Chapter 8 - Practice Questions, Professional Communications Chapter 8-Assessment (PREPU), Chapter 8: Assessment
A nurse is performing a psychosocial assessment of the client. Which questions asked by the nurse can be identified as open ended? Select all that apply. "How did your problems begin?" "Are you feeling better today?" "When was your last visit in the psychiatric facility?" "Is there something wrong with you?" "How can we help you?"
"How can we help you?" "How did your problems begin?" Explanation: Open-ended questions are those questions that require a detailed descriptive answer. Questions like "how can we help you" and "how did your problems begin" cannot be answered in a word or a sentence, but require a detailed explanation. Open-ended questions need to be asked in order to understand the client's perception of the situation. Questions like "are you feeling better today," "is there something wrong with you," and "when was your last visit in the psychiatric facility" require a very precise answer. These are the examples of closed-ended questions. These questions do not allow the client to give more information.
The nurse has entered a hospital client's room and asked the client if the client plans to attend the morning's scheduled group life-skills session. Which response should signal the presence of thought blocking to the nurse? The client makes eye contact with the nurse but does not respond verbally. "Warning, warning, watch your back." "I might. I'll give it some..." "Well, that's certainly the end of that."
"I might. I'll give it some..." Explanation: Blocking refers to a sudden stoppage in the spontaneous flow or stream of thinking or speaking for no apparent external or environmental reason. Clanging involves perceived similarities in meaning between words of similar sound ("morning"; "warning"). Mutism is the absence of a verbal response.
During assessment of a client with schizophrenia, the nurse notes the client has ideas of reference. Which statement of the client would have led the nurse to conclude this? "The news of the terrorist attack is directed to me. The terrorists are trying to warn me." "I am sure you know what I am thinking. Everybody knows what I am thinking." "My family is taking my thoughts away. I am unable to think now." "My dead friend is putting these ideas in my mind."
"The news of the terrorist attack is directed to me. The terrorists are trying to warn me." Explanation: Ideas of reference are the inaccurate perception of the client that general events are personally directed to him or her. Thinking that the news of the terrorist is a warning to the client indicates that the client has ideas of reference. The delusion that other people (dead friend) are putting thoughts in the client's mind is referred to as thought insertion. The delusion that others are taking the client's thoughts away is referred to as thought withdrawal. The delusion that others know what the client is thinking is referred to as thought broadcasting.
Which client statement indicates the most insight into his or her issue with auditory hallucinations? "The voices are telling me to hurt myself." "The voices aren't real but it's hard to ignore them." "I take medication so the voices will stop." "I can't remember a time when I didn't hear voices."
"The voices aren't real but it's hard to ignore them." Explanation: Initially, clients perceive hallucinations as real experiences, but later in the illness, they may recognize them as hallucinations. Insight is the ability to understand the true nature of one's situation and accept some personal responsibility for that situation. The correct option is the only one that demonstrates these abilities.
The nurse is performing a psychosocial assessment of a client. Which questions should the nurse ask to assess the client's self-concept? Select all that apply. "How do you think you look today?" "Which country do you live in?" "What do you do when you have a problem?" "Are you thinking about killing yourself?" "Could you tell me what time it is?"
"What do you do when you have a problem?" "How do you think you look today?" Explanation: Self-concept is the way one views oneself. It includes perception of body image, coping skills, social image, and academic and occupational image. By asking "how do you think you look today," the nurse is trying to understand the client's body image. By asking "what do you do when you have a problem," the nurse is trying to understand the client's method of coping with problems. Thus, these questions indicate that the nurse is assessing the self-concept of the client. By asking "which country do you live in," the nurse is assessing the memory of the client. By asking "are you thinking about killing yourself," the nurse is assessing if the client has suicidal ideation. By asking "what time is it," the nurse is assessing the client's orientation.
When assessing orientation, the nurse completes the assessment by asking which questions? Select all that apply. "What is your name?" "Can you tell me where you are?" "What day of the week is it?" "What did you eat for breakfast today?" "Would you count from 1 to 10 backward, please?"
"What is your name?" "Can you tell me where you are?" "What day of the week is it?" Explanation: Asking the client to give the client's name, identify the client's location, and name the day of the week assess orientation. Asking the client to relate what the client ate for breakfast assesses short memory, and asking the client to count backward assesses intellectual abilities, neither of which is a reflection of orientation.
Which question asked by the nurse indicates that the nurse is assessing the judgment of the client? "What would you do if you found $10 on the side of the road?" "Could you please repeat the days of the week backward?" "Could you please explain the meaning of proverb 'barking dogs seldom bite'?" "In which country do you live?"
"What would you do if you found $10 on the side of the road?" Explanation: Judgment is the ability to understand one's environment and situation correctly and to adapt one's behavoir and decisions accordingly. To determine if the client is able to make just decisions, the nurse should present a hypothetical scenario like "what would you do if you found $10 on the side of the road?" Questions such as "in which country do you live" should be asked while assessing the memory of the client. Questions such as "could you please repeat the days of the week backward" should be asked while assessing the client's ability to concentrate. Questions such as "could you please explain the meaning of the proverb 'barking dogs seldom bite'?" should be asked by the nurse while assessing the abstract thinking abilities of the client.
The nurse is preparing to assess a client's remote memory. Which questions would be most appropriate for the nurse to ask? "Can you tell me what you have eaten in the last 24-hours?" "When did you get your first job?" "What did you do last evening?" "How are an apple and orange the same?"
"When did you get your first job?" Explanation: Asking the client about when he or she got his or her first job gives information about the client's remote memory or past events. Asking about what the client ate in the past 24 hours or what he or she did last evening provides information about the client's recent memory. Asking how an apple and orange are similar tests abstract reasoning.
The nurse has entered a hospital client's room and asked the client if the client plans to attend the morning's scheduled group life-skills session. Which response should signal the presence of thought blocking to the nurse? A. "I might. I'll give it some..." B. "Well, that's certainly the end of that." C. "Warning, warning, watch your back." D. The client makes eye contact with the nurse but does not respond verbally.
A. "I might. I'll give it some..."
While conducting an interview with a psychiatric-mental health client, the nurse is observing the client's facial expressions and nonverbal cues. What are these physical manifestations known as? A. Affect B. Demeanor C. Mood D. Temperament
A. Affect
The nurse is looking to assess the client's ability to concentrate. Which task should the nurse ask the client to perform? A. Spell "America" backward. B. Explain the perception of inkblot cards. C. Interpret the meaning of a proverb. D. Write the names of family members.
A. Spell "America" backward.
If the client provides a literal explanation of a proverb and cannot interpret its meaning, which thought process is lacking? Memory Abstract thinking Concrete thinking Concentration
Abstract thinking Explanation: To evaluate abstract thinking, the nurse can ask the client to interpret a common proverb such as "a stitch in time saves nine." Concrete thinking occurs when a client gives literal translations. Concentration relates to the ability to stay on task while memory is recall of past events.
While conducting an interview with a psychiatric-mental health client, the nurse is observing the client's facial expressions and nonverbal cues. What are these physical manifestations known as? Demeanor Temperament Mood Affect
Affect Explanation: Affect refers to the physical manifestations of the client's mood and is assessed by observing the client's facial expression in conjunction with other nonverbal clues.
The client spoke of a current event in the national news and described it as it relates to the client. Then the client spoke of a historical event and described it as it relates to the client. Which of the following questions might the nurse ask to determine if the client is experiencing ideas of reference? A) ìWhere were you when this happened?î N U R S I N G K I N G . C O M B) ìWhy do you think that?î C) ìAre you sure?î D) ìThat is unbelievable!î
Ans: A Feedback: Ideas of reference are the client's inaccurate interpretation that general evens are personally directed to him or her, such as hearing a speech on the news and believing the message had personal meaning. ìWhere were you when this happened,î would relate to the place and might give the nurse more information to validate the client's previous comments. ìWhy do you think that,î may be interpreted as the nurse challenging the client. ìAre you sure,î is a closed-ended question and does not encourage the client to elaborate. ìThat is unbelievable,î is a statement rather than a question and could be interpreted as the nurse's opinion of the information provided by the client.
A patient reported 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 stated, ìI pulled over, of course.î Which of the following was the nurse trying to assess? A) The client's judgment B) The client's insight C) The client's concentration D) The client's self-concept
Ans: A Feedback: Judgment refers to the ability to interpret one's environment and situation correctly and to adapt one's behavior and decisions accordingly. Insight is the ability to understand the true nature of one's situation and accept some personal responsibility. Self-concept is the way one views oneself in terms of personal worth and dignity. The nurse assesses the client's ability to concentrate by asking the client to perform certain cognitive tasks. To assess a client's self-concept, the nurse can ask the client to describe himself or herself and what characteristics he or she likes and what he or she would change.
he 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? A) Delusional thinking B) Ideas of reference C) Word salad D) Hallucination
Ans: A Feedback: N U R S I N G K I N G . C O M A delusion is a fixed false belief not based in reality. Ideas of reference are client's inaccurate interpretation that general events are personally directed to him or her, such as hearing a speech on the news and believing the message had personal meaning. Word salad is flow of unconnected words that convey no meaning to the listener. Hallucinations are false sensory perceptions or perceptual experiences that do not really exist.
The nurse asks the client, ìWhat is similar about a cow and a horse?î and ìWhat do a bus and an airplane have in common?î These questions would best assess which of the following areas? A) Intellectual function B) Insight C) Judgment D) Memory
Ans: A Feedback: N U R S I N G K I N G . C O M These questions would elicit information about the client's intellectual function. Insight is the ability to understand the true nature of one's situation and accept some personal responsibility for that situation. Judgment refers to the ability to interpret one's environment and situation correctly and to adapt one's behavior and decisions accordingly. Questions about memory would require that the client identify knowledge of past events.
During the admission assessment, the nurse asks the client, ìHow are you feeling?î The client responds, ìI was able to purchase gas for 7 cents a gallon less than yesterday, which saved me a total of 84 cents. My car has a 12-gallon gas tank. Usually I am able to put in 11.7 gallons. I am very happy to have saved so much money.î The nurse recognizes this response as which of the following? A) Circumstantial thinking B) Echolalia C) Flight of ideas D) Neologisms
Ans: A Feedback: N U R S I N G K I N G . C O M With circumstantial thinking, the client eventually answers a question but only after giving excessive unnecessary detail. Echolalia is repetition or imitation of what someone else says. Flight of ideas is excessive amount and rate of speech composed of fragmented or unrelated ideas. Neologisms are invented words that have meaning only for the client.
The client tells the nurse, ìThat new TV anchor is telling the world about me.î This is an example of A) ideas of reference. B) persecutory delusions. C) thought broadcasting. D) thought insertion.
Ans: A Feedback: The client's inaccurate interpretation that general events are personally directed to him or her is an example of ideas of reference. Persecutory delusions involve the client's belief that ìothersî are planning to harm the client. Thought broadcasting is a delusional belief that others can hear or know what the client is thinking. Thought insertion is a delusional belief that others are putting ideas or thoughts into the client's head.
A client is being evaluated for dementia. The nurse knows that a client who is able to complete very few tasks is most likely to have A) a greater cognitive deficit. B) A less precise mental status exam. C) more potential for agitation. D) no bearing on mental status.
Ans: A Feedback: The fewer tasks the client competes accurately, the greater the cognitive deficit. The other choices are not true.
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 B) Memory C) Orientation D) Abstract thinking
Ans: A Feedback: The nurse assesses the client's ability to concentrate by asking the client to perform certain tasks such as repeating the days of the week backward. The nurse directly assesses memory, both recent and remote, by asking questions with verifiable answers. Orientation refers to the client's recognition of person, place, and time. Abstract thinking is to making associations or interpretations about a situation or comment.
Sexuality and self-harm behaviors are often difficult areas for nurses to assess. An effective way for nurses to deal with this discomfort includes A) recognizing that these areas may also be uncomfortable for the patient to discuss. B) share feelings of discomfort with the patient. C) defer assessing these areas to a more experienced nurse. D) develop a standard question to ask of all patients during this area of assessment
Ans: A Feedback: N U R S I N G K I N G . C O M Two areas that may be uncomfortable or difficult for the nurse to assess are sexuality and self-harm behaviors. The beginning nurse may feel uncomfortable, as if prying into personal matters, when asking questions about a client's intimate relationships and behavior and any self-harm behaviors or thoughts of suicide. Asking such questions, however, is essential to obtaining a thorough and complete assessment. The nurse needs to remember that it may be uncomfortable for the client to discuss these topics as well.
When assessing a patient's mental health status, which of the following describe the purpose of the psychosocial assessment? Select all that apply. A) To assess the client's current emotional state B) To assess the client's mental capacity C) To assess the client's behavioral function D) To assess the client's plan of care E) To assess the client's physical health status
Ans: A, B, C Feedback: The purpose of the psychosocial assessment is to construct a picture of the client's current emotional state, mental capacity, and behavioral function. This assessment serves as the basis for developing a plan of care to meet the client's needs. The client's physical health status would need to be completed as another assessment or an extended assessment.
Which of the following are the types of roles that are usually included when assessing roles and relationships? Select all that apply. A) Family B) Hobbies C) Occupation D) Activities E) Race F) Ethnicity
Ans: A, B, C, D Feedback: N U R S I N G K I N G . C O M The number and type of roles may vary, but they usually include family, occupation, and hobbies or activities.
The nurse plans to assess a patient's self-concept in the admission assessment knowing that self-concept influences which of the following? Select all that apply. A) Body image B) Cognitive processing C) Frequently experienced emotions D) Coping strategies E) Responsiveness to medications
Ans: A, C, D Feedback: Self-concept is the way one views oneself in terms of personal worth and dignity. The client's description of self in terms of physical characteristics gives the nurse information about the client's body image. Also included in an assessment of self concept are the emotions that the client frequently experiences and whether or not the client is comfortable with those emotions. The nurse also must assess the client's coping strategies. Cognitive processing and response to medications are biologically based.
Which of the following are components of the assessment of thought process and content? Select all that apply. A) What the client is thinking B) Abstract thinking abilities C) How the client is thinking D) Clarity of ideas E) Self-harm or suicide urges
Ans: A, C, D, E Feedback: The components of the assessment of thought process and content include content (what the client is thinking), process (how the client is thinking), clarity of ideas, self-harm, or suicide urges. Abstract thinking abilities are an element of the abnormal sensory experiences or misperception assessment.
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? A) Focus on each piece of information obtained from the patient. B) Look for patterns reflected in the overall assessment. C) Consider only the abnormal findings in the assessment. D) Present all data obtained in the treatment team meeting.
Ans: B Feedback: After completing the psychosocial assessment, the nurse analyzes all the data that he or she has collected. Data analysis involves thinking about the overall assessment rather than focusing on isolated bits of information. The nurse looks for patterns or themes in the data that lead to conclusions about the client's strengths and needs and to a particular nursing diagnosis. No one statement or behavior is adequate to reach such a conclusion.
Which of the following is the most compelling reason for the nurse to discuss matters of sexuality and suicide? A) It is required by the law by the federal government and in most states in the union. B) It is the nurse's professional responsibility to keep safety needs first and foremost. C) This is commonly required documentation for every encounter with every client. D) It allows the nurse to gain valuable experience in these kind of difficult discussions.
Ans: B Feedback: It is the nurse's professional responsibility to keep the client's safety needs first and foremost, and this includes overcoming any personal discomfort in talking about suicide. This is not required by any laws nor is it commonly required documentation for every encounter with every client. The nurse needs to gain experience in these kind of difficult discussions, but that is not a compelling reason for the nurse to discuss it if not warranted.
Which of the following questions is best to ask when assessing the client's judgment? A) ìCan you describe your usual daily activities for me?î B) ìIf you found yourself downtown without money or a car, how would you get home?î C) ìOn a scale of 1 to 10, how stressed would you rate yourself?î D) ìWhat problem would you like to work on while you're hospitalized?î
Ans: B Feedback: Judgment refers to the ability to interpret one's environment and situation correctly and to adapt one's own behavior and decisions accordingly. This question will elicit information about the client's problem-solving and decision-making abilities. The other choices do not assess the concept of judgment.
Which of the following would best assess a client's judgment? A) Counting by serial sevens B) Discussing hypothetical situations C) Interpreting proverbs D) Spelling words backward
Ans: B Feedback: The client's judgment can be elicited by asking the client to discuss hypothetical situations, which would indicate one's ability to interpret one's environment and situation correctly and to adapt one's behavior and decisions accordingly. Counting by serial sevens and spelling words backward would assess the client's ability to concentrate. Interpreting proverbs would assess the client's abstract thinking.
The nurse reviews results of the Minnesota Multiphasic Personality Inventory (MMPI) recorded in a patient record. While considering the usefulness of these data, the nurse is mindful that the MMPI has which limitation? A) The patient must be able to read to complete the MMPI. B) The results of the MMPI could be culturally biased. C) The MMPI assesses a narrow scope of functioning. D) The MMPI does not have established validity.
Ans: B Feedback: N U R S I N G K I N G . C O M Both intelligence tests and personality tests are frequently criticized as being culturally biased. It is important to consider the client's culture and environment when evaluating the importance of scores or projections from any of these tests. Objective personality tests compare the client's answers with standard answers or criteria and obtain a score or scores. The MMPI provides scores on 10 clinical scales such as hypochondriasis, depression, hysteria, and paranoia; four special scales such as anxiety and alcoholism; three validity scales to evaluate the truth and accuracy of responses. Page 11
A nurse can best assess a patient's ability to use abstract thinking by asking the patient which of the following questions? A) ìWhat would you do if you found a wallet containing $100 on the sidewalk?î B) ìWhat do I mean when I say, 'Don't sweat the small stuff?'î C) ìWhat are you going to do next time you hear voices?î D) ìCan you begin with the number 100 and subtract 7, and then subtract 7 again?î
Ans: B Feedback: N U R S I N G K I N G . C O M The nurse assesses the client's ability to use abstract thinking, which is to make associations or interpretations about a situation or comment. The nurse usually can do so by asking the client to interpret a common proverb. If the client can explain the proverb correctly, his or her abstract thinking abilities are intact. Judgment refers to the ability to interpret one's environment and situation correctly and to adapt one's behavior and decisions accordingly. Insight is the ability to understand the true nature of one's situation and accept some personal responsibility for that situation. The nurse assesses the client's ability to concentrate by asking the client to perform certain tasks such as ìserial sevens.î
A nurse assesses that a depressed patient is lethargic during the day and does not actively participate in unit activities. The notes from the night shift document that the patient did not sleep well. The most probable interpretation of these data is A) the patient's medications are ineffective. B) the patient is being kept awake at night due to noise on the unit. C) the patient's depressed mood is impairing restful sleep patterns. D) the patient is resisting treatment recommendations to participate in unit activities
Ans: C Feedback: Emotional problems often affect some areas of physiologic function. Emotional problems can greatly affect eating and sleeping patterns. Therefore, the nurse must assess the client's usual patterns of eating and sleeping and then determine how those patterns have changed.
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 A) flight of ideas. B) lack of insight. C) labile mood. D) tangential thinking.
Ans: C Feedback: N U R S I N G K I N G . C O M Moods that shift rapidly, displaying a range of emotions, are termed labile. Flight of ideas is manifested by excessive amount and rate of speech composed of fragmented or unrelated ideas. Lack of insight would be manifested by the lack of the ability to understand the true nature of one's situation and accept some personal responsibility for that situation. Tangential thinking would be manifested by wandering off the topic and never providing the information requested.
Which of the following factors influencing assessment is under the nurse's control? A) Client participation and feedback B) Client's health status C) Nurse's attitude and approach D) Client's ability to understand
Ans: C Feedback: N U R S I N G K I N G . C O M The factors that influence assessment include client participation and feedback, client's health status, client's ability to understand, client's previous experiences, and misconceptions about health care. The only one of these that is under the control of the nurse is the nurse's attitude and approach.
A nurse suspects that a patient is abusing alcohol while taking prescribed medications. The nurse plans to educate the patient on the dangers of mixing medicine with alcohol. Which of the following would be the most effective way for the nurse to approach this subject with the patient? A) Firmly inform the patient of the dangers of mixing medications with alcohol. B) Recommend a higher level of care, so the patient can be more closely supervised. C) Emphasize the importance of truthful information using a nonjudgmental approach N U R S I N G K I N G . C O M D) Recognize the patient's right to self-determination and avoid addressing the subject.
Ans: C Feedback: Noncompliance with prescribed medications is an important area. If the client has stopped taking medication or is taking medication other than as prescribed, the nurse must help the client feel comfortable enough to reveal this information. The nurse also explores the client's use of alcohol and over-the-counter or illicit drugs. Such questions require nonjudgmental phrasing; the nurse must reassure the client that truthful information is crucial in determining the client's plan of care.
A patient is known to express tangential thinking. The nurse would assess for which of the following when interacting with the patient? A) Stopping abruptly in the middle of expressing himself B) Jumping from one idea to another C) Wandering off the topic and never answering the question D) Excessive and fast talking about an array of ideas
Ans: C Feedback: Tangential thinking is wandering off the topic and never providing the information requested. Thought blocking is stopping abruptly in the middle of a sentence or train of thoughts, sometimes unable to continue the idea. Loose associations are disorganized thinking that jumps from one idea to another with little or no evident relation between the thoughts. Flight of ideas is excessive amount and rate of speech composed of fragmented or unrelated ideas.
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? A) Tangential thinking B) Ideas of reference C) Loose associations D) Word salad
Ans: C Feedback: The client displayed ideas that were loosely associated to one another. Tangential thinking is manifested by wandering off the topic and never providing the information requested. Ideas of reference are the client's inaccurate interpretation that general events are personally directed to him or her. Word salad is a flow of unconnected words that convey no meaning to the listener.
A client is admitted to the psychiatric unit and states, ìI am president of the largest corporation in the world. Everyone comes to me for advice.î The client is exhibiting which of the following? A) Flight of ideas B) Thought broadcasting C) Delusion D) Loose associations
Ans: C Feedback: The client has a delusion (a fixed false belief not based in reality) about his superiority over others. Flight of ideas is excessive amount and rate of speech composed of fragmented or unrelated ideas. Thought broadcasting is a delusional belief that others can hear or know what the client is thinking. Loose associations are disorganized thinking that jumps from one idea to another with little or no evident relation between the thoughts.
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 A) admitting diagnosis. B) communication skills. C) perception of the problem. D) personal needs.
Ans: C Feedback: The question will elicit information about the client's view or perspective of the problem.
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? A. ìHow would you carry out this plan?î B. ìDo you have a plan to kill yourself?î C. ìAre you thinking of killing yourself?î D. ìHow do you plan to kill yourself?î
Ans: C, B, D, A Feedback: Suicide assessment should be performed through direct questioning. First, the nurse would need to know if the patient has ideations: ìAre you thinking about killing yourself?î; then if the patient has a plan, ìDo you have a plan to kill yourself?î If the patient has a plan, then the nurse would ask about method: ìHow do you plan to kill yourself?î If the patient has ideations, a plan, a method, then does the patient have access to that method the nurse asks, ìHow would you carry out this plan? Do you have access to the means to carry out the plan?î
A delusion represents a problem in which of the following areas? A) Memory B) Motivation C) Orientation D) Thinking
Ans: D Feedback: A delusion is a fixed false idea or thought. Memory relates to the client's knowledge of past events. Motivation relates to the client's interest in doing things. Orientation relates to the client's perception of reality.
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 patient's affect? A) Blunt affect B) Restricted affect C) Broad affect D) Flat affect
Ans: D Feedback: Common terms used in assessing affect include blunted affect: showing little or a slow to-respond facial expression; broad affect: displaying a full range of emotional expressions; flat affect: showing no facial expression; inappropriate affect: displaying a facial expression that is incongruent with mood or situation, often silly or giddy regardless of circumstances; restricted affect: displaying one type of expression, usually serious or somber.
. Knowing that relationships with others are significant to mental health, the nurse effectively assesses a patient's family relationships through which of the following? A) ìDo you feel your family helps you?î B) ìHow many people are in your family?î C) ìWhom are you closest to in your family?î D) ìDescribe your relationships with your family.î
Ans: D Feedback: The nurse must assess the relationships in the client's life, the client's satisfaction with those relationships, or any loss of relationships. Open-ended questions and statements elicit more descriptive responses from the patient than direct questions.
The nurse best assesses a patient's memory by asking which of the following questions? A) ìDo you have any problems with memory?î B) ìWhat did you have for lunch yesterday?î C) ìDo you know where you are?î D) ìWho is the current president?î
Ans: D Feedback: N U R S I N G K I N G . C O M The nurse directly assesses memory, both recent and remote, by asking questions with verifiable answers such as ìWhat is the name of the current president?î The nurse may not be able to verify the accuracy of the client's responses to questions such as ìDo you have any memory problems?î or ìWhat did you do yesterday?î Orientation refers to the client's recognition of person, place, and time.
When the nurse asks the client to restate the following in his or her own words, which sensorium and intellectual process is the nurse attempting to identify? The nurse states, ìA stitch in time saves nine.î A) The client's orientation B) The client's memory C) The client's ability to concentrate D) The client's ability to use abstract thinking
Ans: D Feedback: N U R S I N G K I N G . C O M When the nurse states, ìA stitch in time saves nine,î and asks the client to restate it in his or her own words, the nurse is assessing the client's ability to use abstract thinking. The client's orientation is recognizing person, place, and time. The client's memory, both recent and remote, can be assessed by asking the client questions that have verifiable answers. The client's ability to concentrate can be assessed by asking the client to perform certain tasks including spelling the word ìworldî backward.
When completing a physical assessment of an individual's response to stress, the nurse should observe and inquire about what? Concentration Appetite and sleep Mood Judgement and insight
Appetite and sleep Explanation: Biologic data are essential for analyzing an individual's physical responses to stress, coping efforts, and adaptation. Nurses should pay particular attention to alterations in vegetative functions (e.g., appetite and eating patterns, sleep, energy level, and sexual activity).
The nurse has been asked to assess a 54-year-old client's memory. Which technique would allow the nurse to evaluate recent memory? Provide the client with three words and ask the client to recall the words several minutes later. Ask the client to recall events that have occurred over the past few weeks. Ask the client to recall events from childhood. Provide the client with three words and ask the client to recall the words several months later.
Ask the client to recall events that have occurred over the past few weeks. Explanation: Immediate memory refers to the ability to retain information presented within the last several minutes. Nurses may ask clients to repeat three words and then recall those three words several minutes later. Recent memory refers to the client's ability to recall information from within the past few weeks, while remote memory involves recall of events from many years ago.
The nurse notes that an older adult client is wearing layers of clothing on a warm, fall day. Which would be the priority assessment at this time? Observing the client's overall hygiene Reviewing the client's culture for possible influence Asking whether the client often feels cold Assessing the client's developmental level
Asking whether the client often feels cold Explanation: Dress is typically appropriate for occasion and weather, and dress varies considerably from person to person. Some older adults may wear excess clothing because of slowed metabolism and loss of subcutaneous fat resulting in cold intolerance. The nurse needs to determine this first before performing any other assessments.
Which type of hallucination is the most common? Auditory Visual Gustatory Olfactory
Auditory Explanation: Auditory hallucinations are the most common. Visual hallucinations are the second most common.
While talking with a schizophrenic client, the nurse observes that the client is looking straight ahead, maintains no eye contact, and shows no facial expression, even though the client is telling the nurse about a very emotional episode the client just experienced with a roommate. When describing the client's affect, the nurse documents it as what? A. Blunted B. Flat C. Constricted D. Labile
B. Flat
During a conversation, the client states, "It's raining outside and raining in my heart. Did you know that St. Valentine used to visit jails? I've never been to jail." The nurse can correctly identify this thought process as what? A. Neologisms B. Flight of ideas C. Perseveration D. Circumstantiality
B. Flight of ideas
Which would not be included as a purpose of the psychosocial assessment? A. Current emotional state B. Previous compliance with treatment regimen C. Mental capacity D. Behavioral function
B. Previous compliance with treatment regimen
During a mental status exam, what conclusion should the nurse draw when the client is able to complete fewer than half of tasks accurately? A. The client did not understand the test instructions B. The client's cognitive deficit is significant C. The test needs to be readministered D. The test environment was not appropriate
B. The client's cognitive deficit is significant
During the assessment of a client with schizophrenia, the nurse notes the client has ideas of reference. Which statement of the client would have led the nurse to conclude this? A. "I am sure you know what I am thinking. Everybody knows what I am thinking." B. "My family is taking my thoughts away. I am unable to think now." C. "The news of the terrorist attack is directed to me. The terrorists are trying to warn me." D. "My dead friend is putting these ideas in my mind."
C. "The news of the terrorist attack is directed to me. The terrorists are trying to warn me."
A 20-year-old client who has a diagnosis of schizophrenia frequently experiences delusions of persecution. At the prompting of the client's mother, the nurse attempts to determine the character and severity of these delusions on a particular day. In doing so, the nurse is conducting what type of assessment? A. Comprehensive B. Screening C. Focused D. Secondary
C. Focused
A psychiatric-mental health client informs the nurse that a tornado that hit a neighboring town was the client's fault because the client dislikes a neighbor. This disturbance of thought content is known as what? A. Thought broadcasting B. Magical thinking C. Ideas of reference D. Obsession
C. Ideas of reference
As the nurse is conducting an interview with a client with a diagnosis of schizophrenia, the client states, "Bunnies are cute as a button, buttons are on my shirt, shirts can be bought in a store." Which is a term used to describe this thought process? A. Magical thinking B. Neologisms C. Loose associations D. Ideas of reference
C. Loose associations
A nurse is seeing a client for a weekly therapeutic session in an outpatient psychiatric clinic. The client discloses to the nurse that the client often has thoughts about killing a neighbor. What should be the nurse's first response? A. Review the client's history to determine presence of past of violent behavior. B. Document the session thoroughly and meet with the client again the next day. C. Warn the client's neighbor and report to the authorities. D. Review coping strategies for anxiety and set new therapeutic goals.
C. Warn the client's neighbor and report to the authorities.
The nurse is preparing a psychosocial assessment for use with clients with various mental health conditions. For which group of clients should the nurse include mostly closed-ended questions? Clients with adult attention deficit hyperactivity disorder Clients with antisocial personality disorder Clients with depression Clients with post-traumatic stress disorder
Clients with adult attention deficit hyperactivity disorder Explanation: Clients with attention deficit hyperactivity disorder have reduced attention span, which in turn causes disorganization in their thought processes. These clients may be unable to answer open-ended questions that require a detailed explanation. Thus, the nurse should try to include the maximum number of closed-ended questions in the assessment. Disordered thought is not commonly seen in depression, post-traumatic stress disorder, or antisocial personality disorder. More open-ended questions should be asked of these clients in order to understand their perception of their illness.
Asking the client to complete serial sevens assesses what? Concentration Orientation Judgment Insight
Concentration Explanation: Asking the client to complete serial sevens is assessing the client's ability to concentrate. Orientation refers to the client's recognition of person, place, and time. Judgment refers to the ability to interpret one's environment and situation correctly and to adapt one's behavior and decisions accordingly. Insight is the ability to understand the true nature of one's situation and accept some personal responsibility for that situation.
The nurse is conducting an admission interview with a psychiatric-mental health client. The nurse uses observational skills to identify that the client has a flat affect. The nurse is engaging in which part of the nursing process? A. Diagnosis B. Planning C. Evaluation D. Assessment
D. Assessment
A client is being admitted to an inpatient setting. It is important for the nurse to first obtain which information about the client? A. Insurance information B. Social status C. Educational level D. Assessment of history
D. Assessment of history
A nurse assesses a 29-year-old client in the outpatient mental health clinic. The nurse notes the client is speaking very quickly and jumping from topic to topic very rapidly. There is some connection between ideas, but they are difficult to follow. Which term most accurately describes this thought process? A. Incoherence B. Circumstantiality C. Derailment D. Flight of ideas
D. Flight of ideas
The nurse has been asked to identify a location to conduct an interview with a psychiatric-mental health client. Which is an essential consideration when choosing a location? A. The amount of distracters in a given location B. The amount of lighting in a given location C. The client's right to a stress-free environment D. The client's right to privacy
D. The client's right to privacy
A nurse documents that "the client describes the recent breakup of a dating relationship with an emotionless tone and a flat facial expression." In which section of the mental status exam would the nurse have documented this statement? A. feelings B. blocking C. mood D. affect
D. affect
Which is the most effective way in which the nurse can assess the progress of a client's mental status based on the expected outcome of the therapeutic plan? Planning Evaluation Assessment Professional practice evaluation
Evaluation Explanation: Evaluation is the assessment of a client's progress after an identified plan has been implemented. Planning is done after diagnosis and just before implementing therapeutic strategies. Assessment is the initial data collection from the client. Professional practice evaluation is the evaluation of nursing care against professional standards.
A nurse has been asked to complete a mental status examination of a psychiatric-mental health client. Which is a necessary component of this assessment? Questions regarding past behaviors A review of systems Evaluation of insight and judgment Evaluation of medication compliance
Evaluation of insight and judgment Evaluation: The mental status examination is a central aspect of the psychiatric assessment process that assesses current cognitive and affective functioning through data collection on appearance, behavior, level of consciousness, speech, thought content and processes, cognitive ability, mood and affect, insight, and judgment. This assessment relies almost exclusively on observation rather than inquiry and is expected to change during treatment.
While talking with a schizophrenic client, the nurse observes that the client is looking straight ahead, maintains no eye contact, and moves facial muscles very little, even though the client is telling the nurse about a very emotional episode the client just experienced with a roommate. When describing the client's affect, the nurse documents it as what? Blunted Flat Labile Constricted
Flat Explanation: The client's affect, or facial expression, would be described as "flat." Labile affect is the abnormal fluctuation or variability of one's expressions, such as repeated, rapid, or abrupt shifts. Constricted affect relates to a reduction in one's expressive range and intensity of affective responses. Blunted affect is a severe reduction or limitation in the intensity of one's affective responses to a situation.
During a conversation, the client states, "It's raining outside and raining in my heart. Did you know that St. Valentine used to visit jails? I've never been to jail." The nurse can correctly identify this thought process as what? Perseveration Circumstantiality Neologisms Flight of ideas
Flight of ideas Explanation: Flight of ideas is the expression of multiple, unrelated ideas in a string of statements. Neologisms are new words, circumstantiality is when the client speaks about topics that are loosely related with each other, and perseveration is the repetition of words or ideas over and over.
A nurse assesses a 29-year-old client in the outpatient mental health clinic. The nurse notes the client is speaking very quickly and jumping from topic to topic very rapidly. There is some connection between ideas, but they are difficult to follow. Which term most accurately describes this thought process? Derailment Flight of ideas Circumstantiality Incoherence
Flight of ideas Explanation: This represents flight of ideas, because the ideas are connected in some logical way. Derailment, or loosening of associations, has more disconnection within clauses. Circumstantiality is characterized by the patient speaking "around" the subject and using excessive detail, though thoughts are meaningfully connected. Incoherence lacks meaningful connection and often has odd grammar or word use. Although severe flight of ideas can produce this condition, evidence is not present in this vignette.
A 20-year-old client who has a diagnosis of schizophrenia frequently experiences delusions of persecution. At the prompting of the client's mother, the nurse attempts to determine the character and severity of these delusions on a particular day. In doing so, the nurse is conducting what type of assessment? Focused Screening Comprehensive Secondary
Focused Explanation: A focused assessment includes the collection of specific data regarding a particular problem as determined by the client, a family member, or a crisis situation. A comprehensive assessment is broader in scope, while a screening assessment aims to identify the presence or absence of health problems.
A young adult client is brought to the outpatient mental health clinic by the client's father. The client was diagnosed with schizophrenia 6 months ago and has been taking medication since. The father reports the client continues to hear voices despite adhering to the medication. Which term best describes the client's abnormality of perception? Illusion Hallucination Fugue state Perseveration
Hallucination Explanation: A hallucination is a subjective sensory perception in the absence of real external stimuli. The client can hear, see, smell, taste, or feel something that does not exist in reality. In this case, the client's sister died and cannot be speaking to the client, although in the client's mind the client can hear her. This is an example of an auditory hallucination, but hallucinations can occur with any of the five senses.
Under which component of the psychosocial assessment should the nurse document observations concerning the client's cultural considerations? Thought Process and Content Roles and Relationships Self-Concept History
History Explanation: The assessment information concerning culture is documented under the History component of the psychosocial assessment.
During an initial assessment, a client exhibits pressured speech and points to patterns on the wallpaper stating, "This is the writing about the tsunami. Thousands of people died because I read the writing." Which term should the nurse use to document this observation? Hallucination Ideas of reference Illusion Religious delusion
Ideas of reference Explanation: The client falsely believes that she is responsible for catastrophic events unrelated to her. The nurse would document "ideas of reference" and quote the patient's statements. Believing that the wallpaper contains secrets is not a misperception of a real stimulus or an illusion. The client believes she is responsible for the events she is describing. Hallucinations are false sensory perceptions. In a hallucination, the client sees, smells, hears, tastes, or feels something for which there are no external stimuli. While the ideas of reference would be considered a delusion, no religious or spiritual theme is involved with the patient's false beliefs.
A mental health nurse is caring for a client with schizophrenia. The nurse observes the client laughing about the recent death of the client's father. The nurse would correctly document this mood as what? Blunted Incongruent Flat Labile
Incongruent Explanation: The correct answer is incongruent affect or lack of harmony between one's voice and movements with one's speech or verbalized thoughts. Blunted affect is a severe reduction or limitation in the intensity of one's affective responses to a situation. Flat affect describes absence or near absence of any signs of affective responses. Labile affect is the abnormal fluctuation of one's expressions.
What is the most significant benefit of using Beck's Depression Inventory to the practice of evidence-based nursing practice? It has 21 focused questions to be asked of the client. It is a standardized, reliable depression tool. It is easily graded by the nurse. It identifies a client's level of depression.
It is a standardized, reliable depression tool. Explanation: Evidence-based practice promotes the use of standardized, valid, and reliable tools, guidelines, and protocols in mental health, based on aggregate data. Tools based on the majority of the population presume similarity and stability over time. While the other options are true statements about this screening tool, none are associated with evidence based practice.
As the nurse is conducting an interview with a client with a diagnosis of schizophrenia, the client states, "Bunnies are cute as a button, buttons are on my shirt, shirts can be bought in a store." Which is a term used to describe this thought process? Neologisms Ideas of reference Loose associations Magical thinking
Loose associations Explanation: In some cases a client presents several thoughts that don't make sense in conjunction with one another. This is often seen in clients with acute exacerbations of schizophrenia and is described as loose association.
A client with psychosis who was recently admitted to a psychiatric unit says to the nurse, "The car is red. Are you ready for lunch? My head is hurting. Dogs bark loud." The client is exhibiting which type of speech? Echolalia Clang association Neologism Loose associations
Loose associations Explanation: Looseness of association is a disturbance of thinking shown by speech in which ideas shift from one unrelated or minimally unrelated subject to another. Echolalia is the parrot-like repetition of overheard words or phrases. Clang association is a type of thinking in which the sound of a word (rhyming) substitutes for logic during communication. Neologism describes the use of a new word or combination of several words coined or self-invented by a person and not readily understood by others.
A nurse is conducting an interview with a psychiatric-mental health client and notices the client is using made-up words. This is known as what? Neologisms Clangs Word themes Broadcasting
Neologisms Explanation: Clients with thought disorders (e.g., schizophrenia) may rhyme (clang associations) or use made-up words (neologisms).
When assessing a client who has been referred to the outpatient mental health clinic with symptoms of depression, the psychiatric nurse should closely observe the client's affect and which assessment component? Recollection of the problem's related details Fine motor skills Physical appearance Ability to describe the problem
Physical appearance Explanation: When assessing a client suspected of being depressed, the psychiatric nurse pays close attention to the client's affect and physical appearance. An ability to describe a problem, recall details, and use fine motor skills are not typically the first things to pay attention to when assessing a client suspected of being depressed.
Which would not be included as a purpose of the psychosocial assessment? Behavioral function Previous compliance with treatment regimen Current emotional state Mental capacity
Previous compliance with treatment Explanation: The previous amount of compliance with the treatment regimen would not be included as a purpose of the psychosocial assessment. Current emotional state, behavioral function, and mental capacity are included in the psychosocial assessment.
The psychiatric nurse correctly identifies the client's form of communication as circumstantiality when the client does what? Provides long, irrelevant explanations when asked why the client abuses alcohol. Repeats the phrase, "Mary had a little lamb," whenever feeling stressed. Fails to complete what the client is saying as if distracted. Answers the question, "May we talk?" by responding, "Walk the walk."
Provides long, irrelevant explanations when asked why the client abuses alcohol. Explanation: With circumstantiality, the person gives much unnecessary detail that delays meeting a goal, stating a point, or answering a question. This impairment may be found in clients who abuse substances. The other options provided do not provide unnecessary details and thus are not examples of circumstantiality.
The nurse is caring for a client who has recently developed psychomotor retardation. Based on this information, which behavior would the nurse expect to see in this client? Slowness of body movements Repeated tapping of the foot Speaking meaningless words Maintenance of an awkward posture for a long time
Slowness of body movements Explanation: Slowing of thought processes and bodily movements is referred to as psychomotor retardation. Repeated tapping of foot is referred to as automatism which is often caused due to anxiety. Speaking words that are only meaningful to the client and nobody else is referred to as neologisms. Maintenance of an awkward posture for a long time is an abnormal behavior and is referred to as waxy flexibility.
The nurse is looking to assess the client's ability to concentrate. Which task should the nurse ask the client to perform? Explain the perception of inkblot cards. Interpret the meaning of a proverb. Write the names of family members. Spell "America" backward.
Spell "America" backward. Explanation: To assess the concentration of the client, the nurse should ask the client to spell "America" backward. This activity requires a good amount of concentration. Interpretation of a proverb or idiom is the task used to determine the use of abstract thinking by the client. Explaining the perception of inkblot cards is the Rorschach test and is useful to understand the coping styles, interpersonal attitudes, and characteristics of ideation of the client. Asking the client to write the names of family members is a task useful for assessing the memory of the client.
During an assessment, which would be the most important question topic? Suicidal ideation History Roles and relationships Motor behavior
Suicidal ideation Explanation: The client's safety is a priority. Asking clients clearly and directly about suicidal ideation is essential.
The nurse is performing an assessment of a client with a psychiatric illness. The nurse has 10 cards with different inkblot shapes. Which test is the nurse about to perform? The Rorschach Test The Thematic Apperception Test The Tennessee Self-Concept Scale The Psychological Screening Inventory
The Rorschach Test Explanation: The Rorschach Test is a projective personality test. It includes the use of 10 stimulus cards with inkblots. The client has to describe perceptions of inkblots. This test is useful to understand the coping styles, interpersonal attitudes, and characteristics of ideation. The Thematic Apperception Test uses 20 stimulus cards with pictures. The client tells a story about the picture. The Tennessee Self-Concept Scale and the Psychological Screening Inventory are objective personality tests. The Tennessee Self-Concept Scale includes 100 true-false questions that provide information on 14 scales related to self-concept. The Psychological Screening Inventory consists of 103 true-false questions. The result of the test indicates whether the client needs psychological help.
The nurse is performing an assessment of a client with psychiatric illness. The nurse documents that the client has a restricted affect. Which behavior of the client is indicative of restricted affect? Choose the best answer. The client displays a facial expression that is incongruent with mood. The client displays a full range of emotional expressions. The client displays only one type of facial expression. The client displays no facial expression.
The client displays only one type of facial expression. Explanation: A restricted affect indicates that the client displays only one type of facial expression, usually a serious expression. Displaying no facial expression is referred to as a flat affect. Displaying a full range of emotional expressions is indicative of a broad affect. Displaying a facial expression that is incongruent with mood is referred to as inappropriate affect.
Of the following clinical information, which one would be the most important in determining whether the client would be diagnosed with a mental disorder? The client is unable to continue school work and has been sitting on the client's bed for 3 days. The client has been receiving good grades in college and has a grade point average of 3.8. The client used cocaine up until 1 week ago. The client's father died in a tragic automobile accident when the client was 10 years old.
The client is unable to continue school work and has been sitting on the client's bed for 3 days. Explanation: Disturbance in functional status, or activities of daily living, is the most important factor in determining whether or not a mental disorder is present. Other data in the answers listed could be present even in the absence of mental disorder.
A nurse is performing a psychosocial assessment of a client in the psychiatric unit. The nurse finds that the client is unable to understand the questions. Which explanations should the nurse consider? Select all that apply. The client may not be paying attention to the nurse. The client may not be highly educated. The client may have a low socioeconomic status. The client may have a hearing disability. The client may not understand the nurse's language.
The client may have a hearing disability. The client may not understand the nurse's language. Explanation: Inability of understand the nurse's questions may be due to a hearing disability or the client may speak a different language. Psychosocial assessment includes the use of simple language; the client need not be well educated to answer the questions of the nurse. Impaired understanding is not associated with poor socioeconomic status. Inability to understand what the nurse says does not indicate that the client is not trying to pay attention.
During a mental status exam, what conclusion should the nurse draw when the client is able to complete fewer than half of tasks accurately? The client did not understand the test instructions The client's cognitive deficit is significant The test environment was not appropriate The test needs to be readministered
The client's cognitive deficit is significant Explanation: The fewer tasks the client competes accurately, the greater the cognitive deficit. None of the other options provide a plausible conclusion.
The nurse has been asked to identify a location to conduct an interview with a psychiatric-mental health client. Which is an essential consideration when choosing a location? The client's right to privacy The amount of lighting in a given location The client's right to a stress-free environment The amount of distracters in a given location
The client's right to privacy Explanation: The client's right to privacy is an essential setting consideration. It is an ethical responsibility of the nurse as well as a legal right of the client. Nurses must make critical clinical judgments about the optimal setting that maintains privacy while also ensuring safety.
The nurse finds that the client is constantly rubbing the hands. Under which component of psychosocial assessment should the nurse document this finding? The abnormal sensory experiences or misperceptions component The general assessment and motor behavior component The mood and affect component The history component
The general assessment and motor behavior component Explanation: Constant rubbing of the hands is a type of unusual movement or mannerism. This finding should be documented under general assessment and motor behavior. This abnormal motor behavior is not documented in the history, mood and affect, or abnormal sensory experiences or misperceptions.
When conducting a psycho-social assessment, the nurse inquires about the client's social supports. In order to effectively do this, which does the nurse need to explore? The length and quality of relationships The proximity of the networks to the client Challenges faced with social networks The number of networks
The length and quality of relationships Explanation: Social assessment also includes identification of the person's social network. The nurse should elicit the information about the size and extent of the network, both relatives and nonrelatives, and the length and quality of the relationships.
A nurse is seeing a client for a weekly therapeutic session in an outpatient psychiatric clinic. The client discloses to the nurse that the client often has thoughts about killing a neighbor. What should be the nurse's first response? Warn the client's neighbor and report to the authorities. Document the session thoroughly and meet with the client again the next day. Review the client's history to determine presence of past of violent behavior. Review coping strategies for anxiety and set new therapeutic goals.
Warn the client's neighbor and report to the authorities. Explanation: When the client makes specific threats or has a plan to harm another person, health care providers are legally obligated to warn the target of the threats. Legally this is called duty to warn. Although the nurse must document the session thoroughly and can meet with the client again the next day, this should not be the nurse's first action. The nurse should eventually review coping strategies for anxiety and set new therapeutic goals; however, duty to warn is the priority.
A nurse is reviewing material about assessing mental status. The nurse demonstrates a competent understanding of this assessment by identifying which area as a component of cognition? abstract reasoning posture mood speech
abstract reasoning Explanation: To assess the client's cognition, that is, the ability to think and know, the nurse uses memory, calculation, and reasoning tests to identify specific areas of impairment. The cognitive areas include (1) attention and concentration, (2) abstract reasoning and comprehension, (3) memory, and (4) insight and judgment. Mood, speech, and posture are not components of a cognitive assessment.
A nurse documents that "the client describes the recent breakup of a dating relationship with an emotionless tone and a flat facial expression." In which section of the mental status exam would the nurse have documented this statement? blocking feelings affect mood
affect Explanation: Affect refers to a person's emotional expression (in this case, the manner in which the client talks about the client's experiences). Feelings are emotional states or perceptions. Blocking is the interruption of thoughts. Moods are prolonged emotional states expressed by the affect.
Which client behavior would the nurse document as being an automatism? asking that the question be repeated staring off into space drumming one's fingers on the table top frequently repeating his or her statements
drumming one's fingers on the table top Explanation: An automatism is a repeated purposeless behaviors often indicative of anxiety, such as drumming fingers, twisting locks of hair, or tapping the foot. None of the other options are generally associated with an expression of anxiety.
During the assessment of a client who has a pattern of eating-disordered behavior, the nurse asks, "What would you change about your body, if you could?" The nurse is assessing which component of the psychosocial assessment? roles and relationships thought process and content sensory-perceptual alterations self-concept
self-concept Explanation: By asking the question "What would you change about your body, if you could?" the nurse is assessing self-concept. The client's description of self in terms of physical characteristics gives the nurse information about the client's body image which is also a part of self concept. Sensory-perceptual alterations refer to a change in the client's perception of the world. Often this results in hallucinations or a false sensory perception or perceptual experience that does not really exist. When assessing roles and relationships, the nurse would ask questions such as "Do you feel close to your family?" or "Do you have a significant other?" to determine the existence and quality of the client's sources of support and/or stress. Thought process and content refers to how the client thinks and what they actually say. The aim of this component of the assessment is to determine if the client's ability to think is impaired or intact.
When considering where to conduct a psychosocial assessment, the nurse can effectively interview which client in the unit's conference room? the suicidal client the anxious client the paranoid client the aggressive client
the anxious client Explanation: The nurse should not choose an isolated location such as a conference room for the interview, if the client is unknown to the nurse or has a history of any threatening behavior either to themselves or to others. The anxious client by diagnosis does not present a threat and so is the one best suited for the nurse to use the conference room for the interview.
