C)

D)

1.Which of the following questions is best to ask when assessing the client's judgment?
Can you describe your usual daily activities for me?
If you found yourself downtown without money or a car, how would you get
home?
On a scale of 1 to 10, how stressed would you rate yourself?
What problem would you like to work on while you're hospitalized?

A)
B)
C)
D)

2.A delusion represents a problem in which of the following areas?

Memory
Motivation
Orientation
Thinking

A)
B)
C)
D)

3.During the assessment, the nurse asks the client to describe his problems. The purpose of
this question is to obtain information about the client's
Admitting diagnosis
Communication skills
Perception of the problem
Personal needs

A)
B)
C)
D)

4.Throughout the assessment, the client displays disorganized thinking, jumping from one
idea to another with no clear relationship between the thoughts. The nurse would assess
the client as having which of the following?
Concrete thoughts
Ideas of reference
Loose associations
Word salad

A)
B)
C)
D)

5.The nurse asks the client, What is similar about a cow and a horse? and What do a bus
and an airplane have in common? These questions would best assess which of the
following areas?
Intellectual function
Insight
Judgment
Memory

A)
B)
C)
D)

6.In the space of 5 minutes, the client has been laughing and euphoric, then angry, and then
crying for no reason that is apparent to the nurse. This behavior would be best described
as
Flight of ideas
Lack of insight
Labile mood
Tangential thinking

A)
B)

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A)
B)
C)
D)

7.A client is admitted to the psychiatric unit and states, I am president of the largest
corporation in the world. Everyone comes to me for advice. The client is exhibiting
which of the following?
Confabulation
Delirium
Grandiosity
Loose associations

A)
B)
C)
D)

8.Which of the following would best assess a client's judgment?

Counting by serial sevens
Discussing hypothetical situations
Interpreting proverbs
Spelling words backward

A)
B)
C)
D)

9.During the admission assessment, the nurse asks the client, How are you feeling? The
client responds, I feel, I kneel, do you steal? The nurse recognizes this response as
which of the following?
Clang association
Echolalia
Flight of ideas
Neologisms

A)
B)
C)
D)

10.The client tells the nurse, That new TV anchor is telling the world about me. This is an
example of
Ideas of reference
Persecutory delusions
Thought broadcasting
Thought insertion

A)
B)
C)
D)

11.When assessing a patients mental health status, the nurses includes which of the
following as a major focus of the assessment?
Family history
Mental capacity
Response to medications
Support system

12.The nurse asks a patient to list the days of the week in reverse order. The nurse is
assessing which of the following?
A)
Concentration.

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B)
C)
D)

Memory
Orientation
Abstract thinking

A)
B)
C)
D)

13.The nurse is assessing suicide potential in a patient who has expressed hopelessness. In
what order does the nurse question the patient about suicidal thoughts?
How would you carry out this plan?
Do you have a plan to kill yourself?
Are you thinking of killing yourself?
How do you plan to kill yourself?

A)
B)
C)
D)

14.The nurse best assesses a patients memory by asking which of the following questions?
Do you have any problems with memory?
What did you have for lunch yesterday?
Do you know where you are?
Who is the current president?

A)
B)
C)
D)

15.A patient shows no facial expression when engaging in a game with peers during an
outing at a park. The nurse uses which of the following terms when documenting the
patients affect?
Blunt affect
Restricted affect
Broad affect
Flat affect

A)
B)
C)
D)

16.The patient states that he is 14 trillion years old and created the world. The nurse
documents this statement as an example of which type of thinking displayed by the
patient?
Delusional thinking
Ideas of reference
Word salad
Hallucination

A)
B)
C)
D)

17.A patient is known to express tangential thinking. The nurse would assess for which of
the following when interacting with the patient?
Stopping abruptly in the middle of expressing himself
Jumping from one idea to another.
Wandering off the topic and never answering the question
Excessive and fast talking about an array of ideas

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A)
B)
C)
D)

18.A nurse can best assess a patients ability to use abstract thinking by asking the patient
which of the following questions?
What would you do if you found a wallet containing $100 on the sidewalk?
What do I mean when I say, Dont sweat the small stuff?
What are you going to do next time you hear voices?
Can you begin with the number 100 and subtract 7, then subtract 7 again?

A)
B)
C)
D)

19.A patient reports to the nurse that on his way to the clinic a policeman in a patrol car
turned on his lights and pulled him over. When asked what he did next, the patient sates,
I pulled over of course. The nurse documents that the patient displayed appropriate:
judgment.
insight.
concentration.
self-concept.

A)
B)
C)
D)
E)

20.The nurse plans to assess a patients self-concept in the admission assessment knowing
that self-concept influences which of the following? (Select all that apply)
Cognitive processing
Concrete thinking
Frequently experienced emotions
Coping strategies
Responsiveness to medications

A)
B)
C)
D)

21.Knowing that relationships with others are significant to mental health, the nurse
effectively assesses a patients family relationships through which of the following?
Do you feel your family helps you?
How many people are in your family?
Who are you closest to in your family?
Describe your relationships with your family.

A)
B)
C)
D)

22.A client is being evaluated for dementia. The nurse knows that when completing a mental
status exam, the fewer tasks the client completes accurately, the
Greater the cognitive deficit
Less the cognitive deficit
Greater the cognitive ability
Task completion has no bearing on mental status

23.A nurse assess that a depressed patient is lethargic during the day and does not actively
participate in unit activities. When reviewing the chart form the night shift it is noted that
the patient did not sleep well. The most probable interpretation of this data is:
A)
the patients medications are ineffective.

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B)
C)
D)

the patient is being kept awake at night due to noise on the unit.
the patients depressed mood is impairing restful sleep patterns.
the patient is resisting treatment recommendations to participate in unit activities

A)
B)
C)
D)

24.A nurse suspects that a patient is abusing alcohol while taking prescribed medications.
The plan is to educate the patient on the dangers of mixing medicine with alcohol. The
most effective way for the nurse to approach this subject with the patient includes which
of the following?
Firmly inform the patient of the dangers of mixing medications with alcohol
Recommend a higher level of care so the patient can be more closely supervised
Emphasize the importance of truthful information using a non-judgmental approach
Recognize the patients right to self-determination and avoid addressing the subject

A)
B)
C)
D)

25.The nurse has completed the psychosocial assessment. Which of the following is the best
approach toward analysis of the data to identify nursing diagnoses and develop an
appropriate plan of care?
Focus on each piece of information obtained from the patient
Look for patterns reflected in the overall assessment
Consider only the abnormal findings in the assessment
Present all data obtained in the treatment team meeting

A)
B)
C)
D)

26.The nurse reviews results of the Minnesota Multiphasic Personality Inventory (MMPI)
recorded in a patient record. While considering the usefulness of this data, the nurse is
mindful that the MMPI has which limitation?
The patient must be able to read to complete the MMPI
The results of the MMPI could be culturally biased
The MMPI assesses a narrow scope of functioning
The MMPI does not have established validity

A)
B)
C)
D)

27.Sexuality and self-harm behaviors are often difficult areas for nurses to assess. An
effective way for nurses to deal with this discomfort includes:
recognizing that these areas may also be uncomfortable for the patient to discuss.
share feelings of discomfort with the patient.
defer assessing these areas to a more experienced nurse.
develop a standard question to ask of all patients during this area of assessment

28.When the nurse asks the client, Are you thinking about killing yourself? The nurse is
questioning which component of a suicide assessment?
A)
Ideation
B)
Plan
C)
Method

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D)

A)
B)
C)
D)

Access
29.The nurse must determine whether the depressed or hopeless client has suicidal ideation
or a lethal plan. When the nurse asks the client, How do you plan to kill yourself? the
nurse is questioning which component of a suicide assessment?
Ideation
Plan
Method
Access

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Answer Key
1.B
2.D
3.C
4.C
5.A
6.C
7.C
8.B
9.A
10.A
11.B
12.A
13.A, B, C, D
14.D
15.D
16.A
17.C
18.B
19.A
20.A, C, D
21.D
22.A
23.C
24.C
25.B
26.B
27.A
28.A
29.C

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