drinks per week Binge drinking for men - - CORRECT ANSWER- - 5 or more drinks per occasion Binge drinking for women - - CORRECT ANSWER- - 4 or more drinks per occasion Cocaine withdrawal - - CORRECT ANSWER- - Psychomotor agitation Heavy drinking for women - - CORRECT ANSWER- - 8 or more drinks per week Nicotine intoxication - - CORRECT ANSWER- - Alert, increased HR, nausea, vomiting, jittery feeling Heroin withdrawal - - CORRECT ANSWER- - dilated pupils, fever, insomnia, runny nose, sweating Cocaine intoxication - - CORRECT ANSWER- - Pupil dilation, chills, weight loss

Cannabis withdrawal - - CORRECT ANSWER- - Mild, loss of appetite Nicotine withdrawal - - CORRECT ANSWER- - Vasodilation, headaches, anxiety, difficulty concentrating Heroin intoxication - - CORRECT ANSWER- - Pinpoint pupils, decreased BP, and respirations Alcohol withdrawal - - CORRECT ANSWER- - Tremor of hands, nausea, tachycardia, anxiety, insomnia Which lobe? Movement, problem solving, concentrating, thinking, behavior, mood, personality - - CORRECT ANSWER- - Frontal Lobe Which lobe? Hearing, language, memory - - CORRECT ANSWER- - Temporal lobe Which lobe? Sensations, language, perception, body awareness, attention - - CORRECT ANSWER- - Parietal lobe Which lobe? Vision, perception - - CORRECT ANSWER- - Occipital lobe Brain structure that controls posture, balance, and coordination of movement - - CORRECT ANSWER- - Cerebellum

Landmark to find the thyroid - - CORRECT ANSWER- - Cricoid cartilage Function of the parathyroid - - CORRECT ANSWER- - Calcium regulation Goiter - - CORRECT ANSWER- - Enlarged thyroid Pilar cyst (wen) - - CORRECT ANSWER- - Smooth, firm, fluctuant swelling on scalp, pressure of contents causes overlying skin to be shiny and taut; benign When is the parotid gland palpable? - - CORRECT ANSWER- - Mumps (causes rapid, painful parotid inflammation) Cushing's Syndrome - - CORRECT ANSWER- - Excessive cortisol, lots of fat, apple-shaped Graves' disease - - CORRECT ANSWER- - Hyperthyroidism, "look like they're going to the grave", thin Bell's Palsy - - CORRECT ANSWER- - One-sided facial paralysis (Treated w/steroids) Strabismus - - CORRECT ANSWER- - "Cross-eyed" There are various forms w/different names Anisocoria - - CORRECT ANSWER- - Unequal pupil size (opposite of PERRLA) Miosis - - CORRECT ANSWER- - Pupil constriction

Mydriasis - - CORRECT ANSWER- - Pupil dilation Conjunctivitis - - CORRECT ANSWER- - Pink eye Subconjunctival hemorrhage - - CORRECT ANSWER- - Pressure causes pop of tiny blood vessels (Labor, straining from pooping) What size speculum to use for otoscope? - - CORRECT ANSWER- - Largest one that will fit How to position ear for examination? - - CORRECT ANSWER- - Tilt head away from nurse, pull pinna up and back (adult) Normal color of tympanic membrane - - CORRECT ANSWER- - Pearly gray What if you don't see the "cone of light" off tympanic membrane? - - CORRECT ANSWER- - Possible swelling, fluid Scarring on tympanic membrane - - CORRECT ANSWER- - Dense white patch on tympanic membrane, often due to repeated ear infections How far behind patient do you stand for whisper test? - - CORRECT ANSWER- - 1 - 2 ft (30- 60 cm) Where is the tuning fork placed during a Weber test? - - CORRECT ANSWER- - Top of the head in the middle The nurse is assessing a patient who has a hearing impairment. How should the nurse communicate with this patient?

1. Use a low tone voice and speak slowly
2. Use a normal tone of voice and speak slowly
3. Speak loudly with normal rate
4. Face the patient and speak slowly - - CORRECT ANSWER- - 4. Face the patient and speak slowly