Author Question: A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four ... (Read 106 times)

kwoodring · **on:** Jun 25, 2018

A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she could not ____ four unrelated words ____.

a. Invent; within 5 minutes
b. Invent; within 30 seconds
c. Recall; after a 30-minute delay
d. Recall; after a 60-minute delay

Question 2

A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient has dysarthric speech and is lethargic. The nurse's best approach regarding this examination is to:

a. Plan to defer the rest of the mental status examination.
b. Skip the language portion of the examination, and proceed onto assessing mood and affect.
c. Conduct an in-depth speech evaluation, and defer the mental status examination to another time.
d. Proceed with the examination, and assess the patient for suicidal thoughts because dysarthria is often accompanied by severe depression.

jlaineee · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: C
The Four Unrelated Words Test tests the person's ability to lay down new memories. It is a highly sensitive and valid memory test. It requires more effort than the recall of personal or historic events. To the person say, I am going to say four words. I want you to remember them. In a few minutes I will ask you to recall them. After 5 minutes, ask for the four words. The normal response for persons under 60 years is an accurate three- or four-word recall after a 5-, 10-, and 30-minute delay.

Answer to Question 2

ANS: A
In the mental status examination, the sequence of steps forms a hierarchy in which the most basic functions (consciousness, language) are assessed first. The first steps must be accurately assessed to ensure validity of the steps that follow. For example, if consciousness is clouded, then the person cannot be expected to have full attention and to cooperate with new learning. If language is impaired, then a subsequent assessment of new learning or abstract reasoning (anything that requires language functioning) can give erroneous conclusions.