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

Organize clinical observations

Obtain information about the client’s medical history

Establish limit setting

Determine the client’s IQ

Answer and Explanation

Correct Answer : A,B

The correct answer is a, b.

Choice A Reason:

The statement “Organize clinical observations” is correct. One of the primary functions of the Mental Status Exam (MSE) is to systematically organize clinical observations. This includes assessing the client’s appearance, behavior, mood, and cognitive functions. By organizing these observations, healthcare providers can create a comprehensive picture of the client’s current mental state, which is crucial for diagnosis and treatment planning.

Choice B Reason:

The statement “Obtain information about the client’s medical history” is correct. The MSE often involves gathering detailed information about the client’s medical history, including past mental health issues, treatments, and any relevant medical conditions. This information helps in understanding the client’s baseline mental status and identifying any changes or abnormalities. It also aids in creating an effective treatment plan tailored to the client’s specific needs.

Choice C Reason:

The statement “Establish limit setting” is incorrect. While limit setting is an important aspect of managing certain mental health conditions, it is not a primary function of the MSE. Limit setting typically involves establishing boundaries and rules to manage behaviors, which is more relevant in therapeutic settings rather than during the assessment phase. The MSE focuses on evaluating the client’s current mental state rather than setting behavioral limits.

Choice D Reason:

The statement “Determine the client’s IQ” is incorrect. The MSE is not designed to measure a client’s intelligence quotient (IQ)4. Instead, it assesses cognitive functions such as memory, attention, and orientation. IQ tests are specialized assessments that require specific tools and are conducted separately from the MSE. The MSE provides a general overview of cognitive functioning but does not quantify intelligence.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A Reason:

Word salad.

Word salad refers to a jumble of words and phrases that lack logical coherence, often seen in severe cases of schizophrenia. The speech is typically incomprehensible and does not follow any recognizable pattern. In this case, the client’s response, while unusual, follows a pattern based on sound rather than meaning, which does not fit the definition of word salad.

Choice B Reason:

Loose association.

Loose association involves a series of thoughts that are only loosely connected to each other. This is a common symptom in schizophrenia, where the person’s thoughts may drift from one topic to another with little logical connection. However, the client’s response in this scenario is more structured and based on rhyming, which is characteristic of clang associations rather than loose associations.

Choice C Reason:

Clang association.

Clang association is a type of thought disorder where the person’s speech is governed by the sound of words rather than their meaning. This often results in rhyming or punning speech. The client’s response, “A match is a catch. A catch is a batch. The batch started to hatch,” is a clear example of clang association because the words are linked by their similar sounds rather than their meanings.

Choice D Reason:

Ideas of reference.

Ideas of reference involve the belief that ordinary events, objects, or behaviors of others have particular and unusual significance specifically for the person. This is often seen in paranoid schizophrenia. The client’s response does not indicate that they believe the words have special personal significance; instead, it shows a pattern of rhyming, which is more indicative of clang association.

A. Ask open-ended questions. B. Focus on what is happening in the here and now. C. Assume knowledge of what is meant when the client talks about “they.” D. Limit contact to one or two short interactions daily.

Correct Answer is B

Explanation

Choice A Reason:

Ask open-ended questions.

While asking open-ended questions can be useful in many therapeutic settings, it may not be the best approach when dealing with delusional clients. Open-ended questions can sometimes lead to more elaborate delusional thinking and may not help in grounding the client in reality. Instead, focusing on the present moment and concrete reality can be more effective in managing delusions.

Choice B Reason:

Focus on what is happening in the here and now.

This is the correct response. Focusing on the present moment helps to ground the client in reality and can reduce the intensity of delusional thoughts. By directing the client’s attention to their immediate environment and current activities, the nurse can help the client stay connected to reality and reduce the impact of their delusions.

Choice C Reason:

Assume knowledge of what is meant when the client talks about “they.”

Assuming knowledge of what the client means when they refer to “they” can reinforce delusional thinking. It is important for the nurse to clarify and understand the client’s perspective without validating the delusion. This approach helps maintain a therapeutic relationship while not reinforcing false beliefs.

Choice D Reason:

Limit contact to one or two short interactions daily.

Limiting contact to one or two short interactions daily is not an effective strategy for managing delusions. Clients with delusions often need consistent and supportive interactions to help them stay grounded in reality. Frequent, brief interactions can provide the necessary support and reassurance without overwhelming the client.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client hears the word “match.” The client replies, “A match is a catch. A catch is a batch. The batch started to hatch.” Which communication pattern does the nurse identify?

Correct Answer is C

Explanation

Which of the following nursing strategies would be most appropriate when caring for an individual who is delusional?

Correct Answer is B

Explanation

A nurse is preparing a presentation at a community center about complementary and alternative therapies. Which of the following therapies should the nurse describe as the use of an electronic monitoring device to help clients learn to control physical responses to stress?

A client with schizophrenia approaches the nurse with a look of distress and anguish on his face. He says, “Can’t you hear him? It’s the devil. He’s telling me I’m going to hell.” Which is the most appropriate response by the nurse?

The nurse notices a client wandering in the hospital hall giggling, with bizarre behavior that is annoying and frightening other clients. A priority in caring for her is to:

A 23-year-old is about to take a math test. A nursing assessment reveals mild anxiety. The nurse explains that this level of anxiety:

A client diagnosed with an Anxiety Disorder tells a nurse that being in crowds creates thoughts of losing control and the need to suddenly leave. What should the nurse recommend as an effective, non-pharmacological therapy for managing the client’s symptoms of anxiety?

A client diagnosed with schizophrenia is prescribed clozapine. The nurse teaches the client and family to call the physician immediately if:

As the discharge date for a client to leave gets closer, the client states, “I’m afraid to leave here. I’m afraid for my well-being and safety.” Which nursing statement is most supportive?

The nurse is teaching a client about lorazepam. The nurse should instruct the client to expect which of the following side effects?