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HA ch. 7 NCLEX
Health Assessment ch. 7 NCLEX questions
| Question | Answer |
|---|---|
| 1. A nurse's performing a mental health assessment on a client. Which of the following is a primary component of the mental status examination? A. Blood pressure measurement B. Mini mental state examination (MMSE) C. Pain assessment D. Nutritional status assessment | B. Mini-Mental State Examination (MMSE) |
| 2. During the mental status examination, the nurse assesses the client's appearance. Which of the following is an example of this assessment? A. Level of consciousness B. Mood and affect C. Dress and grooming D. Thought process | C. Dress and grooming |
| 3. A nurse is using the Glasgow Coma Scale (GCS) to assess a client. Which of the following areas does the GCS evaluate? A. Speech, hearing, and movement B. Eye opening, verbal response, and motor response C. Memory, attention, and concentration D. Orientation, mood, and affect | B. Eye opening, verbal response, and motor response |
| 4. During a mental health assessment, the nurse asks the client to interpret the meaning of a common proverb. This question assesses the client's: A. Memory B. Abstract thinking C. Judgment D. Orientation | B. Abstract thinking |
| 5. A nurse is conducting a mental status examination and notes the client's speech is rapid and pressured. This finding is indicative of: A. Depression B. Mania C. Anxiety D. Schizophrenia | B. Mania |
| 6. A client is being assessed for suicide risk. Which question is most appropriate for the nurse to ask? A. "Do you have any chronic illnesses?" B. "Do you have any plans for the future?" C. "Do you feel hopeless or have thoughts of ending your life?" D. "Do you sleep well at night?" | C. "Do you feel hopeless or have thoughts of ending your life? |
| 7. The nurse asks the client to spell the word "WORLD" backwards. This question assesses: A. Remote memory B. Immediate memory C. Concentration D. Orientation | C. Concentration |
| 8. A client reports hearing voices that others do not hear. The nurse should document this as: A. Illusion B. Hallucination C. Delusion D. Obsession | B. Hallucination |
| 9. Which of the following behaviors would the nurse document as a positive sign of anxiety during a mental health assessment? A. Flat affect B. Calm demeanor C. Restlessness and pacing D. Euphoria | C. Restlessness and pacing |
| 10. A nurse is assessing a client's mood and affect. Which of the following descriptions is appropriate to document if the client displays a consistently sad and tearful demeanor? A. Euthymic mood B. Labile mood C. Dysphoric mood D. Euphoric mood | C. Dysphoric mood |
| 11. During a mental health assessment, the nurse observes that the client has difficulty staying on topic and frequently shifts conversation to unrelated topics. This behavior is known as: A. Tangentiality B. Flight of ideas C. Perseveration D. Clang association | A. Tangentiality |
| 12. The nurse is evaluating a client’s cognitive function. Which test would be most appropriate to assess the client’s ability to concentrate? A. Asking the client to recall three words after 5 minutes B. Asking the client to perform serial 7s C. Asking the client to name the past five U.S. presidents D. Asking the client to interpret a proverb | B. Asking the client to perform serial 7s |
| 13. A nurse is performing a mental status exam and asks the client, “What would you do if you found a stamped, addressed envelope on the ground?” This question assesses the client's: A. Orientation B. Judgment C. Abstract thinking D. Memory | B. Judgment |
| 14. Which of the following is considered an objective finding in a mental health assessment? A. The client reports feeling anxious B. The client states they are hearing voices C. The client appears disheveled and unkempt D. The client says they have a good support system | C. The client appears disheveled and unkempt |
| 15. A client with schizophrenia exhibits a flat affect. This means that the client: A. Has an exaggerated emotional response B. Displays a rapid shift in mood C. Shows no visible emotional expression D. Has an overly cheerful demeanor | C. Shows no visible emotional expression |
| 16. Which assessment tool is used to screen older adults for cognitive impairment? A. Glasgow Coma Scale B. Mini-Mental State Examination (MMSE) C. Beck Depression Inventory D. Hamilton Anxiety Rating Scale | B. Mini-Mental State Examination (MMSE) |
| 17. A nurse is assessing a client’s insight. Which of the following questions is most appropriate? A. “Can you tell me where you are right now?” B. “How would you describe your current health status?” C. “What day of the week is it?” D. “Can you count backward from 100 by sevens?” | B. “How would you describe your current health status? |
| 18. A nurse is conducting a mental health assessment and asks the client to draw the face of a clock and indicate the time “ten past eleven.” This task assesses the client’s: A. Language skills B. Executive function C. Short-term memory D. Long-term memory | B. Executive function |
| 19. Which of the following is a common sign of major depressive disorder that a nurse might observe during a mental health assessment? A. Euphoric mood B. Hyperactivity C. Anhedonia D. Increased appetite | C. Anhedonia |
| 20. The nurse is assessing the thought process of a client with bipolar disorder. Which finding is characteristic of a manic episode? A. Depressive mood B. Slow, monotonous speech C. Grandiose delusions D. Low energy levels | C. Grandiose delusions |
| 21. A nurse is assessing a client who exhibits repetitive handwashing and counting behaviors. These behaviors are characteristic of: A. Schizophrenia B. Obsessive-compulsive disorder (OCD) C. Generalized anxiety disorder (GAD) D. Panic disorder | B. Obsessive-compulsive disorder (OCD) |
| 22. Which of the following should the nurse assess to determine a client’s orientation? A. The client’s ability to recall a list of words B. The client’s knowledge of current events C. The client’s awareness of person, place, and time D. The client’s ability to solve a simple math problem | C. The client’s awareness of person, place, and time |
| 23. A nurse is assessing a client’s mood. Which of the following client statements should be documented as anhedonia? A. “I feel happy all the time.” B. “I don’t enjoy any of the activities I used to.” C. “I can’t stop crying.” D. “I feel anxious about everything.” | B. “I don’t enjoy any of the activities I used to |
| 24. A client diagnosed with post-traumatic stress disorder (PTSD) reports having frequent flashbacks. The nurse should document this symptom as: A. Hallucinations B. Delusions C. Reexperiencing D. Illusions | C. Reexperiencing |
| 25. During a mental health assessment, a client’s speech is noted to be incoherent and involves frequent changes in topic. This speech pattern is known as: A. Flight of ideas B. Echolalia C. Neologism D. Word salad | D. Word salad |
| 26. Which of the following should a nurse assess to evaluate a client’s immediate memory? A. Recalling the events of the past week B. Remembering to take medication C. Repeating a series of numbers D. Describing a favorite childhood memory | C. Repeating a series of numbers |
| 27. A nurse is conducting a mental health assessment and asks the client to repeat the phrase “No ifs, ands, or buts.” This question assesses: A. Remote memory B. Language and speech C. Abstract reasoning D. Cognitive ability | B. Language and speech |
| 28. Which of the following findings during a mental health assessment should prompt immediate intervention by the nurse? A. The client is unable to perform serial 7s B. The client expresses a plan to harm themselves C. The client reports feeling anxious about an upcoming exam D. The client has a flat affect | B. The client expresses a plan to harm themselves |
| 29. The nurse is assessing a client’s affect and notes that it is incongruent with the client’s stated mood. This means that: A. The client’s affect is appropriate to the context B. The client’s affect does not match their mood C. The client’s mood is stable and congruent D. The client’s mood is fluctuating rapidly | B. The client’s affect does not match their mood |
| 30. During a mental health assessment, the nurse asks the client to name the last three presidents of the United States. This question assesses the client’s: A. Immediate memory B. Recent memory C. Remote memory D. Abstract thinking | C. Remote memory |
| 31. A client reports feeling constantly anxious and worried about various aspects of life. The nurse should suspect: A. Generalized anxiety disorder (GAD) B. Panic disorder C. Social anxiety disorder D. Specific phobia | A. Generalized anxiety disorder (GAD) |
| 32. During a mental health assessment, the nurse notes that a client has difficulty making decisions and often defers to others. This behavior is characteristic of: A. Dependent personality disorder B. Borderline personality disorder C. Narcissistic personality disorder D. Avoidant personality disorder | A. Dependent personality disorder |
| 33. A nurse is assessing a client’s nonverbal communication. Which of the following is an example of nonverbal communication? A. The client’s tone of voice B. The client’s facial expressions C. The client’s choice of words D. The client’s rate of speech | B. The client’s facial expressions |
| 34. Which of the following should the nurse assess to evaluate a client’s insight? A. The client’s understanding of their illness B. The client’s ability to perform calculations C. The client’s orientation to time and place D. The client’s ability to recall recent events | A. The client’s understanding of their illness |
| 35. A nurse is performing a mental health assessment on an adolescent client. Which of the following is a common sign of depression in adolescents? A. Hyperactivity B. Increased social interactions C. Irritability D. Weight gain | C. Irritability |
| 36. During a mental health assessment, a client reports feeling worthless and hopeless. The nurse should assess the client for: A. Anxiety disorder B. Schizophrenia C. Bipolar disorder D. Major depressive disorder | D. Major depressive disorder |
| 37. Which of the following is a priority intervention for a client experiencing panic attacks? A. Encourage the client to avoid caffeine B. Teach the client deep breathing exercises C. Suggest the client write in a journal D. Advise the client to exercise regularly | B. Teach the client deep breathing exercises |
| 38. A client with schizophrenia exhibits delusions of persecution. The nurse should: A. Challenge the client’s beliefs B. Validate the client’s feelings C. Agree with the client’s delusions D. Ignore the client’s statements | B. Validate the client’s feelings |
| 39. The nurse is assessing a client’s thought content and notes the presence of obsessions. Which of the following best describes obsessions? A. Persistent, irrational fears B. Repeated, unwanted thoughts C. Fixed, false beliefs D. Sensory perceptions without external stimuli | B. Repeated, unwanted thoughts |
| 40. During a mental health assessment, the nurse asks the client to count backward from 20. This task assesses: A. Immediate memory B. Abstract thinking C. Attention and concentration D. Remote memory | C. Attention and concentration |
| 41. A client presents with a flat affect and reports a lack of interest in previously enjoyable activities. These symptoms are indicative of: A. Anxiety disorder B. Major depressive disorder C. Bipolar disorder D. Obsessive-compulsive disorder | B. Major depressive disorder |
| 42. A nurse is assessing a client’s risk for self-harm. Which of the following is a significant risk factor? A. Strong social support network B. History of previous suicide attempts C. Engagement in recreational activities D. Stable employment | B. History of previous suicide attempts |
| 43. During a mental health assessment, the nurse asks the client to describe their mood over the past week. This question assesses: A. Affect B. Thought process C. Mood D. Cognition | C. Mood |
| 44. A nurse is performing a mental health assessment and observes that the client’s responses are slow and monotonous. This speech pattern is characteristic of: A. Mania B. Depression C. Anxiety D. Schizophrenia | B. Depression |
| 45.Which of the following is an example of a client’s affect? A. The client’s level of energy B. The client’s facial expression C. The client’s thought content D. The client’s memory | B. The client’s facial expression |
| 46. During a mental health assessment, a nurse asks a client to remember three words and recall them later in the interview. This assesses: A. Immediate memory B. Recent memory C. Remote memory D. Long-term memory | B. Recent memory |
| 47. A client reports experiencing frequent mood swings. The nurse should assess for: A. Bipolar disorder B. Schizophrenia C. Generalized anxiety disorder D. Obsessive-compulsive disorder | A. Bipolar disorder |
| 48. Which of the following behaviors would indicate a positive coping mechanism in a client with anxiety? A. Avoiding social interactions B. Practicing relaxation techniques C. Increasing alcohol consumption D. Procrastinating on tasks | B. Practicing relaxation techniques |
| 49. A nurse is assessing a client’s ability to perform daily activities. This assessment focuses on the client’s: A. Cognitive function B. Physical health C. Functional status D. Emotional well-being | C. Functional status |
| 50. During a mental health assessment, a nurse notes that a client exhibits compulsive behaviors. Which of the following is a characteristic of compulsions? A. Persistent, unwanted thoughts B. Repetitive, ritualistic actions C. Fixed, false beliefs D. Sensory distortions | B. Repetitive, ritualistic actions |
Created by:
nursingmvc25