chapter 9
The client is brought to the clinic by his son, who states, "My father just doesn't seem to be able to function as well as he used to." When assessing this client the nurse is aware that she will be a what? Patient advocate Surrogate decision maker Family liaison Diagnostician
Patient advocate Explanation: The nurse may assess the change in the client and will be the advocate and detective, determining when the change occurred and what was new in the treatment. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 6: Assessing Mental Status and Substance Abuse.
The nurse is caring for a woman who presents to the Emergency Department with complaints of abdominal pain, as well as cuts and bruises on the arms. Which comment by the client describes intimidation? "If my husband wants me to know something, he has the kids tell me." "He says I'm stupid even though I have a doctoral degree in history." "I have not seen my parents in 6 months; they live only 30 minutes away." "My husband hits the kitchen wall with his fist just inches from my head."
"My husband hits the kitchen wall with his fist just inches from my head." Explanation: Intimidation makes the victim afraid through the use of looks, action, or gestures. Emotional abuse refers to the victim being put down or made to feel bad about them self. A perpetrator uses children to relay messages to exert power or control the victim. Isolation refers to controlling what victims do or read, whom they see or talk to, or where they go. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 188. Chapter 9: Mental Health, Violence, and Substance Use - Page 188
The nurse performs a Mini-Mental Status Examination of a client with altered thought processes. Which total score would indicate cognitive impairment? 30 20 28 25
20 Explanation: The Mini-Mental Status Examination (MMSE) is a scored test. A total of 23 or lower on the MMSE indicates cognitive impairment. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 203. Chapter 9: Mental Health, Violence, and Substance Use - Page 203
When the nurse asks the client to explain similarities and differences between objects, what cognitive ability is being tested? Memory to learn new information. Abstract reasoning. Judgment. Concentration.
Abstract reasoning. Explanation: Abstract reasoning is the ability to compare objects. For example, "How are an apple and orange the same? How are they different?" Also, asking to explain a proverb. For example, "A rolling stone gathers no moss" or "A stitch in time saves nine." Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 6: Assessing Mental Status and Substance Abuse.
Which of the following would be the most likely example of emotional or psychological abuse? Scolding a child for playing with matches Punishing a child for crossing the street Belittling a child in front of others Asking a child to perform a dance routine for her grandmother
Belittling children can be as hurtful to them as physical abuse because it prevents them from being able to achieve. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 187. Chapter 9: Mental Health, Violence, and Substance Use - Page 187
The nurse utilizes the Depression Questionnaire on a client who has recently moved to a long-term care facility. The total score is 22. What would the nurse to do next? Refer for further evaluation. Document this as a normal score. Assess further for dementia. Evaluate benefits versus risks of a mental health label.
Refer for further evaluation. Explanation: A score of 22 denotes very severe depression; referral is clearly warranted. Dementia is not indicated by this score. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 191. Chapter 9: Mental Health, Violence, and Substance Use - Page 191
An emergency department nurse has utilized the Confusion Assessment Method (CAM) in the assessment of a 79-year-old client with a new onset of urinary incontinence. This assessment tool will allow the nurse to confirm the presence of what health problem? Delirium Vascular dementia Psychosis Schizophrenia
Delirium Explanation: The CAM assesses for delirium; it does not assess for dementia, schizophrenia, or psychosis. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 190. Chapter 9: Mental Health, Violence, and Substance Use - Page 190
The client states, "I don't know why God as abandoned me; I am a good person." Which tool would be most appropriate for the nurse to administer? Mini-Cog HOPE MMSE CAGE
HOPE Explanation: The HOPE tool is used to assess spirituality. The CAGE is used to assess for substance abuse. The MMSE and the Mini-Cog are used to assess cognitive function. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use.
A nurse is working with a client who confides in the nurse that her boyfriend will not let her get a job and insists on controlling all of their money. He gives her only a small allowance each month to buy food and a few necessities. When the nurse offers information on how to seek help for economic abuse, the client just shakes her head and says, "It's no use. Nothing can be done." Which of the following nursing diagnoses would be most appropriate in this situation? Dysfunctional family processes related to family violence Anxiety related to not having enough money to purchase necessities due to significant other Hopelessness related to remaining in a prolonged abusive relationship and inability to seek counseling and healthy supportive relationships Risk for violence (other directed) related to taking out frustrations with an abusive partner on their children
Hopelessness related to remaining in a prolonged abusive relationship and inability to seek counseling and healthy supportive relationships Explanation: This client seems to be expressing a hopelessness regarding her situation. There is no evidence that the client is experiencing anxiety nor is their evidence that violence is occurring in the home, or that she is at risk for abusing her children as a result of her abusive relationship. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 207. Chapter 9: Mental Health, Violence, and Substance Use - Page 207
A nurse uses the Glasgow Coma Scale to assess a client's response to stimuli. The client receives a score of 10. Which of the following is the client's status? Fully conscious Comatose Confused In need of emergency attention
In need of emergency attention Explanation: The Glasgow Coma Scale is useful for rating one's response to stimuli. The client who scores 10 or lower needs emergency attention. The client with a score of 7 or lower is generally considered to be in a coma. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 189. Chapter 9: Mental Health, Violence, and Substance Use - Page 189
A nurse wants to assess a client's orientation. The nurse recognizes that which orientation is usually lost first when the client is confused? Location Place Person Time
Time Explanation: Orientation to time is usually lost first and orientation to person is lost last. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 202. Chapter 9: Mental Health, Violence, and Substance Use - Page 202
The CAGE assessment is used by the nurse to determine if further assessment is needed. The nurse may assess that it is highly likely the client has a problem and would seek additional assessments if the client answered "yes" to one of the four CAGE questions. answered "no" to all of the four CAGE questions. answered "no" to three of the four CAGE questions. answered "yes" to three of the four CAGE questions.
answered "yes" to three of the four CAGE questions. Explanation: The CAGE assessment is a quick questionnaire used to determine if an alcohol assessment is needed. If two or more of these questions is answered yes, then further assessment is advised. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 204. Chapter 9: Mental Health, Violence, and Substance Use - Page 204
The client's daughter asks the nurse why the nurse is asking her mother depression-related questions. The nurse explains that even though the client has symptoms of dementia, the Geriatric Depression Scale is being used because depression often mimics signs and symptoms of dementia. finding out why she is depressed will help determine the cause of her dementia. depression and dementia are one in the same disorder. it is the most accurate tool to determine the stage of dementia.
depression often mimics signs and symptoms of dementia. Explanation: The Geriatric Depression Scale is used if depression is suspected in the older client. Read the questions to the client if the client cannot read. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 198. Chapter 9: Mental Health, Violence, and Substance Use - Page 198
An auditory hallucination is considered an alteration in which component of the mental health assessment? A. perceptionsB. thought processesC. affectD. insight
perceptions Explanation: Perception is the sensory awareness of objects in the environment and their interrelationships (external stimuli). Perception also refers to internal stimuli such as dreams or hallucinations. Thought processes involve the logic, coherence, and relevance of a client's thought as it leads to selected goals or how people think. Affect is the observable, usually episodic, feeling or tone expressed through voice, facial expression, and demeanor. Insight is considered the awareness that symptoms or disturbed behaviors are normal or abnormal, for example, distinguishing between daydreams and hallucinations that seem real. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 198. Chapter 9: Mental Health, Violence, and Substance Use - Page 198
During the health history inquiry about alcohol intake, which of the following is a CAGE question? "Describe the types of alcohol that you prefer." "How often do you have a hangover?" "How many days per week do you drink?" "Have you ever felt annoyed by criticism about drinking?"
"Have you ever felt annoyed by criticism about drinking?" Explanation: "Have you ever felt annoyed by criticism about drinking?" is one of the 4 questions that make up the CAGE questionnaire. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, pp. 194-204. Chapter 9: Mental Health, Violence, and Substance Use - Page 194-204
A client states reports feeling like a burden to the family and totally worthless. Which response would be appropriate for the nurse to make to this client? "I'm sure that you aren't worthless." "Where does your family live?" "Everyone feels that way every now and then." "Have you thought of killing yourself?"
"Have you thought of killing yourself?" Explanation: Feelings of worthlessness and being a burden could indicate that the client is depressed and at risk for suicide. The nurse should ask if the client has ever thought of suicide. Asking about the family does not address the client's statement. Stating that the client isn't worthless or that everyone feels that way now and then minimizes the client's statement and does not assess if the client is experiencing suicide ideation. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 211. Chapter 9: Mental Health, Violence, and Substance Use - Page 211
Report this Question Which of the following assessment questions is most likely to allow the nurse to assess a client's judgment?
"How do you plan to meet your responsibilities at work?" Explanation: Asking the client to explain his or her response to financial, interpersonal, or logistical challenges can yield insight into the client's judgment. Asking the client to explain the cause of mood changes can help the clinician gauge the client's insight but not judgement, while asking about seeing and hearing things addresses perception, specifically hallucinations. Asking about previous successful coping strategies can be useful but does not assess judgment. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, pp. 192-193. Chapter 9: Mental Health, Violence, and Substance Use - Page 192-193
A nurse is conducting an initial interview with a client who has paranoid delusions. What statement by the nurse can help to establish rapport as well as alleviate some of the suspicion the client may experience? "Don't worry about the questions. Just answer to the best of your ability." "I am going to ask you a series of questions, and I need you to answer me truthfully." "I will be asking you some questions, and they shouldn't be hard to answer." "I will be asking you a series of questions that I ask of all of my clients."
"I will be asking you a series of questions that I ask of all of my clients." Explanation: It is important to establish rapport and trust prior to beginning the interview process. If there is not time to establish this rapport and trust, the nurse can begin the interview by letting the client know that the questions are being asked of all clients who are interviewed. Questions in mental health are designed to elicit information about various mental health risks and problems. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 190. Chapter 9: Mental Health, Violence, and Substance Use - Page 190
The emergency department nurse is assessing a female client with traumatic injuries. To assess whether or not the client's injuries have resulted from abuse, which question would be most appropriate for the nurse to ask the client? "Why do you think your husband has beaten you?" "It looks like someone has hurt you. Tell me about it." "Can you describe the person who did this to you?" "Is your partner being mean to you?"
"It looks like someone has hurt you. Tell me about it." Explanation: The nurse should say to the client, "It looks like someone has hurt you. Tell me about it." This is an open-ended statement and allows the client to verbalize her thoughts and feelings. Asking if the partner is being mean or why the client thinks the husband has beaten her already assume that the client has been abused. Asking about the person who did this to the client would be ineffective be survivors of violence are unlikely to disclose sensitive information unless they perceive the nurse to be trustworthy and nonjudgmental. Additionally, this question is a closed question that does not allow the client to verbalize her thoughts and feelings openly. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 195. Chapter 9: Mental Health, Violence, and Substance Use - Page 195
The nurse is performing an initial mental status examination on a client with depression. To obtain subjective data, what is the best question made by the nurse? "Why are you here?" "Tell me how you are feeling right now?" "How long have you felt this way?" "Do you have a history of alcohol or drug use?"
"Tell me how you are feeling right now?" Explanation: Subjective data are things that the client says directly to the nurse. The best way to obtain subjective data is to ask open-ended questions during an interview. This encourages the client to elaborate when answering. It also allows the nurse to assess the client's cognitive processes. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 190. Chapter 9: Mental Health, Violence, and Substance Use - Page 190
An emergency department nurse asks a client to complete an intimate partner violence assessment screening. How should the nurse best explain the rationale for this assessment? "This is just something we need to do for reimbursement." "We routinely screen everyone because violence affects so many people." "We don't think you're abused but we have to ask." We are required by law to ask you these questions
"We routinely screen everyone because violence affects so many people." Explanation: To begin screening an individual for violence, it is important for the nurse to tell the client that it is important to routinely screen all clients for intimate partner violence because it affects so many women and men in our society. This statement helps to build trust and rapport without being judgmental. Telling the client that the screening is required by law or that screening is necessary for reimbursement is not therapeutic. Telling the client that the nurse doesn't think that she is abused blocks any communication that might help to provide clues to abuse. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 186. Chapter 9: Mental Health, Violence, and Substance Use - Page 186
Which question is appropriate for a nurse to ask a client to assess the client's recent memory? "How are an orange and an apple different?" "Why are you at the health care clinic today?" "What did you eat for breakfast today?" "When is your birthday?"
"What did you eat for breakfast today?" Explanation: Recent memory or short term memory asks the client about things and events that are happening currently. Asking the client what they ate for breakfast is testing recent memory. Asking the client their birth date tests remote memory. How an orange and an apple are different tests a client's ability for abstract reasoning. If a client can tell the nurse why they are at the clinic, this assesses the client's orientation (location). Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use.
As part of the mental status examination, a nurse assesses the cognitive abilities of a client. Which question should the nurse ask to assess the judgment ability in the client?
"What do you do if you have pain?" Explanation: To assess judgment ability in a client, the nurse should ask the client what he or she does when in pain. Asking about the first job and the last hospitalization helps in assessing remote memory. Asking the client about the difference between an apple and an orange elicits abstract reasoning. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 193. Chapter 9: Mental Health, Violence, and Substance Use - Page 193
A nurse is assessing a client's spirituality. Which question would be most appropriate to ask? "Have you every tried to harm yourself?" "How do you define good and evil?" "What gives your life meaning?" "How important is your family to you?"
"What gives your life meaning?" Explanation: Spirituality refers to a unifying force of a person that is unique to each individual. Thus, asking a client about what gives meaning to his or her life addresses this area. Asking about self-harm provides information about suicidal ideation. Asking about the importance of family provides information about the social system of the family. Asking about how the client defines good and evil reflects the client's cultural beliefs. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 199. Chapter 9: Mental Health, Violence, and Substance Use - Page 199
Which type of elder abuse involves leaving an older adult and no longer providing care for the individual? Abandonment Neglect Emotional Physical
Abandonment Explanation: The six types of elder abuse are physical (injury by hitting, kicking, pushing, slapping, burning, and so on), sexual (unconsented sexual act), emotional (harm of self-worth or emotional well-being), neglect (failure to meet the older adult's basic needs of shelter, food, and so on), abandonment (leaving an older adult alone and no longer providing care), and financial (illegally misusing money, property, or assets). Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 187. Chapter 9: Mental Health, Violence, and Substance Use - Page 187
Which approach would be most appropriate when counseling a woman who is a suspected victim of violence? Offer her a pamphlet about the local battered women's shelter. Wait until she comes in a few more times to make a better assessment. Call her home to ask her some questions about her marriage. Ask, "Have you ever been physically hurt by your partner?"
Ask, "Have you ever been physically hurt by your partner?" Explanation: If violence is suspected, the nurse must used direct or indirect questions to screen for abuse. Asking the woman if she has ever been physically hurt by her partner is most appropriate. Offering her a pamphlet, calling her at home, or waiting until she returns are inappropriate and do not validate the suspicion. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 186. Chapter 9: Mental Health, Violence, and Substance Use - Page 186
The nurse notes that an older adult client is wearing multiple layers of clothing on a warm fall day. What would be the nurse's priority assessment at this time? Asking whether the client often feels cold Assessing the client's developmental level Reviewing the client's culture for possible influence Observing the client's overall hygiene
Asking whether the client often feels cold Explanation: Dress typically is appropriate for occasion and weather. 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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 201. Chapter 9: Mental Health, Violence, and Substance Use - Page 201
A nurse is examining a 16-year-old girl who is visibly distraught. The client has a bruise on her face and tells the nurse that her boyfriend got rough with her recently. On further questioning, the client tells the nurse that her boyfriend raped her. Which of the following is the priority nursing intervention at this point? Assess the client for signs of psychological abuse Determine whether the boyfriend was abused as a child Apply ice to the bruise on the client's face to reduce swelling Conduct a forensic interview
Conduct a forensic interview Explanation: If a nurse discovers signs of sexual abuse, including rape, on assessing a client, the nurse should conduct a forensic interview to gather data for potential legal proceedings. The other answers are of lesser priority than conducting a forensic interview. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 207. Chapter 9: Mental Health, Violence, and Substance Use - Page 207
Which clients are most at risk for depressive symptoms? (Select all that apply.) Males Chronically ill clients Divorced clients Females Married clients
Divorced clients Females Chronically ill clients Explanation: Watch carefully for depressive symptoms, especially in clients who are young, female, single, divorced or separated, seriously or chronically ill, or bereaved. Those with a prior history or family history of depression are also at risk. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 192. Chapter 9: Mental Health, Violence, and Substance Use - Page 192
The nurse is caring for a woman being seen for possible pregnancy. When would nurse screen the woman for intimate partner violence? Once the woman begins her second trimester of pregnancy At a point when the woman states she is comfortable with being screened As soon as an appointment can be scheduled with the woman's partner During the woman's first prenatal visit to the clinic
During the woman's first prenatal visit to the clinic Explanation: Screening for pregnant mothers should be started at the initial prenatal visit and continued periodically and postnatally. The partner should not be present during screening. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 186. Chapter 9: Mental Health, Violence, and Substance Use - Page 186
The nurse is caring for a woman in the prenatal clinic who comments that she just cannot seem to get things "right" anymore at home and that her husband says she knows so little about life. Which type of abusive or controlling behavior is the woman describing?
Emotional abuse Explanation: Emotional abuse refers to the victim being put down or made to feel bad about them. The perpetrator makes light of abuse and says abuse did not occur through minimizing and blaming. Intimidation makes the victim afraid through the use of looks, action, or gestures. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 186. Chapter 9: Mental Health, Violence, and Substance Use - Page 186
A nurse is assessing an elderly client who may be a victim of elder mistreatment. Which of following are examples of elder mistreatment? Select all that apply. Administering the wrong medication to an elder inadvertently Shoving an elder into a wheelchair Having an elder sign financial documents without an understanding of what is being signed Failure to provide adequate nutrition to an elder Forcing an elder to perform a sexual act
Failure to provide adequate nutrition to an elder Shoving an elder into a wheelchair Forcing an elder to perform a sexual act Having an elder sign financial documents without an understanding of what is being signed Explanation: Elder mistreatment, also known as elder abuse, includes neglect (e.g., failure to provide adequate nutrition); physical abuse (e.g., shoving an elder into a wheelchair); sexual abuse (e.g., forcing an elder to perform a sexual act); financial abuse (e.g., having an elder sign financial documents without an understanding of what is being signed); psychological abuse (including humiliation, intimidation and threats; exploitation; and abandonment or prejudicial attitudes that decrease one's quality of life, and are demeaning to those over the age of 65 years. Administering the wrong medication to an elder inadvertently is a medical error but is not elder mistreatment, as it is an accident. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 187. Chapter 9: Mental Health, Violence, and Substance Use - Page 187
A nurse is interviewing a woman who has been physically abused by her husband. When the nurse asks about the husband's background, the client explains that in their native country, women are still viewed as inferior to men, and that it is common for husbands to beat their wives. Which theory of family violence does this example best support? Feminist theory Social learning theory Biological theory Cycle of violence theory
Feminist theory Explanation: The feminist theory of family violence contends that male/female inequity in patriarchal societies leads to violence. According to the biological theory of family violence, physiologic changes from childhood trauma, head injuries, or through heredity cause violent behavior. Social learning theory states that violence is a learned behavior from childhood. According to the cycle of violence theory, abuse occurs in a predictable pattern. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 186. Chapter 9: Mental Health, Violence, and Substance Use - Page 186
A 29-year-old woman comes to the office. During history taking, the nurse notices that the client is speaking very quickly and jumping from topic to topic so rapidly that it is difficult to follow her. The nurse can find some connections between ideas, but it is difficult. Which word best describes this thought process? Flight of ideas Derailment Incoherence Circumstantiality
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 client 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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 213. Chapter 9: Mental Health, Violence, and Substance Use - Page 213
The nurse suspects a client has undiagnosed Alzheimer disease but changes the care plan after talking with a family member. What information caused the nurse to alter the client's plan of care? Surgery for spinal stenosis two years ago Ingests a 6-pack of beer every evening Follows a Mediterranean eating plan Diagnosed with osteoarthritis of both knees
Ingests a 6-pack of beer every evening Explanation: Drinking in some older adults may cause symptoms of forgetfulness or confusion which could be mistaken for signs of Alzheimer disease. A Mediterranean eating plan, previous spinal surgery, or osteoarthritis would not cause symptoms similar to Alzheimer disease. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 202. Chapter 9: Mental Health, Violence, and Substance Use - Page 202
During the review of systems within the comprehensive health history, the nurse notes that a client has multiple previous injuries and accidents. Which of the following issues is a priority in the nurse's assessment? Inquire about the client's substance use Complete the CAGE Questionnaire Investigate the possibility of physical abuse Assess the client's gait and balance
Investigate the possibility of physical abuse Explanation: Physical abuse should be considered if the client has a past history of repeated injuries or accidents. There is not enough information for the nurse to suspect that the client has a health problem that impacts balance. The nurse will assess the client for substance and alcohol abuse during the health patterns component of the comprehensive health history. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 35. Chapter 9: Mental Health, Violence, and Substance Use - Page 35
A client arrives at the clinic accompanied by her husband. When the client is in the examination room she says to the nurse, "He loves me so much. He only lets me go out when he is with me because he says other men look at me." What type of behavior is this husband exhibiting? Coercion Isolation Intimidation Privilege
Isolation Explanation: Isolation is when someone is controlling what victims do or read, whom they see or talk to, or where they go, limiting their involvement outside of the home; it is a way of using jealousy to justify actions. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 193. Chapter 9: Mental Health, Violence, and Substance Use - Page 193
A nurse asks a client the following question: "What do you do if you have pain?" The nurse is assessing which of the following? Memory Orientation Judgment Abstract reasoning
Judgment Explanation: Asking a client about what he or she does or would do if he or she has pain evaluates a client's judgment. Asking about the client's name, time, and place evaluates his or her orientation. Asking a client to compare and contrast things evaluates abstract reasoning. Asking the client about recent and past events evaluates memory. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 202. Chapter 9: Mental Health, Violence, and Substance Use - Page 202
A victim of intimate partner violence tells a nurse, "I don't know how I'd live if I left my husband. And what about my children? I have no skills and haven't worked since I was a teenager." When developing the plan of care for this client, which nursing diagnosis would be best? Anxiety related to the physical escalation of the violence Low self-esteem related to lack of confidence in ability Impaired parenting related to family violence Risk for violence related to inadequate coping abilities
Low self-esteem related to lack of confidence in ability Explanation: The client's statements indicate that her self-esteem is low due to her feelings of not being able to survive outside the violent relationship. The client may be anxious, but this anxiety would most likely be related to her low self-esteem, not to the escalation of the violence. Although impaired parenting might apply, the client's statements are more reflective of her feelings of low self-esteem, which would, in turn, contribute to her feelings about whether she was a good parent. The partner, not the client, would most likely have a nursing diagnosis of risk for violence. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 201. Chapter 9: Mental Health, Violence, and Substance Use - Page 201
A 23-year-old ticket agent is brought in by her husband because he is concerned about her recent behavior. He states that for the last 2 weeks she has been completely out of control. She hasn't showered in days, stays awake most of the night cleaning their apartment, and has run up more than $5,000 on their credit cards. While he is talking the client interrupts him frequently, declares this is all untrue, and says she has never been so happy and fulfilled in her whole life. She speaks very quickly, changing the subject often. After a longer than normal interview, the nurse learns that the client has had no recent illnesses or injuries. Her past medical history is unremarkable. Both her parents are healthy, but the husband has heard rumors about an aunt with similar symptoms. The client and her husband have no children. She smokes one pack of cigarettes a day (although she has been chain smoking in the last 2 weeks), drinks four to six times a week, and smokes marijuana occasionally. She is very loud and outspoken. Physical examination findings are unremarkable. Which mood disorder does she most likely have? Schizophrenia Major depressive episode Manic episode Dysthymic disorder
Manic episode Explanation: Mania consists of a persistently elevated mood for at least 1 week with symptoms such as inflated self-esteem, decreased need for sleep, pressured speech, racing thoughts, and involvement in high-risk activities (e.g., drug use, spending sprees, indiscriminate sexual activity). In this case, the client has racing thoughts and pressured speech, a decreased need for sleep, and engagement in high-risk activities (spending sprees). Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 191. Chapter 9: Mental Health, Violence, and Substance Use - Page 191
During the health-history interview, which of the following components of cognitive function can the nurse quickly assess? Judgment and behavior Calculation and language Abstract thinking and perceptions Memory and attention
Memory and attention Explanation: While gathering the health history, it is possible to quickly discern the client's level of alertness and orientation, mood, attention, and memory. As the history unfolds, the nurse will learn about the client's insight and judgment and any recurring or unusual thoughts or perceptions. Calculation, behavior, and abstract thinking are less likely to emerge during this phase of assessment. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 202. Chapter 9: Mental Health, Violence, and Substance Use - Page 202
During the health-history interview, which of the following components of cognitive function can the nurse quickly assess? Memory and attention Abstract thinking and perceptions Judgment and behavior Calculation and language
Memory and attention Explanation: While gathering the health history, it is possible to quickly discern the client's level of alertness and orientation, mood, attention, and memory. As the history unfolds, the nurse will learn about the client's insight and judgment and any recurring or unusual thoughts or perceptions. Calculation, behavior, and abstract thinking are less likely to emerge during this phase of assessment. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 202. Chapter 9: Mental Health, Violence, and Substance Use - Page 202
A nurse is assessing a boy who appears to be undernourished. She can find no signs of physical abuse. She considers whether this may be a case of child abuse. Which of the following are included in the definition of child abuse? Select all that apply. Sexual abuse Physical abuse Neglect Emotional abuse Intimate partner violence Elder abuse
Neglect Physical abuse Sexual abuse Emotional abuse Explanation: There are four broad categories of child abuse: neglect, emotional abuse, sexual abuse, and physical abuse. Intimate partner violence involves victims who are adult women and men. Elder abuse involves victims who are over the age of 65 years. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 191. Chapter 9: Mental Health, Violence, and Substance Use - Page 191
The nurse notes that an adolescent male has ptosis of the left eye. What should the nurse suspect as the reason for this finding? Undiagnosed eye disease Nerve damage caused by repeated eye injuries Need for corrective lenses Undiagnosed neurologic disease
Nerve damage caused by repeated eye injuries Explanation: Unilateral ptosis of an eye would occur because of repeated injuries to the eye causing nerve damage to the eyelids. This finding does not indicate an undiagnosed eye or neurologic disease. This finding does not indicate the need for corrective lenses. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 204. Chapter 9: Mental Health, Violence, and Substance Use - Page 204
The nurse documents findings from the client's Mini-Mental State Examination. The following information will be documented as a result of this test. Mood, feelings, expressions, and perceptions. Appropriateness of dress, grooming, and eye contact. Orientation, memory, and cognitive function. Energy level, satisfaction, and social participation.
Orientation, memory, and cognitive function. Explanation: Cognitive abilities include orientation, concentration, recent and remote memory, abstract reasoning, judgment, visual perception, and constructional ability. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 203. Chapter 9: Mental Health, Violence, and Substance Use - Page 203
The nurse is admitting a client to the unit for surgery the next morning. The nurse notes that the client speaks at an accelerated pace and jumps from topic to topic, none of which progresses to sensible conversation. What would the nurse document about this client? Patient is depressed Patient demonstrates flight of ideas Patient demonstrates schizophrenia Patient demonstrates confabulation
Patient demonstrates flight of ideas Explanation: Flight of ideas is an almost continuous flow of accelerated speech in which a person changes abruptly from topic to topic. Changes are usually based on understandable associations, plays on words, or distracting stimuli, but the ideas do not progress to sensible conversation. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 213. Chapter 9: Mental Health, Violence, and Substance Use - Page 213
The nurse has identified that a female client desires to leave her abusive husband and move with her children to her parent's house. Which nursing diagnosis would be most appropriate for this client? Readiness for enhanced family processes Disturbed personal identity related to moving to parent's house Impaired parenting related to loss of relationship Grieving related to loss of ideal relationship
Readiness for enhanced family processes Explanation: Because the client expressed a desire to leave her husband and start over, there is a readiness for enhanced family processes. Grieving may be appropriate if the client stated feelings related to the loss of the relationship. Disturbed personal identity would be appropriate if the client demonstrated an inability to function effectively outside the victimized role. Impaired parenting would be appropriate if the client had decided to remain in the abusive relationship with her children. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use.
The nurse is performing an acute mental health assessment on a client who states, "I am going to hang myself with my belt. I just want to die!" What is the priority nursing diagnosis for this client? Risk for Suicide Impaired Social Interaction Sensory Perceptual Alteration Ineffective Individual Coping
Risk for Suicide Explanation: The client is at risk for potentially fatal, purposefully self-inflicted injury. The client has stated a desire to die, which indicates a risk for suicide. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 207. Chapter 9: Mental Health, Violence, and Substance Use - Page 207
After reviewing a client's completed danger assessment questionnaire, the nurse determines that the client is in significant danger of intimate partner violence (IPV) leading to homicide. The client says that she would prefer to return home and that she does not have a safety plan. Which of the following nursing interventions should the nurse implement at this point? Select all that apply. Schedule a follow-up appointment. Have the client complete Assessment Tool 10-2: Assessing a Safety Plan. Encourage the client to return home to avoid raising suspicion in the abuser. Provide the client with contact information for shelters and groups. Encourage the client to call with any concerns. Call the police and ask them to pick up the abuser.
Schedule a follow-up appointment. Have the client complete Assessment Tool 10-2: Assessing a Safety Plan. Provide the client with contact information for shelters and groups. Encourage the client to call with any concerns. Explanation: If screening for IPV is positive and the client's answers on the danger assessment questionnaire indicate a high probability for serious violence, the nurse should ask the client if she has a safety plan and where she would like to go when she leaves the nurse's agency, and should schedule a follow-up appointment and/or refer the client as appropriate. If the client says she prefers to return home, the nurse should ask her whether it is safe for her to do so and have her complete Assessment Tool 10-2. The nurse should also provide the client with contact information for shelters and groups, and encourage her to call with any concerns. The nurse should not encourage the client to return home, as it may not be safe for her to do so. The nurse should also not call the police and ask them to pick up the abuser, as there may not be sufficient legal grounds on which to arrest and incarcerate him. In doing so, the client could be put at further risk of abuse. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 196. Chapter 9: Mental Health, Violence, and Substance Use - Page 196
A 19-year-old college student, Todd, comes to the clinic with his mother, who is concerned that there is something seriously wrong with him. She states that for the past 6 months, her son's behavior has become peculiar, and that he has flunked out of college. Todd denies any recent illness or injuries. His past medical history is remarkable only for a broken foot. His parents are healthy. He has a paternal uncle who had similar symptoms in college. The client admits to smoking cigarettes and drinking alcohol. He also admits to marijuana use but not in the last week. He denies use of any other substances and feelings of depression or anxiety. The nurse does a complete physical examination, which is essentially normal. When the nurse questions the client about how he is feeling, he says that he is worried that his software for creating a better browser has been stolen. He says that he has seen a black van in his neighborhood at night, and he is sure that it is full of computer programmers stealing his work through special gamma waves. The nurse asks why Todd believes they are trying to steal his programs. He replies that the programmers have been telepathing their intents directly into his head. He says he hears these conversations at night, so he knows this is happening. What psychotic disorder is most consistent with Todd's history and physical examination findings? Psychotic disorder due to a medical illness Substance-induced psychotic disorder Schizophrenia Generalized anxiety disorder
Schizophrenia Explanation: Onset of schizophrenia generally happens in the late teens to early 20s. It often is seen in other family members. Symptoms must be present for at least 6 months and must have at least two features of (1) delusions (thieves are stealing his programs), (2) hallucinations (technicians sending telepathic signals), (3) disorganized speech, (4) disorganized behavior, and (5) negative symptoms such as a flat affect. The catalysts of delirium and substance ingestion that denote a psychotic disorder due to medical illness and substance-induced psychotic disorder are absent. Generalized anxiety is not present. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 191. Chapter 9: Mental Health, Violence, and Substance Use - Page 191
Susanne is a 27-year-old woman who has had headaches, muscle aches, and fatigue for the last 2 months. The nurse has completed a thorough history, examination, and laboratory workups, the results of which are normal. What would the next action be? A referral to a neurologist A referral to a rheumatologist Telling the client nothing has been found Screening for depression
Screening for depression Explanation: Although the nurse may consider referrals to help with diagnosis and treatment of this client, screening is a time-efficient way to recognize depression. This will allow her to be treated more expediently. The nurse may tell the client that no answer is clear yet, but also that he or she will not stop investigating until the client has gotten the help she needs. Research has shown that health care providers routinely fail to screen for depression. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 190. Chapter 9: Mental Health, Violence, and Substance Use - Page 190
The nurse is assessing an older adult client's mental status. Consistently, the client pauses after the nurse poses a question, but then the client provides a response that is correct or appropriate. How should the nurse best interpret this characteristic of the client? The client may be trying to anticipate the nurse's desired response. The client may be experiencing an early sign of delirium. The client is displaying a sign of early Alzheimer's disease. Slight delays in mental processing are normal in older adults.
Slight delays in mental processing are normal in older adults. Explanation: Slight delays in information processing are considered to be an age-related change and are not necessarily pathologic. There is no indication that the client may be trying to anticipate the nurse's desired response. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use.
The intensive care nurse is working with a client who has increased intracranial pressure secondary to a traumatic brain injury. The nurse is performing the hourly assessment of the client's level of consciousness and observes that the client's eyes are closed. How should the nurse first stimulate the client to assess for arousability? Press down on one of the client's nail beds. Gently shake the client's right shoulder and then his left shoulder. Rub the client's sternum with the knuckles. Speak to the client clearly from a close distance.
Speak to the client clearly from a close distance. Explanation: When assessing the level of consciousness, always begin with the least noxious stimulus: verbal, tactile, to painful. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 201. Chapter 9: Mental Health, Violence, and Substance Use - Page 201
The nurse uses the SAD PERSONAS to assess the suicide risk for a client. The total score was 3. Which interpretation by the nurse is correct? Further evaluation is needed to make a determination. The score suggests suicide may be a problem. The client is at high risk for suicide. The client is at low risk for suicide.
The client is at low risk for suicide. Explanation: Scores on the SAD PERSONAS can range from 0 to 10. Higher scores indicate greater suicide risk. A score of 3 indicates relatively low risk. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, pp. 196-198. Chapter 9: Mental Health, Violence, and Substance Use - Page 196-198
The nurse observes the spouse of a client pinch the client's arm when someone talks with the client in the waiting room of the community clinic. What should this observation indicate to the nurse? The client is not permitted to have contact with others The spouse is jealous The client was sharing too much information with the other person The spouse was trying to get the client's attention
The client is not permitted to have contact with others Explanation: Abusive partners often control the activities of the partner and do not allow outside friendships or significant contact with others. There is not information about the situation to determine if the spouse was jealous. Pinching is not required to get someone's attention. Since the exchange was limited in the waiting room it is unlikely that the client was sharing too much information with the other person. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 204. Chapter 9: Mental Health, Violence, and Substance Use - Page 204
An older adult client scores a 15 on a Mini-Mental Status Examination (MMSE). What does this score tell the nurse about the client? The client's score is in the normal range The score is inconclusive and the test must be repeated The client's score indicates cognitive impairment The score is borderline, so another examination is needed
The client's score indicates cognitive impairment Explanation: Taking only 5 to 10 minutes to administer makes the MMSE easy to use with elderly clients or clients with poor attention span. A score of 24 to 30 is in the normal range. A score of 23 or lower on the MMSE indicates cognitive impairment. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 200. Chapter 9: Mental Health, Violence, and Substance Use - Page 200
A nurse suspects abuse on a client with a fractured forearm, who does not want to discuss how the fracture happened. What is something the nurse could do to let the client know the client is not alone? The nurse can call the authorities and have the abuser arrested The nurse can contact a social worker so the woman will be removed from the situation The nurse can ask more questions so the client feels it is necessary to talk about it The nurse can educate the client about the high prevalence of human violence
The nurse can educate the client about the high prevalence of human violence Explanation: When a nurse asks about violence, some clients decide that the time, setting, or health care professional is not a comfortable fit for them to disclose their story. In such cases, violence-screening questions provide an opportunity for the nurse to let clients know about the high prevalence of human violence so that they do not feel singled out or alone. Contacting a social worker to remove the woman from the situation or calling the authorities to have the abuser arrested is not an appropriate response. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 188. Chapter 9: Mental Health, Violence, and Substance Use - Page 188
The nurse is admitting a 7-month-old child with bruising of the arms and chest to the pediatric unit. Which action should the nurse take? No action by the nurse is needed. The nurse should alert the nurse manager. The nurse should monitor the situation. The nurse should alert protective services.
The nurse should alert protective services. Explanation: The nurse should report the incident to protective services. The nurse should suspect child abuse in infants with bruising prior to walking. Nurses are mandated to report when child, elder, or vulnerable-adult abuse or neglect is disclosed, assessed, or suspected. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 191. Chapter 9: Mental Health, Violence, and Substance Use - Page 191
When assessing an older adult about possible mistreatment, which question would be appropriate for the nurse to ask first? Are you alone often at home? Did you ever signs papers you didn't understand? Have you ever been abused? What is a typical day in your life like?
What is a typical day in your life like? Explanation: The nurse would begin to assess an older adult for possible mistreatment by asking the client to tell the nurse about a typical day in his or her life. Then the nurse would ask questions related to signing papers or being alone at home. Asking the client if he or she was ever abused would be nontherapeutic and block further communication. The client may be fearful about the ramifications of reporting the abuse if it is occurring. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 192. Chapter 9: Mental Health, Violence, and Substance Use - Page 192
The nurse uses the Mini-Mental State Examination to assess a client. For which reason is this assessment tool most likely used? dementia bipolar disorder depression schizophrenia
dementia Explanation: The Mini-Mental State Examination is a brief questionnaire which has been widely used to screen clients for cognitive dysfunction or dementia. The Mini-Mental State Examination is not routinely used to assess depression, schizophrenia, or bipolar disorder. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 200. Chapter 9: Mental Health, Violence, and Substance Use - Page 200
If a nurse suspects that a client is depressed, asking the client about any suicidal thoughts: will stimulate clients to act on suicidal ideation is important, but not an early priority will stimulate thoughts of suicide is important and will not stimulate the thought of suicide
is important and will not stimulate the thought of suicide Explanation: Many clinicians avoid the topic of self-harm or suicide because they worry that broaching it will implant the idea in the client's mind. There is little risk that talking about suicide with someone who is not already thinking about it will prompt him or her to do it. Consequently, the issue should be prioritized and directly addressed with clients who are or may be depressed. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 190. Chapter 9: Mental Health, Violence, and Substance Use - Page 190
When interviewing a pediatric client and attempting to determine the presence of abuse, the nurse should offer a reward to the child for answering difficult questions. ask leading questions to convince the child to offer information. remain calm and accepting in response to any information the client discloses. confine the interview to yes/no questions to keep the interview simple.
remain calm and accepting in response to any information the client discloses. Explanation: Remember when asking questions to allow the client to answer completely. Do not interrupt the client. Convey a concerned and nonjudgmental attitude. Show appropriate empathy. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Mental Health, Violence, and Substance Use, p. 190. Chapter 9: Mental Health, Violence, and Substance Use - Page 190