assessment ch 9

An 88-year-old woman has been admitted to the acute medical unit for the treatment of a urinary tract infection that is thought to be progressing to urosepsis. When assessing the client's orientation, how should the nurse best gauge the client's orientation to time?

"Are you able to tell the month and the year that we're in?"

The nurse in a prenatal clinic is performing an assessment on a pregnant client. When it is noted that clumps of hair are missing from the client's scalp, the nurse should ask what assessment question?

"Do you feel safe in your home setting?"

When assessing the client's ability to make sound judgments, what question should the nurse ask? a) "How many dimes are in one dollar?" b) "Can you keep track of your finances on an ongoing basis?" c) "Do you eat breakfast?" d) "How do you plan to pay rent if you lose your job?"

"How do you plan to pay rent if you lose your job?"

The nursing instructor is educating her students on the important of assessing for victims of abuse and violence. What statement by the students indicate an understanding of when to assess for abuse and violence?

"I will assess a client for abuse and violence with every client encounter."

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? a) "I am going to ask you a series of questions, and I need you to answer me truthfully." b) "Don't worry about the questions. Just answer to the best of your ability." c) "I will be asking you some questions, and they shouldn't be hard to answer." d) "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."

A client tearfully admits to the nurse that her husband beats her when he drinks alcohol excessively. How should the nurse best respond to the client's statement?

"It took a great deal of courage for you to tell me that."

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? a) "We don't think you're abused but we have to ask." b) "We are required by law to ask you these questions." c) "This is just something we need to do for reimbursement." d) "We routinely screen everyone because violence affects so many people."

"We routinely screen everyone because violence affects so many people."

A nurse is assessing a patient's spirituality. Which question would be most appropriate to ask?

"What gives your life meaning?"

A nurse assesses a client who was physically assaulted by her boyfriend. The nurse learns that the client was stabbed in the thigh with a knife. After marking the area of injury on the body map, what score should the nurse document for this abuse? a) 6 b) 7 c) 4 d) 5

6

With which of the following is the documentation most consistent?

A patient who has had a recent stroke

The nurse observes a client's entire body posture to be somewhat stiff, with his shoulders elevated upward toward the ears. The nurse would most likely interpret this to indicate that the client is experiencing which of the following?

Anxiety

A nurse suspects that a 9-year-old girl who is in the office today regarding a sprained wrist has been physically abused. The nurse would like to screen the girl for signs of abuse. The girl's father is in the examination room. What should the nurse do in this situation? a) Ask that the mother also be present for the screening b) Ask the father to leave the room so that the nurse can talk with the child in private c) Proceed with the screening with the father present d) Postpone the screening until a more opportune time

Ask the father to leave the room so that the nurse can talk with the child in private

The nurse notes that an older adult client is wearing multiple layers of clothing on a warm fall day. Which of the following would be the nurse's priority assessment at this time?

Asking whether the client often feels cold

A nurse is assigned to care for a client who has been physically abused by her husband. The nurse finds that client has an abuse score of 4 in her documents. Which of the following descriptions corresponds to the abuse score?

Beating up and severe contusions

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? a) Determine whether the boyfriend was abused as a child b) Apply ice to the bruise on the client's face to reduce swelling c) Assess the client for signs of psychological abuse d) Conduct a forensic interview

Conduct a forensic interview

When interviewing a client who is abused by the partner, the nurse should attempt to display which type of behavior towards the client? a) Convey a concerned and nonjudgmental attitude b) Allow the partner to be present with the client c) Screen if there are any safety concerns for the client d) Avoid discussion of legal issues at the start

Convey a concerned and nonjudgmental attitude

The nurse is admitting a patient to the mental health unit with a diagnosis of attempted suicide. Which is the best question for the nurse to ask first?

Do you have any thoughts of wanting to harm or kill yourself?

A nurse is conducting a mental status assessment of a 70-year-old male client who is being treated for depression. When assessing the client's facial expression and eye contact, the nurse should consider which of the following?

Eye contact is strongly influenced by cultural norms.

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? a) Derailment b) Incoherence c) Flight of ideas d) Circumstantiality

Flight of ideas

A nurse is assigned to care for a client who has been physically abused by her stepfather. The nurse finds that client has an abuse score of 5 in her documents. Which of the following descriptions corresponds to the abuse score?

Head injury and internal injury

Which of the following is not a true statement about intimate partner violence?

Intimate partner violence is caused by the "victim" refusing her husband's desire for sex.

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 most likely apply? A) Anxiety related to the physical escalation of the violence b) Impaired parenting related to family violence c) Low self-esteem related to lack of confidence in ability d) Risk for violence related to inadequate coping abilities

Low self-esteem related to lack of confidence in ability

When assessing the speech of an older adult client, which of the following would the nurse expect to find?

Moderately paced

A nurse reviews the documentation of the nurse on the previous shift and finds that the client was obtunded. The nurse anticipates that the client will respond to stimulation in what manner? a) Awakens only to a vigorous shake or painful stimuli b) Opens eyes, answers the question, and falls back to sleep c) Opens eyes to a loud voice and answers with confusion d) Does not respond even to painful stimuli

Opens eyes to a loud voice and answers with confusion

The nurse documents findings from the client's Mini-Mental State Examination. The following information will be documented as a result of this test.

Orientation, memory, and cognitive function.

You are admitting a patient to your unit for surgery the next morning. You note that the patient speaks at an accelerated pace and jumps from topic to topic, none of which progresses to sensible conversation. What would you document about this patient?

Patient demonstrates flight of ideas

The nurse is conducting a health history of a patient at the local community mental health clinic. Which assessment tool would the nurse administer to determine the suicide risk for the patient?

SAD PERSONAS

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? a) Gently shake the client's right shoulder and then his left shoulder. b) Speak to the client clearly from a close distance. c) Press down on one of the client's nail beds. d) Rub the client's sternum with the knuckles.

Speak to the client clearly from a close distance.

An older adult client scores a 15 on a Mini-Mental Status Examination (MMSE). What does this score tell the nurse about the client? a) The client's score indicates cognitive impairment b) The client's score is in the normal range c) The score is inconclusive and the test must be repeated d) The score is borderline, so another examination is needed

The client's score indicates cognitive impairment

A woman has accompanied her 80-year-old husband to a scheduled clinic visit and expresses concern about subtle declines in his cognition. Which of the following principles should guide the nurse's assessment of the client's mental status?

The nurse must differentiate between age-related changes and the signs and symptoms of dementia.

A nurse wants to assess a client's orientation. The nurse recognizes that which orientation is usually lost first when the client is confused?

Time

The nurse is admitting a 23-year-old woman to the acute care mental health unit. Physical examination reveals vertical cuts on the patient's forearms approximately 6 inches long bilaterally. On the care plan, the nurse enters a nursing diagnosis of Risk for Self-Mutilation. What would be the most immediate

Treat medical injuries.

A nurse is interviewing a child who is suspected of being abused. Which of the following would be most appropriate? a) Use direct, nonleading questions b) Offer the child a reward for answering questions c) Ask questions that are highly detailed d) Use simple yes and no questions regardless of the child's age

Use direct, nonleading questions

Which nursing action is essential in caring for the victim of violence? a) Normalizing victimization b) Minimizing confidentiality c) Trivializing the abuse d) Validating the abuse experience

Validating the abuse experience

As part of a mental status assessment, the nurse asks a client to draw the face of a clock. This will allow the nurse to assess which of the following domains of mental status? a) Perceptions and thought processes b) Visual perceptual and constructional ability c) Concentration and orientation d) Expressions and feelings

Visual perceptual and constructional ability

A nurse is evaluating a client who may have Alzheimer's disease. Which of the following are warning signs of Alzheimer's disease? Select all that apply.

• Losing one's ability to pay bills • Getting lost in familiar surroundings • Neglecting to bathe • Asking the same question over and over again

A nurse is collecting both subjective and objective data in assessment of a client's mental health. Which of the following are examples of subjective data? Select all that apply.

• Onset of memory lapses • History of hospitalization for a mental health problem • History of Alzheimer's disease in a family member • Use of recreational drugs

What are some basic rules for nurses to follow when assessing for violence? Select all that apply. a) Perform assessment and screening only when the client is alone in a safe, private environment b) Ask only specific questions c) Demonstrate compassion, not judgment d) Make sure a family member is present e) Be very patient when the client talks

• Perform assessment and screening only when the client is alone in a safe, private environment • Be very patient when the client talks • Demonstrate compassion, not judgment

Violence has many effects on the mental health of clients. Some mental health problems that may be related to violent experiences include which of the following? Select all that apply. a) Schizophrenia b) Relationship and marital problems c) Posttraumatic stress disorder (PTSD) d) Bipolar disorder e) Depression f) Acting out violently

• Posttraumatic stress disorder (PTSD) • Relationship and marital problems • Acting out violently • Depression

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. • Provide the client with contact information for shelters and groups. • Encourage the client to call with any concerns.