PrepU Ch. 10 Interview & Assessment

When conducting a focused assessment on a newly admitted client who attempted suicide, the nurse asks what? Select all that apply. a) "Are you willing to tell us if you plan to harm yourself again?" b) "Have you ever tried to hurt yourself before?" c) "Did you really want to kill yourself?" d) "Is there a history of depression in your family?" e) "Do you still have a plan to harm yourself?"

a) "Are you willing to tell us if you plan to harm yourself again?" b) "Have you ever tried to hurt yourself before?" e) "Do you still have a plan to harm yourself?" Explanation: In the event of a suicide attempt, the nurse would assess the client's mood, affect, and behavior. Data regarding the attempted suicide and any previous attempts of self-destructive behavior would also be collected. Questions related to the client's actual intent and family history would not be part of a focused assessment.

The nurse is performing a psychosocial assessment of a client. Which questions should the nurse ask to assess the self-concept of the client? Select all that apply. a) "What do you do when you have a problem?" b) "Could you tell me what time it is?" c) "How do you think you look today?" d) "Which country do you live in?" e) "Are you thinking about killing yourself?"

a) "What do you do when you have a problem?" c) "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.

A nurse who provides care at a community mental health center (CMHC) is conducting an assessment of a new client who has long-standing diagnosis of major depression. How can the nurse best assess the client's perspective of her mental health problem? a) "What do you think has contributed to your depression in the past?" b) "Do you have a family history of depression?" c) "Have you had any thoughts of suicide in the past 24 hours?" d) "Have you been taking your medications consistently?"

a) "What do you think has contributed to your depression in the past?" Explanation: Asking for a client's explanation of the etiology and contributing factors to his or her disease can provide insight into the client's overall perspective of the illness. Questions about medications, family history, and medication use are appropriate assessment questions, but they do not ascertain the client's perspective of her illness.

Which of the following standardized rating scales is used to identify adverse effects associated with antipsychotic medications? a) Abnormal Involuntary Movement Scale b) Global Assessment of Functioning Scale c) Folstein's Mini-Mental Status Examination d) The Beck Depression Inventory

a) Abnormal Involuntary Movement Scale Explanation: The Abnormal Involuntary Movement Scale relies on clinician observation to identify abnormal movements associated with adverse effects from antipsychotic medications. The Beck Depression Inventory is a scale that assesses the client's report of various degrees of depression symptoms. Folstein's Mini-Mental Status Examination has been identified as a common tool used to assess cognitive functions. The Global Assessment of Functioning Scale (GAF) incorporates overall functioning.

When interviewing a psychiatric client whose ability to communicate effectively is impaired, the nurse initially influences the situation therapeutically by a) Acknowledging to the client that there is a problem b) Being extremely attentive to the client's nonverbal communication behaviors c) Asking the client to repeat any conversation that is not understood d) Suggesting that the client write his or her responses to critical questions

a) Acknowledging to the client that there is a problem Explanation: Talking openly and communicating with the client can provide valuable information about compliance and behavior. Acknowledging that differences do exist is the most important thing that the psychiatric-mental health nurse can do. While the other options are not necessarily inappropriate, they are not the first things a nurse should strive for.

The focused purpose of a comprehensive assessment on a newly admitted psychiatric client is to a) Be aware of the client's medical needs to avoid medical emergencies b) Begin to establish the therapeutic nurse-client relationship c) Provide care in accordance with established standards of nursing care d) Encourage the client to discuss issues important to their recovery

a) Be aware of the client's medical needs to avoid medical emergencies Explanation: A comprehensive assessment includes data related to the client's biological, psychological, cultural, spiritual, and social needs. Psychiatric facilities require a comprehensive assessment, including medical clearance, before or within 24 hours of admission to avoid medical emergencies in the psychiatric setting. While the other options are true statements, they are not focused on the psychiatric client.

Which of the following would be an inappropriate manner by the nurse to conduct a psychosocial assessment? a) By interjecting personal feelings b) Matter-of-factly c) In a nonjudgmental way d) Professionally

a) By interjecting personal feelings Explanation: The nurse must conduct the assessment professionally, in a nonjudgmental way, and matter-of-factly while not allowing personal feelings to influence the interview.

A client with schizophrenia is being interviewed by the nurse. The client states, "Train, brain, stain." This is an example of which altered speech pattern? a) Clang associations b) Stuttering c) Pressured d) Neologism

a) Clang associations Explanation: Clients with thought disorders may use rhyming speech (clang associations). Made-up words are neologisms. Stuttering and pressured speech may signal anxiety, agitation, mania, or all of these responses.

Which of the following must be addressed to establish a trusting working relationship before proceeding with the assessment? a) Client's feelings and perceptions b) Client's compliance c) Client's behavior d) Client's willingness to participate

a) Client's feelings and perceptions Explanation: The nurse must address the client's feelings and perceptions to establish a trusting working relationship before proceeding with the assessment.

Which of the following types of affect is represented by showing no facial expression? a) Flat b) Inappropriate c) Blunted d) Restricted

a) Flat Explanation: A flat affect is exhibited by no facial expression. A blunted affect is showing little or a slow-to-respond facial expression. An inappropriate affect is displaying a facial expression that is incongruent with the mood or situation. A restricted affect is displaying one type of expression, usually serious or somber.

The client tells the nurse, "That new TV anchor is telling the world about me." This is an example of a) Ideas of reference b) Thought insertion c) Thought broadcasting d) Persecutory delusions

a) Ideas of reference Explanation: General events inaccurately interpreted by the client as personal are ideas of reference. Persecutory delusions involve the client's belief that "others" 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.

When a client talks about the recent loss of a family member while laughing or smiling, this type of affect would be labeled as which of the following? a) Inappropriate b) Blunted c) Flat d) Restricted

a) Inappropriate Explanation: An inappropriate affect is displaying a facial expression that is incongruent with the mood or situation. A blunted affect is showing little or a slow-to-respond facial expression. A restricted affect is displaying one type of expression, usually serious or somber. A flat affect is exhibited by no facial expression.

The nurse asks the client, "What is similar about a cow and a horse?" and "What do a bus and an airplane have in common?" These questions would best assess which of the following areas? a) Intellectual function b) Insight c) Memory d) Judgment

a) Intellectual function Explanation: These questions would elicit information about the client's general fund of knowledge.

A client is expressing concerns about the problems at the workplace. Which nonverbal cues would indicate that the nurse is attentive to the client? Select all that apply. a) Leaning towards the client b) Having a sad facial expression c) Sitting with closed arms and crossed legs d) Looking down to the floor e) Maintaining eye contact with the client

a) Leaning towards the client e ) Maintaining eye contact with the client Explanation: The nonverbal cues that convey that the nurse is paying attention are leaning towards the client and maintaining eye contact while speaking to the client. If the nurse looks down towards the floor when the client is trying to talk, this indicates that the nurse is disinterested. Having a sad facial expression does not indicate attentiveness. Sitting with closed arms and crossed legs indicates that the nurse is not willing to listen to the client.

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) Loose associations b) Word salad c) Concrete thoughts d) Ideas of reference

a) Loose associations Explanation: The client displayed ideas that were loosely associated to one another. Concrete thoughts occur when the client continually gives literal translations. 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.

When a client states, "I'm thinking about a sunny day, so you won't need a raincoat." The nurse knows that this is an example of which of the following thought content disturbance? a) Magical thinking b) Thought broadcasting c) Obsessions d) Ideas of reference

a) Magical thinking Explanation: Magical thinking is a belief that thinking about something will make it happen. Ideas of reference are beliefs that external events have personal significance. Thought broadcasting is the belief that thoughts are known by others. Obsessions are unwanted repetitive thoughts.

The nurse says to the client, "You become very anxious when we start talking about your drinking." Which of the following techniques is the nurse using? a) Making an observation b) Confronting behavior c) Verbalizing the implied d) Translating into feelings

a) Making an observation Explanation: The nurse is stating what he or she sees; the client can validate it or reject it. The nurse is not confronting the behavior in this situation. The nurse is not translating the message into feelings, nor is he verbalizing the implied.

A group of students is reviewing material about assessing mental status. The students demonstrated understanding of the material when they identify which of the following as a cognitive ability to be assessed? a) Orientation b) Posture c) Thought processes d) Speech

a) Orientation Explanation: Cognitive abilities include orientation, concentration, recent and remote memory, abstract reasoning, judgment, visual perception, and constructional ability. Posture, speech, and thought processes are components of a comprehensive mental status examination.

A hospital patient is unwilling to enter the unit's shower room, stating, "That's the place where the special forces lie in wait." The nurse would recognize that this patient may have what kind of delusion? a) Persecution b) Nihilism c) Somatic d) Grandeur

a) Persecution Explanation: Delusions of persecution involve a perception that a person is under threat or being singled out for harassment. A nihilistic delusion involves the denial of a body part or self, and a delusion of grandeur is a misperception of importance.

Which of the following is crucial when a nurse is trying to obtain accurate and complete information from the client during the assessment process? a) Self-esteem b) Self-awareness c) Self-control d) Self-motivation

a) Self-awareness Explanation: Self-awareness is crucial when a nurse is trying to obtain accurate and complete information from the client during the assessment process.

A client expresses worry about her child's aggressive behavior. The nurse says "If I would have been in your situation, I too would worry about my child." What does this nurse's statement indicate? a) The nurse is empathizing with the client. b) The nurse is comforting the client. c) The nurse is sympathizing with the client. d) The nurse is showing genuine interest in the client.

a) The nurse is empathizing with the client. Explanation: Empathizing is the ability of the nurse to perceive the feelings and emotions that the client is trying to communicate. The nurse's statement indicates that the nurse is trying to perceive the problem by relating the problem with self. This would help the client to feel comfortable and safe while sharing feelings with the nurse. Sympathy is the ability of the nurse to project his or her concern towards the client. The nurse does not perceive the problem of the client. If the nurse is able to empathize with the client then it indicates that the nurse is showing genuine interest and is listening actively to the client

The nurse is interviewing the parents of a child with conduct disorder. Which question is appropriate for the nurse to ask? a) What type of discipline do you use at home?" b) "What type of punishments do you give your child?" c) "How often do you punish your child?" d) "What words do you use while scolding your child?"

a) What type of discipline do you use at home?" Explanation: While asking questions on sensitive topics like parenting, the nurse should use nonjudgmental language and a matter-of-fact tone. This avoids giving the client verbal cues to become defensive or to not tell the truth and to be free while expressing thoughts. Asking about the type of discipline used at home indicates that the nurse does not have any presumptions about the parental behavior. Asking about the frequency of punishments to the child indicates that the nurse presumes that the child gets punished by the parents. Questions such as "What words do you use while scolding your child" indicates the nurse's notion that the parents scold their child. Asking about the types of punishment the parents give indicates that the parents punish the child in different ways. These questions reflect the judgmental behavior of the nurse.

The nurse asks the client to explain the meaning of the proverb "A stitch in time saves nine." Which explanation given by the client indicates concrete thinking? a) You should not forget to sew up holes in your clothes. b) If you solve one problem, you will prevent 9 problems in future. c) Fixing things on time would prevent bigger problems in future. d) One should always stitch before nine o'clock.

a) You should not forget to sew up holes in your clothes. Explanation: When a client always gives a literal translation of a comment or situation, it indicates that the client uses concrete thinking. The literal translation of the proverb "a stitch in time saves nine" is that "You should not forget to sew up holes in your clothes." Thus, this statement of the client indicates concrete thinking. The statement "One should always stitch before nine o'clock" indicates that the client has not even understood the literal meaning of the proverb. As for "Fixing things on time would prevent bigger problems in future" and "If you solve one problem, you will prevent nine problems in future," both are correct explanation of the proverb. If the client gives these explanations, then the client uses abstract thinking.

As part of a focused assessment, the nurse asked the client to describe her mood this morning. In response, the client stated, "It is what it is." Which of the following examples of nursing documentation is most appropriate? a) "Client feels resigned to her symptoms of depression." b) "Client states about her mood, 'It is what it is.'" c) "Client is nonspecific about her mood." d) "Client is currently feeling ambivalent."

b) "Client states about her mood, 'It is what it is.'" Explanation: When documenting assessment findings, it is important to use the client's own words whenever possible. Subjectively describing a client's mood or speculating about underlying meanings is inappropriate and potentially inaccurate.

A nurse is performing a psychosocial assessment of the client. Which questions asked by the nurse are open-ended? Select all that apply. a) "Is there something wrong with you?" b) "How did your problems begin?" c) "When was your last visit in the psychiatric facility?" d) "Are you feeling better today?" e) "How can we help you?"

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

Which of the following statements made by a client would indicate that she has delusions of grandeur? a) "I hear messages from aliens that tell me to steal cars." b) "I am a magician, and my magic powers are good when the moon is full." c) "I let my baby die. I don't deserve to live." d) "I can't eat this food. It's poisoned."

b) "I am a magician, and my magic powers are good when the moon is full." Explanation: The correct answer is the only statement that reflects that the client believes she has powers, abilities, or characteristics that go beyond those of normal individuals (delusions of grandeur).

When assessing orientation, the nurse notes the client's response when asked which of the following? Select all that apply. a) "Would you count from 1 to 10 backward, please?" b) "What is your name?" c) "Can you tell me where you are?" d) "What did you eat for breakfast today?" e) "What day of the week is it?"

b) "What is your name?" c) "Can you tell me where you are?" e) "What day of the week is it?" Explanation: Asking the client to give his name, identify his location, and name the day of the week assess orientation. Asking the client to relate what he ate for breakfast assesses his short memory, and asking the client to count backward assesses his intellectual abilities, neither of which is a reflection of orientation.

The nurse is completing a psychosocial assessment on a newly admitted client. By asking the client to complete serial sevens, the nurse assesses which of the following? a) Orientation b) Ability to concentrate c) Insight d) Judgment

b) Ability to concentrate 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 to accept some personal responsibility for that situation.

Asking the client to complete serial sevens assesses which of the following? a) Judgment b) Ability to concentrate c) Insight d) Orientation

b) Ability to concentrate Correct 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.

If the client provides a literal explanation of a proverb and cannot interpret its meaning, which thought process is lacking? a) Concrete thinking b) Abstract thinking c) Flight of ideas d) Loose associations

b) 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. Loose associations display disorganized thinking that jumps from one idea to another with little or no evident relation between the thoughts. Flight of ideas is an excessive amount and rate of speech composed of fragmented or unrelated ideas.

A nurse documents that "the client describes the recent breakup of her dating relationship with an emotionless tone and a flat facial expression." The nurse will be able to document this quality as a descriptive statement of which aspect of mental status? a) Feelings b) Affect c) Mood d) Blocking

b) Affect Explanation: Affect refers to a person's emotional expression (in this case, the manner in which the client talks about her experiences). Feelings are emotional states or perceptions. Blocking is the interruption of thoughts. Moods are prolonged emotional states expressed by the affect.

The nurse notes that an older adult client is wearing layers of clothing on a warm, fall day. Which of the following would be the priority assessment at this time? a) Reviewing the client's culture for possible influence. b) Asking whether the client often feels cold. c) Observing the client's overall hygiene. d) Assessing the client's developmental level.

b) 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.

The nurse is initiating a conversation with a client who appears depressed. Which therapeutic communication technique is being utilized when the nurse asks the client, "Is there something you'd like to talk about?" a) Accepting b) Broad openings c) Focusing d) Exploring

b) Broad openings Explanation: This is an example of a broad opening, which allows the client to take the initiative in introducing the topic. Accepting is indicating reception. Exploring is delving further into a subject or idea. Focusing is concentrating on a single point.

Which of the following would best assess a client's judgment? a) Counting by serial sevens b) Discussing hypothetical situations c) Spelling words backward d) Interpreting proverbs

b) Discussing hypothetical situations Explanation: The client's problem-solving and decision-making abilities can be elicited by discussing solutions to hypothetical situations.

While talking with a schizophrenic client, the nurse observes that he is looking straight ahead, maintains no eye contact, and moves his facial muscles very little, even though he is telling her about a very emotional episode he just experienced with his roommate. When describing the client's affect, the nurse documents it as what? a) Labile b) Flat c) Constricted d) Blunted

b) 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.

A 29-year-old woman comes to the clinic. As you take the history, you notice that she is speaking very quickly and jumping from topic to topic so rapidly that you have trouble following her. You can find some connections between ideas, but it is difficult. Which word describes this thought process? a) Circumstantiality b) Flight of ideas c) Derailment d) Incoherence

b) 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 22-year-old man is brought to the clinic by his father. The patient was diagnosed with schizophrenia 6 months ago and has been taking medication since. The father states that his son's dose isn't high enough and adds that the patient has been hearing things. The patient responds that his father is jealous because his sister talks to him. His father says, "Your sister died 2 years ago!" The son replies, "She still talks to me all the time!" Which best describes this patient's abnormality of perception? a) Illusion b) Hallucination c) Perseveration d) Fugue state

b) Hallucination Explanation: A hallucination is a subjective sensory perception in the absence of real external stimuli. The patient can hear, see, smell, taste, or feel something that does not exist in reality. In this case, the patient's sister died and cannot be speaking to him, although in his mind he can hear her. This is an example of an auditory hallucination, but hallucinations can occur with any of the five senses.

When the nurse asks the client, "If you found a stamped addressed envelope on the ground, what would you do?" The nurse is assessing which component of the assessment? a) Orientation b) Judgment c) Self-concept d) Insight

b) Judgment Explanation: The nurse may assess a client's judgment by asking the client hypothetical questions, such as "If you found a stamped addressed envelope on the ground, what would you do?"

In the space of five 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) Labile mood c) Tangential thinking d) Lack of insight

b) Labile mood Explanation: Moods that shift rapidly, displaying a range of emotions, are termed labile.

Which of the following is used to describe invented words that have meaning only for the client? a) Automatisms b) Neologisms c) Loose associations d) Flight of ideas

b) Neologisms Explanation: A neologism is an invented word that has meaning only for the client. Automatisms are repeated, purposeless behaviors often indicative of anxiety. Loose associations indicate disorganized thinking that jumps from one idea to another with little or no evident relation between the thoughts. Flight of ideas is an excessive amount and rate of speech composed of fragmented or unrelated ideas.

When initiating an assessment, the nurse should use which type of questioning? a) Utilize "Why" questioning b) Open-ended questions c) Closed-ended questions d) Focused on several symptoms

b) Open-ended questions Explanation: The nurse should use open-ended questions when gathering assessment data from the client. Doing so allows the client to begin as he or she feels comfortable, and also gives the nurse an idea about the client's perception of his or her situation.

A group of students is reviewing material about assessing mental status. The students demonstrated understanding of the material when they identify which of the following as a cognitive ability to be assessed? a) Speech b) Orientation c) Thought processes d) Posture

b) Orientation Explanation: Cognitive abilities include orientation, concentration, recent and remote memory, abstract reasoning, judgment, visual perception, and constructional ability. Posture, speech, and thought processes are components of a comprehensive mental status examination.

When assessing a client suspected of being depressed, the psychiatric nurse pays close attention to the client's affect and ... a) Fine motor skills b) Physical appearance c) Ability to describe the problem d) Recollection of the problem's related details

b) 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.

The most important priority in conducting a mental health assessment interview is the determination of which of the following? a) Hygiene b) Safety c) Wellness d) Behavior

b) Safety Explanation: The most important priority in conducting a mental health assessment interview is determination of the client's safety toward self, toward others, and from others.

Which of the following areas may be uncomfortable or difficult for the nurse to assess? a) Motor behavior b) Sexuality c) Roles and relationships d) Mood

b) Sexuality Explanation: Two areas that may be uncomfortable or difficult for the nurse to assess are sexuality and self-harm behaviors.

The nurse is assessing a 40-year-old client and notes that the client is experiencing an identity crisis. How does the nurse interpret this information? Choose the best answer. a) The client may have a cognitive disorder. b) The client may have delayed development. c) The client is very mature. d) The client may become very aggressive.

b) The client may have delayed development. Explanation: Self-identity is typically developed during adolescence. If the client is experiencing an identity crisis, this indicates that the client's age and developmental level is not in congruence with expected norms. The nurse should explore the situation to determine if the client has a developmental delay or mental retardation. Identity crisis in this client indicates reduced maturity. On the basis of this finding, the nurse cannot conclude that the client has impaired cognition. There is no association between aggressive behavior and identity crisis.

As part of a focused assessment, the nurse asked the client to describe her mood this morning. In response, the client stated, "It is what it is." Which of the following examples of nursing documentation is most appropriate? a) "Client is nonspecific about her mood." b) "Client feels resigned to her symptoms of depression." c) "Client states about her mood, 'It is what it is.'" d) "Client is currently feeling ambivalent."

c) "Client states about her mood, 'It is what it is.'" Explanation: When documenting assessment findings, it is important to use the client's own words whenever possible. Subjectively describing a client's mood or speculating about underlying meanings is inappropriate and potentially inaccurate.

A well-known client with a diagnosis of schizophrenia has been brought to the emergency department by police after causing a disturbance in a store. Which of the nurse's assessment questions would best identify whether the client has insight into his illness? a) "Has anything like this happened to you before?" b) "Why do you think the police brought you here?" c) "Do you think that you're sick?" d) "Do you ever hear voices or see things that other people do not see?"

c) "Do you think that you're sick?" Explanation: Insight is defined as self-understanding about the origin, nature, and mechanisms of one's attitudes and behavior; it can often be ascertained by asking whether the client believes himself to be in need of treatment. Asking a client about hallucinations or previous encounters with the law or the medical system is less likely to reveal the client's presence or absence of insight.

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? a) "My dead friend is putting these ideas in my mind." 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) "I am sure you know what I am thinking. Everybody knows what I am thinking."

c) "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.

The nurse is performing a psychosocial assessment of a client. Which questions should the nurse ask to assess the self-concept of the client? Select all that apply. a) "Could you tell me what time it is?" b) "What do you do when you have a problem?" c) "Are you thinking about killing yourself?" d) "Which country do you live in?" e) "How do you think you look today?"

c) "What do you do when you have a problem?" e) "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.

The nurse observes a female client rubbing the chest of her asthmatic daughter with a coin. Which of the following reflects a culturally sensitive, or transcultural, response to this client? a) "Stop! You're hurting your child!" b) "You are making your daughter cry." c) "What is it that you are doing right now?" d) "I'll have to inform the doctor that you are not following instructions."

c) "What is it that you are doing right now?" Explanation: The correct answer reflects that the nurse is attempting to ask a question that will help her to understand the client's behaviors, which would be a culturally sensitive approach. The other answers demonstrate non-acceptance or a negative attitude from the nurse.

Which GAF score is noted by superior functioning in a wide range of activities? a) 60 b) 20 c) 100 d) 40

c) 100 Explanation: A GAF score of 100 indicates superior functioning in a wide range of activities. A score of 20 indicates that there is some danger of hurting self or others. A score of 40 indicates some impairment in reality testing or communication. A score of 60 indicates moderate symptoms or moderate difficulty in social, occupational, or school functioning.

The Global Assessment of Functioning (GAF) score describes the client's current level of functioning and the highest level of functioning within the past year or a) 1 month b) 9 months c) 6 months d) 3 months

c) 6 months Explanation: The GAF is used to make a judgment about the client's overall level of functioning.

When interviewing a 30-year-old Asian client who immigrated to the United States as a child, the nurse best addresses the impact that culture has on the client's perceptions and beliefs by a) Researching the physiological and emotional response to anxiety traditionally exhibited by Asians b) Inquiring how the client feels his symptoms should be managed c) Assessing to what degree the client has embraced the American culture d) Asking the client to explain what he thinks is causing his panic attacks

c) Assessing to what degree the client has embraced the American culture Explanation: By assessing the client's degree of cultural assimilation/acculturation, incorrect assumptions regarding the impact of culture on the client's perceptions and beliefs will be minimized. While the other options provided are not inappropriate, none is the best tactic that addresses the impact that culture has on the client's perceptions and beliefs.

A screening tool used to identify whether alcohol use is problematic includes which of the following? a) Global Assess of Functioning Scale b) Abnormal Involuntary Movement Scale c) CAGE questionnaire d) The Beck Depression Inventory

c) CAGE questionnaire Explanation: A short screening tool such as the CAGE questionnaire can be useful at the outset to identify whether alcohol use is problematic. The Abnormal Involuntary Movement Scale relies on clinician observation to identify abnormal movements associated with adverse effects from antipsychotic medications. The Beck Depression Inventory is a scale that assesses the client's report of various degrees of depression symptoms. The Global Assessment of Functioning Scale (GAF) incorporates overall function.

During the admission assessment, the nurse asks the client, "How are you feeling?" The client responds, "I feel, I kneel, do you steal?" The nurse recognizes this response as which of the following? a) Flight of ideas b) Echolalia c) Clang association d) Neologisms

c) Clang association Explanation: Responses based on rhyming or alliteration, rather than content, are called clang associations. 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

Which of the following psychiatric conditions is associated with the physical examination of nosebleeds? a) Bulimia nervosa b) ADHD c) Cocaine snorting d) Trichotillomania

c) Cocaine snorting Explanation: Nosebleeds are associated with cocaine snorting. Refer to Physical Assessment Findings That May Be Psychiatric or Medical in Origin.

A client is admitted to the psychiatric unit and states, "I am president of the largest corporation in the world. Everyone comes to me for advice." The client is exhibiting which of the following? a) Confabulation b) Delirium c) Grandiosity d) Loose associations

c) Grandiosity Explanation: The client has a delusion about his superiority over others. Confabulation occurs when the client may make up answers to fill memory gaps. Delirium is a syndrome that involves a disturbance of consciousness accompanied by a change in cognition. Loose associations are disorganized thinking that jumps from one idea to anther with little or no evident relation between the thoughts.

During an initial assessment, a patient exhibits pressured speech and launches into a lengthy explanation of her ability to read "the writing on the wall." She points to certain patterns on the wallpaper and says, "This is the writing about the tsunami. Thousands of people died because I read the writing. I should never have read the writing; it was my fault." When documenting the patient's behaviors, which of the following terms should the nurse use? a) Hallucination b) Illusion c) Ideas of reference d) Religious delusion

c) Ideas of reference Explanation: The patient 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 patient believes she is responsible for the events she is describing. Hallucinations are false sensory perceptions. In a hallucination, the patient 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.

During the assessment of a psychiatric client, the nurse documents "oriented x 3" on the client's assessment sheet. What does this indicate? a) The client knows her hometown. b) The client knows her mother's name. c) The client knows the correct date. d) The client knows basic arithmetic.

c) The client knows the correct date. Explanation: Orientation, usually documented as "oriented x 3" means that the client is aware of person, time, and place. Time refers to knowing the correct day, date, and year. If the client is able to tell the nurse about her hometown and her mother's name, it indicates that the client has good memory. When the client knows basic arithmetic, it indicates that the client's intellectual abilities are not impaired.

The nurse finds that the client is constantly rubbing her hands. Under which component of psychosocial assessment should the nurse document this finding in? a) The mood and affect component b) The abnormal sensory experiences or misperceptions component c) The general assessment and motor behavior component d) The history component

c) 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.

The nurse suspects that the newly admitted client's psychiatric disorder includes obsessive thinking when the client reports a) "Every time I get anxious I find myself wanting to cut myself." b) "I don't go out alone since I was abducted by aliens last year." c) "I know I have cancer even though the biopsy came back negative." d) "I can't stop thinking about where I can get the money to get more drugs."

d) "I can't stop thinking about where I can get the money to get more drugs." Explanation: Obsessions are insistent, preoccupying thoughts; a client who "can't stop thinking about where" to get money to get more drugs is having obsessive thoughts. Wanting to cut is not an obsession but rather a compulsive behavior. Fearing alien abduction is not an obsession but rather a delusion. And, believing oneself to have cancer in spite of biopsy results to the contrary represents somatic delusion.

Which question is appropriate for a nurse to ask a client to assess the client's recent memory? a) "Why are you at the health care clinic today?" b) "When is your birthday?" c) "How are an orange and an apple different?" d) "What did you eat for breakfast today?"

d) "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).

A nurse needs to encourage a Hispanic client who has severe depression to express her feelings. What distance between the nurse and the client may help facilitate therapeutic communication? a) 10 to 12 inches b) 15 to 18 feet c) 15 to 18 inches d) 3 to 6 feet

d) 3 to 6 feet Explanation: A distance of approximately 3 to 6 feet may help facilitate good therapeutic interaction between a Hispanic client and the nurse. A distance of 10 to 12 inches or 15 to 18 is considered the intimate communication zone, which may make the nurse and client feel uncomfortable. A distance of 15 to 18 feet between the nurse and the client is considered the public communication zone, which is unlikely to facilitate therapeutic communication.

When interviewing a psychiatric client whose ability to communicate effectively is impaired, the nurse initially influences the situation therapeutically by a) Being extremely attentive to the client's nonverbal communication behaviors b) Suggesting that the client write his or her responses to critical questions c) Asking the client to repeat any conversation that is not understood d) Acknowledging to the client that there is a problem

d) Acknowledging to the client that there is a problem Explanation: Talking openly and communicating with the client can provide valuable information about compliance and behavior. Acknowledging that differences do exist is the most important thing that the psychiatric-mental health nurse can do. While the other options are not necessarily inappropriate, they are not the first things a nurse should strive for.

A nurse is assigned to care for a client whose sexual orientation differs from her own. She would need to seek clinical supervision if she attempted to ... a) Identify anxieties regarding the client's values and sexuality b) Empathize with the client c) Discuss her feelings about the client with a supervisor d) Assist the client to change values

d) Assist the client to change values Explanation: It is not the nurse's role to change the values of the client.

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 assesses that the client is experiencing a speech pattern commonly seen in manic episodes called what? a) Perseveration b) Circumstantiality c) Neologisms d) Flight of ideas

d) 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.

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? a) Abstract reasoning b) Judgment c) Insight d) Orientation

d) Orientation Explanation: One of the most basic assessments of cognitive function is the client's orientation to person, place, and time. Judgment may be viewed as the action-oriented counterpart to insight. To assess abstract reasoning, the nurse may ask the client to describe the meaning of well-known proverbs. Insight is the cognitive process of understanding.

A nurse is caring for a client in the mental health unit. The client states, "They are poisoning my food by telepathy?" This is an example of which types of delusion? a) Grandiose b) Somatic c) Erotomanic d) Paranoid

d) Paranoid Explanation: This is an example of a paranoid delusion, which is caused by false suspicions. Refer to Thought Content Disturbances for other types of delusions.

The information gathered in a psychosocial assessment can be organized in many different ways. Which of the following would not be included as a purpose of the psychosocial assessment? a) Behavioral function b) Mental capacity c) Current emotional state d) Previous compliance with treatment regimen

d) Previous compliance with treatment regimen Explanation: The previous compliance with 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.

Which of the following would not be included as a purpose of the psychosocial assessment? a) Mental capacity b) Behavioral function c) Current emotional state d) Previous compliance with treatment regimen

d) Previous compliance with treatment regimen 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.

A former soldier has returned from a tour of duty with posttraumatic stress disorder. During a therapy session, he has been asked to describe some of the scenes he witnessed. Which of the following responses would prompt the nurse to document the client's affect as flat? a) The client fights back tears when describing a fellow soldier's suffering from injuries. b) The client describes the death of a fellow soldier in darkly comic terms. c) The client adamantly refuses to describe what he witnessed overseas. d) The client provides a factual but monotone and non-expressive description of wartime events.

d) The client provides a factual but monotone and non-expressive description of wartime events. Explanation: A flat affect is characterized by an absence or near absence of any signs of affective responses, such as an immobile face and monotonous tone of voice.

Which of the following occurs during problem identification of the working phase? a) The client identifies issues or concerns. b) The nurse guides the client to examine feelings. c) The nurse assists the client to have a more positive self-image. d) The nurse assists the client to develop better coping skills.

The client identifies issues or concerns. Explanation: The client identifies issues or concerns during problem identification of the working phase. During exploration, the nurse guides the client to examine feelings and responses and to develop better coping skills and a more positive self-image.

A client who is verbally expressing angry feelings while smiling is exhibiting which type of facial expression? a) Impassive b) Expressive c) Emotionless d) Confusing

d) Confusing Explanation: A confusing facial expression is one that is the opposite of what the person wants to convey. An expressive face portrays the person's moment-by-moment thoughts, feelings, and needs. An impassive face is frozen into an emotionless deadpan expression similar to a mask. An impassive face is an emotionless face.

The nurse is giving care to a 71-year-old man with increasing lower back pain. In the course of assessment, the nurse learns that the client became a widower 10 weeks ago. The client's response to this revelation is to smile and reply, "Them's the breaks!" How should the nurse best interpret and act on this response? a) The nurse should recognize that the grieving process is highly individual, and responses need not match societal or cultural norms. b) The nurse should recognize that the client is depersonalizing the death of his wife. c) The nurse should redirect the assessment toward mental status assessment. d) The nurse should recognize the incongruity between content and behavior and find ways of exploring the matter.

d) The nurse should recognize the incongruity between content and behavior and find ways of exploring the matter. Explanation: An apparent disconnect between content and the client's behavior should prompt the nurse to explore the matter more deeply. While grieving is indeed an individual process, it would be imprudent for the nurse to deny the incongruity between the topic and the behavior. The man's statement heightens the relevance of mental status in the assessment, but the priority would be to explore the matter more deeply and ask follow-up questions. It would be presumptuous to conclude that he is depersonalizing his wife's death.

A delusion represents a problem in which of the following areas? a) Orientation b) Memory c) Motivation d) Thinking

d) Thinking Explanation: A delusion is a fixed false idea or thought.

The nurse is assessing which of the following when he asks the client to interpret a common proverb? a) Abstract thinking b) Memory c) Concrete thinking d) Concentration

a) 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. The nurse directly assesses memory, both recent and remote, by asking questions with verifiable answers. The nurse assesses the client's ability to concentrate by asking the client to perform certain tasks such as "Spell the word world backward."

A client is being evaluated for dementia. The nurse knows that when completing a mental status exam, the fewer tasks the client completes accurately, the a) Less the cognitive deficit b) Task completion has no bearing on mental status c) Greater the cognitive deficit d) Greater the cognitive ability

c) Greater the cognitive deficit Explanation: The fewer tasks the client competes accurately, the greater the cognitive deficit.

During an assessment, which of the following would be the most important question topic? a) History b) Suicidal ideation c) Motor behavior d) Roles and relationships

Suicidal ideation Correct Explanation: The client's safety is a priority. Asking clients clearly and directly about suicidal ideation is essential.

Which of the following GAF scores is equivalent to a persistent danger of severely hurting self or others? a) 10 b) 20 c) 90 d) 100

a) 10 Explanation: A GAF score of 10 means that there is a persistent danger of severely hurting self or others.

The nurse is preparing to perform a psychosocial assessment of the client. The nurse's attitude and approach should be: Select all that apply. a) unemotional and straightforward. b) accepting. c) judgmental. d) defensive. e) short and crisp questions.

a) unemotional and straightforward. b) accepting Explanation: While performing a psychosocial assessment, the nurse should have an accepting and straightforward approach with the client. If the nurse expresses personal opinions to the client or is judgmental, the client may be reluctant to share sensitive information. The nurse should not be emotionally unstable as this would hinder the nurse's ability for proper assessment. If the nurse asks short and crisp questions, the client may think the nurse is hurried and is not interested in listening. This behavior may prevent the client from providing complete information to the nurse.

A manic client recently admitted to a locked ward in the psychiatric unit is talking with the nurse. He states, "The car is red. Are you ready for lunch? My head is hurting. Dogs bark loud." The client is exhibiting which type of speech? a) Clang association b) Neologism c) Looseness of association d) Echolalia

c) Looseness of association 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.

Which of the following statements made by a client diagnosed with depression would indicate that she may have a thought disorder? a) "I'm a little confused. What time is it?" b) "I'm fine. It's my husband who has the problem." c) "I'm so angry. Wait until my daughter hears about this!" d) "I can't find my mesmer foot holders. Have you seen them?"

d) "I can't find my mesmer foot holders. Have you seen them?" Explanation: The incorrect answers reflect cognitive awareness and clear thought, while the correct answer reveals that the client has made up a new word (neologism) for her shoes, which indicates the presence of a thought disorder.

A mental health nurse is caring for a schizophrenic client. The nurse observes the client laughing about the recent death of her father. The nurse would correctly document this mood as which of the following? a) Blunted b) Labile c) Flat d) Incongruent

d) 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

A client states, "I'm worthless, and I don't deserve to live." This theme in the client's expressed thought may signal unhealthy responses to which disorder? a) Delirium tremens b) Mania c) Depression d) ADHD

c) Depression Explanation: This theme in the client's expressed thoughts may signal unhealthy responses to depression. The other options are not indicative of a depressed state.

When asking a client to "tell me how being schizophrenic has affected your life," the nurse is assessing the client's capacity for ... a) Concrete thinking b) Critical thinking c) Intellectual thought d) Reflective insight

d) Reflective insight Explanation: Insight is defined as self-understanding, or the extent of one's understanding about the origin, nature, and mechanisms of one's attitudes, behavior, and/or condition. Thus, asking a client how schizophrenia has affected his or her life is an example of assessing reflective thinking. Critical thinking (determining the meaning and significance of what is observed or expressed), intellectual ability (a person's ability to use facts comprehensively), and concrete thinking (seeing each situation as unique and lacking the ability to generalize from the similarities between situations) are not the functions being assessed.

The nurse is assessing a patient in the clinic who reports hearing "voices." What would be the most important assessment to make? a) Whether others hear the voices b) How the voices affect the patient c) If the patient also sees things d) The nature of the voices

d) The nature of the voices Explanation: If the patient confirms auditory hallucinations, it is important to ask about their nature. Are they hostile or critical? Do they "command" or tell the patient to do things, such as harm self or others? The other options are appropriate, but not the most appropriate.

The nurse is looking to assess the clien't 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 the family members.

a) 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.

The nurse initiating a therapeutic relationship with a client should explain the purpose, which is to a) Alleviate stressors in life b) Become stabilized on medications c) Facilitate a positive change d) Establish relationships

c) Facilitate a positive change Explanation: The client who has unmet or unsatisfactorily met needs seeks to make changes; the nurse facilitates this desire to change. The focus of the therapeutic relationship is on the client's needs, not the nurse's.

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) Communication skills b) Personal needs c) Perception of the problem d) Admitting diagnosis

c) Perception of the problem Explanation: The question will elicit information about the client's view or perspective of the problem.

The nurse is preparing to assess a client's remote memory. Which question would be most appropriate for the nurse to use? a) "Can you tell me what you have eaten in the last 24-hours?" b) "How are an apple and orange the same?" c) "What did you do last evening?" d) "When did you get your first job?"

d) "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.