The nurse recognizes that a function of the Mental Status Exam is:

to obtain information about the client's medical history.

to establish limit setting.

to determine the client's IQ.

a method of organizing clinical observations.

Answer and Explanation

The Correct Answer is D

a. To obtain information about the client's medical history: While the MSE might reveal medical history clues, its primary focus is on mental status.
b. To establish limit setting: Limit setting is a separate therapeutic technique, not a function of the MSE.
c. To determine the client's IQ: IQ tests are separate assessments used to measure intelligence, not a function of the MSE.
d. a method of organizing clinical observations: A Mental Status Exam (MSE) is a structured way to assess a client's cognitive and emotional state. It focuses on areas like orientation, memory, attention, mood, and thought processes.

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Correct Answer is C

Explanation

a. refuses to eat lunch. Refusal to eat lunch might indicate displeasure or upset but does not directly suggest escalating aggression.
b. requests prn medications. Requesting prn (as needed) medications typically indicates the client is aware of their distress and is seeking help, not escalating aggression.
c. is pacing around the milieu. Pacing can be a sign of increasing agitation and is often observed in clients who are escalating towards aggressive behavior. This physical activity can indicate restlessness and an inability to calm down.
d. sits in a group with their peers. Sitting in a group with peers suggests a level of social engagement and does not indicate escalating aggression.

A. restating B. maintaining neutral responses. C. listening D. asking the client, "Why?"

Correct Answer is D

Explanation

a. restating: Restating involves repeating the client's message to ensure understanding and encourage further communication. It is a therapeutic technique.
b. maintaining neutral responses. Neutral responses can be therapeutic as they provide nonjudgmental listening and support.
c. listening: Active listening is a fundamental therapeutic communication technique, essential for understanding the client's concerns and building rapport.
d. asking the client, "Why?" Asking "Why?" can be non-therapeutic as it may make the client feel defensive and pressured to justify their feelings or actions. It can hinder open communication.

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The nurse recognizes that a function of the Mental Status Exam is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing an inpatient client with a known history of violence. The client suddenly displays clenched fists. What additional behavior by the client would suggest that the aggression is escalating? The client:

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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