Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank

Chapter 06: Mental Health Assessment

Jarvis: Physical Examination & Health Assessment, 3rd Canadian edition

MULTIPLE CHOICE

1. During the health history interview, the patient informs the nurse that she has not been able to
keep a consistent job for the past 2 years, that she was evicted from her apartment, and that
her fiancée just left her. She states, “I don’t know what to do. I wish I could go to sleep and
never wake up.” The nurse recognizes that the patient is:
a. Undergoing abuse
b. Facing mental wellness
c. Demonstrating mental violence
d. Experiencing mental disorder
ANS: D
Mental disorder is the medical term for mental illness and is defined and diagnosed in Canada
according to criteria specified in the Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition (DSM-5) by the American Psychiatric Association. Mental disorders are
depicted as constellations of co-occurring symptoms that may involve alterations in thought,
experience, and emotion that are serious enough to cause distress and impair functioning,
cause difficulties in sustaining interpersonal relationships and performing jobs, and sometimes
lead to self-destructive behaviour and suicide.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control
N R I G B.C M
U S N family,
2. During a home visit with an Indigenous T theO nurse observes that the family members
are very supportive of each other. The mother states that they maintain their cultural practices
and are very connected with the Elder and their Indigenous community. This situation
supports:
a. Psychological neglect
b. Mental wellness
c. Psychological abuse
d. Mental disorder
ANS: B
Within Indigenous communities, mental wellness encompasses support by culture, language,
Elders, families and creation. Purpose, hope, belonging, and meaning are important wellness
outcomes which enrich whole health, balance, and interconnectedness.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

3. The nurse is concerned after a conversation with a patient who appears very upset and
distressed and, through tears, states, “I can’t go on anymore. There is nothing to live for. I
need to end this.” The nurse is concerned that the patient is:
a. Experiencing a cardiovascular event
b. Displaying signs of abuse
c. Demonstrating self-destructive and suicidal behaviour
d. Exhibiting feelings of content and hope

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 Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank

ANS: C
A person experiencing a mental disorder may demonstrate alterations in thought, experience,
and emotion serious enough to cause distress and impair functioning, cause difficulties in
sustaining interpersonal relationships and performing jobs, and sometimes lead to
self-destructive behaviour and suicide.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

4. During assessment of a patient diagnosed with chronic heart failure, the nurse will assess the
patient for:
a. Nutritional deficiencies
b. Symptoms of delirium
c. Dehydration
d. Mental illness
ANS: D
Evidence presented shows comorbidity between chronic physical conditions (especially
cardiovascular disease, hypertension, respiratory disease, diabetes mellitus, and other
metabolic disorders) and mental illness. It is important to assess such patients for mental
illness.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

5. The nurse discovers that the patient with schizophrenia is consuming a 12-pack case of beer
every night. The nurse is concerned
N R thatGtheB.C
I patientM
has a:
a. Abrasive disorder U S N T O
b. Conflicting diagnosis
c. Concurrent disorder
d. Heavy consumption diagnosis
ANS: C
Co-occurrence of a mental health disorder and problematic substance use/substance use
disorder is referred to as a “concurrent disorder.” Concurrent disorders also include
problem/pathological gambling and problematic substance use and/or mental health disorders.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

6. While assessing a patient with a 7-year-history of bipolar disorder, the nurse is mindful of the
connection between:
a. Blunt force trauma and concussive injuries
b. Aggression and violent behaviours
c. Mental illness and chronic physical conditions
d. Physical activity and obesity
ANS: C

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 Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank

It is important to be aware that there is current evidence that demonstrates significant

comorbidity between chronic physical conditions (cardiovascular disease, hypertension,
respiratory disease, diabetes mellitus, and other metabolic disorders) and mental illness.
Keeping this in mind when working with patients with mental disorders will increase
awareness and assessment of potential increased risk for the patient.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

7. To discourage stigmatization of patients with mental illness, the nurse educates nursing
students that:
a. Reflection is not helpful in practice
b. Reality of mental illness is permanence
c. Recovery from mental illness is possible
d. Reducing stigma is not possible
ANS: C
Educating and demonstrating that recovery from mental illness is both possible and real and
debunking the myths associated with recovery can promote an non-stigmatizing approach in
mental health practice.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

8. The nurse working with the homeless population notices that many of them are suffering from
a mental illness. Recognizing that there is a connection between mental health and
homelessness, what does the nurse recommend to more permanently improve health for this
population? NURSINGTB.COM
a. Providing them with warm clothing for the cold.
b. Building more temporary shelters to accommodate the number of homeless people.
c. Developing safe and supportive housing for them.
d. Encouraging more restaurants to provide food for the homeless people.
ANS: C
Mental health may be compromised with continued homelessness or contribute to the duration
of homelessness. Lack of safe, stable housing renders those living with or without mental
illness vulnerable and those with mental illness at greater risk for poor outcomes. A stable and
supportive living environment is essential to maintaining the health and well-being of people
with serious mental illness, and it is integral to their recovery.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

9. The nurse is meeting the 25-year-old patient whose suicide attempt was not successful. The
patient informs the nurse that he had recently returned from deployment to Afghanistan; he
states that he feels angry all the time, he cannot sleep, and he keeps reliving the explosion that
killed his buddy. The nurse recognizes these as symptoms of:
a. Sociopathic disorder
b. Obsessive–compulsive disorder (OCD)
c. Antisocial behaviour
d. Post-traumatic stress disorder (PTSD)

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 Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank

ANS: D
The DSM-5 defines PTSD as a trauma or stressor-related disorder in which symptoms began
or worsened after the experience of one or more traumatic events. Symptoms include, but are
not limited to, flashbacks, disturbing dreams (nightmares), insomnia, persistent frightening
thoughts and memories, anger, irritability, concentration difficulties, and substance use.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

10. The nurse is working with a group of refugees from Syria and is concerned about their mental
health because:
a. Antisocial behaviour is common with dislocation from their home.
b. OCD impulses escalate with the experience of many losses.
c. Social isolation occurs from the increased experience of violence.
d. PTSD is prevalent with refugees from war-affected countries.
ANS: D
A high prevalence of PTSD has been found in war-affected refugees. Refugees and
immigrants often have experienced multiple losses (e.g., family, friends and home) and
dislocations (e.g., culture and place), which are factors that can significantly affect
trauma/violence experiences.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

11. During an interview with a 70-year-old patient, the nurse is concerned when the patient cannot
recall what she had for breakfast
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Imorning
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nurse should assess for: S N O
a. Normal aging memory loss
b. Recent memory loss
c. Poor dietary intake
d. Remote nutritional changes
ANS: B
As part of the mental status examination, recent memory is the ability to recall day-to-day
events, for example, what the patient had for a recent meal consisted of or what the patient did
in the past 24 hours.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

12. During an interview, the patient’s speech is garbled, and the thoughts shared are confused.
What should the nurse do?
a. Nothing, because this is part of normal aging
b. Stop the interview and document that the patient is an alcoholic
c. Perform a mental status examination
d. Call the family to take the patient home
ANS: C
Such behaviour is an indication that something is “not quite right,” and the nurse should
assess the patient’s mental status.

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 Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

13. The nurse is including the mental status examination with the initial physical assessment of
the patient. Which components need to be included?
a. Compressions, airway, behaviour
b. Activity, behaviour, critical thinking
c. Appearance, behaviour, cognition, thinking
d. Airway, breathing, capacity
ANS: C
The mental status examination is used to assess emotional and cognitive functioning. It is a
structured way of observing and describing a person’s current state of mind, under the
domains of appearance, behaviour, cognition, and thought processes (A, B, C, T test).

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

14. The family is concerned about their mother’s recent forgetfulness and constant retelling of the
same stories. The nurse decides to:
a. Perform the Folstein Mini-Mental State Examination
b. Inform the family that their mother is depressed
c. Discuss moving their mother into a long-term care facility
d. Reassure the family that this is part of normal aging
ANS: A
The Folstein Mini-Mental State
NUExamination
RSINGTB.C (MMSE) is used to evaluate a person’s cognitive
and mental function and was initially OM
developed as a screening test for dementia. Symptoms
of dementia include memory loss and a deterioration of cognitive performance and function,
physical capacity, and personality features.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

15. The nurse is admitting a 75-year-old patient to the hospital with new confusion and changes in
behaviour that had developed overnight. The family state that she was just started on
antibiotics for a urinary tract infection. The nurse should assess for:
a. Dementia
b. Depressive disorder
c. Delirium
d. Bipolar disorder
ANS: C
Delirium occurs suddenly and usually is accompanied by an underlying medical disorder (e.g.,
urinary tract infection). The symptoms include disorientation, memory deficit, and changes in
language or perception.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

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 Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank

16. The nurse is interviewing a 17-year-old Indigenous patient after a possible accidental
acetaminophen overdose. The nurse should determine:
a. The patient’s medication preferences for pain management
b. The patient’s intention to self-harm
c. The patient’s need for education on medication use
d. The patient’s ability to perform activities of daily living
ANS: B
Among adolescents ages 15 to 19 years, suicide (intentional self-harm) is the second leading
cause of death. Indigenous youth are at increased risk for compromised mental health from
intergenerational trauma, discrimination, stigmatization, and bullying.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

17. The nurse working with university students is taking a health promotion approach to support
mental health by:
a. Increasing immunization rates with newly admitted students
b. Helping students develop coping skills to handles the stressors of university
c. Providing information to develop academic writing skills
d. Developing cultural cooking groups
ANS: B
Depression and anxiety have been reported to be increasing in the
postsecondary/university/college population. The transition from high school to university is a
time of adjustment, requiring new coping skills; many students experience stress, which
increases the risk for poor mental health.
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DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care

18. During assessment of a 70-year-old patient newly admitted to the hospital, the nurse observes
that the patient has difficulty hearing and shows no interest in the conversation. The family
informs the nurse that the patient’s spouse passed away 2-months ago and that the patient has
lost significant weight and refuses to leave the house. The nurse should assess for:
a. Bulimia
b. Delirium
c. Depression
d. Aphasia
ANS: C
Grief and despair resulting from the loss of a loved one and loss of hearing leading to isolation
are factors that can affect mental health and potentially result in depression.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

19. During a postpartum home visit with a 22-year-old mother discharged 2 days ago from the
hospital, the nurse observes that the mother does not pick up her crying baby, appears listless,
and has a flat affect. The mother states, “I can’t handle this, and I have no one to help me.”
The nurse should:
a. Recommend removal of the infant

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 Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank

b. Discuss with the husband how to better support her

c. Screen her for postpartum depression
d. Suggest inviting her parents to come and help her
ANS: C
Postpartum depression has consequences for the mother, the baby, and the family. Individuals
in the perinatal period (pregnancy up to 1 year postpartum) are at risk for depression. Early
detection and treatment can help eliminate or reduce the effects of perinatal depression,
particularly for immigrant and adolescent moms found to be a most risk.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

20. The nurse needs to determine if the 68-year-old patient is safe to continue living on his own in
his own home. The nurse will complete a(n):
a. Risk assessment
b. Exercise log
c. Elimination routine
d. Functional assessment
ANS: D
The functional assessment, including assessment of abilities for self-care and performance of
activities of daily living, such as bathing, hygiene, dressing, toileting, eating, walking,
housekeeping, shopping, cooking, communicating with others, social relationships, finances,
and coping, can determine the patient’s capability to remain independent and is the basis to
promote and maintain health.

NU(Application)
DIF: Cognitive Level: Applying RSINGTB.COM
MSC: Client Needs: Safe and Effective Care Environment: Management of Care

21. During an interview with a patient who expresses grief over the loss of a loved one and states
his intent to harm himself, what should the nurse ask?
a. “Really! Are you serious?”
b. “Do you have a plan and a time decided on?”
c. “What will be the point?”
d. “Have you seen what happens with suicidal attempts?”
ANS: B
An important warning sign of suicide is the formation of a precise suicide plan to occur within
the next 24 to 48 hours, especially with the use of a lethal method.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

MULTIPLE RESPONSE

1. The nurse is working with the public to improve their understanding of people with mental
illnesses. Which of the following statements reflect a non-stigmatizing view of mental illness?
(Select all that apply.)
a. “People with a mental illness scare me. They are dangerous.”
b. “Mental illness is a disease, and it is like having diabetes or hypertension.”

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 Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank

c. “I know someone with schizophrenia, and he is crazy!”

d. “Did you see the story on the news about the person who killed all those people?
They think he has a mental illness.”
e. “There is treatment for mental illness, and people can recover.”
f. “My roommate with schizophrenia is an excellent architect.”
ANS: B, D, F
A stigmatized view of mental illness labels the person with a mental illness as “crazy” or
“mad”; negatively stereotypes the “difference” with undesirable characteristics and fears, such
as labelling a person with a mental illness as dangerous “others” by creating “us” and “them”
categories; and results in status loss, blame, and discrimination of the labelled person. Rare
cases of violence associated with mental illness are sensationalized by the media.
Acknowledging that mental illness is a disease like any other physical condition, that recovery
from mental illness is possible, and that a person with mental illness can function well in
society demonstrate understanding of people with mental illness.

DIF: Cognitive Level: Analyzing (Analysis)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

2. The nurse is working with the older adult population. The nurse observes a significant change
in a 78-year-old patient who appears dishevelled, is unable to answer questions appropriately,
and is shuffling while walking. The nurse will perform a mental status examination to: (Select
all that apply.)
a. Assess mood and affect
b. Assess spiritual functioning
c. Assess orientation and attention
d. Determine memory and comprehension
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e. Determine cultural practiceU S N T
f. Determine perception
ANS: A, C, D, F
The mental status examination is used to assess emotional and cognitive functioning. It is a
structured way of observing and describing a person’s current state of mind, under the
following four domains: (1) appearance; (2) behaviour (mood and affect, speech); (3)
cognitive function (level of consciousness; orientation to time, place, person, self; memory;
attention and concentration; comprehension and abstract reasoning); (4) thought (perception,
content, process, judgement, and insight).

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

3. Which of the following questions does the nurse use to assess the orientation of the patient?
(Select all that apply.)
a. “What did you have for breakfast today?”
b. “Can you tell me where you are right now?”
c. “How long have you had diabetes?”
d. “What is the today’s date?”
e. “What is your full name?”
f. “How do you feel today?”
ANS: B, D, E

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Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank

Assessing the patient’s orientation includes asking about time (day of week, date, year,
season); place (where person lives, present location, type of building, names of city and
province); person (who examiner is, type of worker); and self (person’s own name, age). The
other questions ask about mood and memory.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

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