Chapter 8: Assessment ~ Mental Health

The nurse is preparing to perform a psychosocial assessment of the client. Which describes the most effective approach taken by the nurse? Select all that apply.

Objective. Accepting.

When the mental health nurse asks the client, "Do you recall what month and year this is?" the nurse is assessing which part of the mental status examination?

Orientation

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?

Physical appearance

Which type of hallucination is the most common?

Auditory

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?

Evaluation of insight and judgment

What is the most significant benefit of using Beck's Depression Inventory in evidence-based nursing practice?

It is a standardized, reliable depression tool.

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?

"I might. I'll give it some..."

Which of the nurse's assessment questions would best identify whether the client has insight into the illness?

"Do you think that your illness prevents you from functioning well, and if so, how?"

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 can we help you?". "How did your problems begin?".

Which statement by the client best demonstrates a healthy relationship with family?

"I feel better after I visit with my Mom."

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."

Which client statement indicates the most insight into his or her issue with auditory hallucinations?

"The voices aren't real but it's hard to ignore them."

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?".

The nurse is preparing to assess a client's remote memory. Which questions would be mostappropriate for the nurse to ask?

"When did you get your first job?"

When completing a physical assessment of an individual's response to stress, the nurse should observe and inquire about what?

Appetite and sleep

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?

Affect

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?

Affect

The nurse has been asked to assess a 54-year-old client's memory. Which technique would allow the nurse to evaluate recent memory?

Ask the client to recall events that have occurred over the past few weeks.

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?

Asking whether the client often feels cold.

The nurse is assessing a client with psychiatric disorder. The nurse finds that when asked a question, the client gives excessive and unnecessary details followed by the answer. This is indicative of which impairment of thought content?

Circumstantial thinking

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

The nurse performs an assessment of a client who presents with symptoms of mental illness for the first time. Which is the nurse's priority?

Collect comprehensive data

A nurse is assessing a hospitalized client who is hearing voices due to psychosis. The client is easily distracted, and this is creating a barrier to completing the assessment. What is the mosteffective way for the nurse to proceed?

Complete the assessment in several short interactions.

Asking the client to complete serial sevens assesses what?

Concentration

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?

Evaluation

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?

Flat

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?

Flight of ideas

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?

Ideas of reference

How should the nurse describe the mood and affect of a client who has a mask-like facial expression but states, "I'm really happy"?

Incongruent

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?

Loose associations

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

Which would not be included as a purpose of the psychosocial assessment?

Previous compliance with treatment regimen

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.

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?

Self-concept

The nurse is looking to assess the client's ability to concentrate. Which task should the nurse ask the client to perform?

Spell "America" backward.

During an assessment, which would be the most important question topic?

Suicidal ideation

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 only one type of facial expression.

During the assessment of a psychiatric client, the nurse documents "oriented x 3" on the client's assessment sheet. What does this indicate?

The client knows the correct date.

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's cognitive deficit is significant

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

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 nurse is assessing an older adult client with lower back pain. In the course of assessment, the nurse learns that the client lost a spouse 10 weeks ago. The client laughs inappropriately and states, "My spouse just up and left me!" Which is the nurse's best response?

The nurse should recognize the incongruity between content and behavior and find ways of exploring further.

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.

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

Which client behavior would the nurse document as being an automatism?

drumming one's fingers on the table top.

When considering where to conduct a psychosocial assessment, the nurse can effectively interview which client in the unit's conference room?

the anxious client