20.6.0: Review Questions

Review Questions

1 .

The nurse prepares to perform a mental health assessment on a newly admitted patient. The patient’s family took him to the doctor with concerns that he believed someone was putting thoughts into his head. After his physical exam, the primary care doctor sent him to the hospital for treatment. What symptom is the patient displaying?

1. thought blocking
2. thought broadcasting
3. thought withdrawal
4. thought insertion

2 .

A nurse assesses a newly admitted patient. What observation most concerns the nurse regarding the patient’s mental health history?

1. The patient states he only likes to eat “gozi blather” for each meal and states this is all he will eat while admitted.
2. The patient mentions that he has thought about suicide for the last few weeks and has collected bottles of pills to “get the job done.”
3. The patient speaks in incoherent, disorganized speech, and his words do not seem to have any meaning.
4. The patient wishes to tell the nurse about his model train set in great detail.

3 .

The nurse is preparing to conduct a mental health assessment on a patient who has been on the unit for one week following a suicide attempt. What test would the nurse likely administer?

1. mental health score
2. head CT (computerized tomography)
3. Beck’s Depression Inventory
4. endoscopy

4 .

The nurse prepares to meet a new patient to administer a mental health assessment. What factor could have an impact on the outcome of the mental health assessment?

1. It is raining outside, and the patient loves the rain.
2. The patient is from New York, and the nurse is from California.
3. The patient expresses that she has had bad experiences with male nurses and requests that all her caregivers be female.
4. The patient had a dose of Tylenol before coming to the hospital.

5 .

The nurse is preparing for a day of admissions. He has to perform three mental status exams. What components is he assessing for in the exams?

1. thought generation, happiness survey, speech, mood and affect
2. appearance, behavior, affect, mood, speech, and cognitive performance
3. behavior, happiness survey, family history of cancer, mood, and speech
4. speech, behavior, agility, mood, and thought control

6 .

The nurse is assessing a 23-year-old male who uses heroin frequently, but he quit “cold turkey” two days ago. What withdrawal symptoms would the nurse expect to see?

1. irritability, attention and sleep problems, depression, increased appetite
2. restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goose bumps, and leg movements
3. depression, anxiety, tiredness
4. depression, tiredness, increased appetite, insomnia, vivid and unpleasant dreams, slowed thinking and movement, restlessness

7 .

Laura has just given birth to a baby girl. Laura admits she drinks five to six beers or glasses of wine daily. When the mother and her new daughter arrive on the mother/baby unit, what symptoms might the nurse expect to see in the baby?

1. no appetite, crying, blue hands and feet
2. diarrhea, a red rash covering the body, vomiting
3. low birth weight, difficulty latching on during breastfeeding, did not pass the hearing test
4. large head, extra fingers and toes, high blood sugar

8 .

A nurse is assessing an 83-year-old newly admitted patient who was transferred from the ER after he suffered alcohol poisoning from drinking a large amount of bourbon the evening before. Now the patient is stable. What assessment tool should the nurse use in his psychosocial assessment?

1. The DSM-5-TR
2. SMAST-G test
3. urinalysis
4. forming a hypothesis

9 .

In a patient’s health history, what assessment finding tells the nurse that the patient is experiencing substance use disorder (SUD)?

1. The patient is experiencing withdrawal symptoms when not using.
2. The patient has multiple speeding tickets.
3. The patient states that he is very depressed.
4. The patient has tested positive for marijuana.

10 .

A 60-year-old female with a history of chronic bilateral hip pain now requires a higher dose of hydrocodone to treat her pain than she did one year ago. What does the nurse assessing her believe this need results from?

1. abuse
2. withdrawal
3. dependence
4. tolerance

11 .

The nurse visits the home of a 57-year-old male who has diabetes and heart disease. He was seen in the clinic three days ago for wound therapy. When the nurse arrives, she notes that the man’s 14-year-old daughter cooks, cleans, and provides her father’s care. The nurse inquires about school, and the girl states that her father asked her to take some time off to care for him. She has been out of school for three weeks. What preliminary assessment is noted by the nurse?

1. The daughter is experiencing sexual abuse.
2. The daughter is experiencing neglect.
3. The father and daughter have worked this out, and it is not the nurse’s concern.
4. The daughter is experiencing a pattern of injuries.

12 .

Bill is a nurse working in the ER. His new patient is a 4-year-old male whose mother brought him in for injuries, reportedly caused by falling off the porch. What symptoms indicate that the child may be experiencing long-term abuse?

1. The patient is huddled under the covers and will not answer any questions.
2. The patient is wearing mismatched socks.
3. The patient’s x-rays show multiple fractures in varying stages of healing.
4. The patient states that he does not have many friends.

13 .

A teacher brings in a second-grade female to the school nurse during lunch. The teacher explains that this student has been acting very fatigued in class, complaining of a stomachache, and refusing to eat her lunches. She never had problems like this until about two weeks ago. When the nurse assesses the student, the child is very guarded in what she shares with them, but does report that an uncle came to stay in her home recently, and he “makes [her] feel uncomfortable.” Once the nurse completes an assessment, they note that the child has small blood spots on her underwear. Based on this, what action should the nurse take next?

1. Remember that a nurse cannot report suspected child abuse unless they have proof.
2. Make an appointment for the child with her pediatrician.
3. Reach out to the uncle to hear his side of the story.
4. Suspect that abuse has occurred and make a call to child protective services.

14 .

The nurse is seeing a 79-year-old established patient for a routine follow-up visit after a UTI. The patient lives with her daughter and son-in-law. Usually, she is brought in by her daughter but today is accompanied by her granddaughter who is home from college on winter break. The patient completed her prescribed course of TMP-SMX with complete resolution of UTI symptoms. The nurse prepares to take vitals and asks the patient if she needs help removing her bulky winter coat so a blood pressure reading can be taken. When the patient’s arm is removed from the sleeve and presented to the nurse, the granddaughter says, “Nana, what happened to your wrist?” The nurse looks down and notes a soft tissue injury encircling the wrist that appears to be consistent with friction or “rope” burn. What is the next step the nurse will take?

1. Call CPS to report elder abuse.
2. Ask the patient what happened.
3. Ask the granddaughter if she thinks the patient is being abused.
4. Do a more thorough physical assessment to check for other injuries.

15 .

A nurse works in the ER, and a female seen there often is his next patient. This patient has been seen for a black eye, a dislocated shoulder, and two concussions. She admits that her husband has been abusing her for years, but she is afraid to leave him because it would be difficult for her to support herself. During her assessment, she says, “My mother’s dying wish was that I leave him. I may someday.” What is the best response from the nurse?

1. “Do you have any family you can live with? You need to leave him today.”
2. Get the husband’s phone number to confront him.
3. “Will you work with me to put together a safety plan?”
4. Document the patient’s current symptoms and move on.