Psych - Unit 1 - Chapter 8: Assessment
A mental health nurse is caring for a client with schizophrenia. The nurse observes the client laughing about the recent death of the client's father, then cries when the family delivers the news. What will the nurse explain to the family regarding this behavior? "This behavior displays the intensity of the mood." "The client feels happy to see you but sad with the news." "The client is displaying elements of euphoria." "A labile mood is seen with this type of reaction."
"A labile mood is seen with this type of reaction." The correct answer is labile mood, which is changeable, as seen in the behavior of the client. In this instance, laughing one minute and crying the next. Labile affect is the abnormal fluctuation of one's expressions. This behavior is not displaying the intensity of the mood. Intensity can be increased, flat, or blunted. The nurse determines whether the emotional response is appropriate for the situation. For example, an inappropriate response is shown by a client who has an extreme reaction to the death of the victims of a mass tragedy, as if the victims were personal friends. In this case the behavior of the client may not be appropriate to the family, but this behavior is a labile affect of abnormal fluctuations. The client is not displaying elements of euphoria. Euphoric mood is one of elation.
A newly hired psychiatric-mental health nurse has learned about the suicide risk assessment. Which statement made by the nurse would indicate a need for further teaching? "It's okay that I feel uncomfortable asking clients about suicidal thoughts." "Asking clients if they are having suicidal thoughts may put that idea into their head." "It is our responsibility to keep all clients safe on the unit; therefore, we have to assess for suicidal risk." "A suicide risk assessment is part of our comprehensive assessment."
"Asking clients if they are having suicidal thoughts may put that idea into their head." Self-awareness is crucial when a nurse is trying to obtain accurate and complete information from the client during the psychosocial assessment process. The nurse may feel uncomfortable about certain topics, such as sexuality and suicide, and it is acceptable to hold differing feelings and beliefs about these topics; however, the nurse must remain nonjudgmental and accepting of the client's views and beliefs to maintain a therapeutic relationship with the client. A common misconception that new nurses may hold includes believing if the nurse asks about suicidal thoughts in the client, the client will then act on that thought. Therefore, the nurse's statement, "Asking clients if they are having suicidal thoughts may put that idea into their head", would indicate a need for further teaching. The nurse's statements, "It's okay that I feel uncomfortable asking clients about suicidal thoughts", "It is our responsibility to keep all clients safe on the unit; therefore, we have to assess for suicidal risk", and "A suicide risk assessment is part of our comprehensive assessment", indicates effective teaching.
The nurse is performing an initial assessment for a client newly admitted to the behavioral health unit. When initiating the assessment, which question will the nurse ask to obtain the most relevant data? "Discuss with me what brought you in to the behavioral health unit today?" "Are you feeling well today?" "Have you thought about which goals that you would like to achieve while you are here?" "Do you live at home alone or with family?"
"Discuss with me what brought you in to the behavioral health unit today?" The nurse should use open-ended questions when gathering assessment data from the client. Doing so allows the client to begin as they feel comfortable and also gives the nurse an idea about the client's perception of their situation. When asking the client to discuss what brought them to the unit, an opportunity exists to discover more information. The other questions asked are closed-ended, do not elicit more information, and can be responded to in a yes or no response.
A client is being counseled for depression and anxiety. The client states to the nurse, "It feels like people are not there when I need them to be." What is the nurse's priority question for the client? "Why do you feel alone?" "Has there been a recent change in your social roles?" "How have you been sleeping?" "What do your eating habits look like?"
"Has there been a recent change in your social roles?" The ability to fulfill a social role or the lack of a desired role is often central to the client's psychosocial functioning. Changes in roles may also be part of the client's difficulty. If the client indicates social relationship issues, the nurse should assess the client's roles and relationships further. The client in the scenario is having mental health issues and is indicating a lack of social support. Therefore, the nurse's priority question for the client should be, "Has there been a recent change in your social roles?". The nurse's question, "Why do you feel alone?" is not therapeutic and may cause the client to feel defensive. The nurse's questions, "How have you been sleeping?", and "What do your eating habits look like?" are assessing self-care functioning and should occur after the social roles are assessed by the nurse.
The nurse begins an assessment of an older adult client who was brought to the hospital by her son. The client states, "I don't want your kind of help." What is the nurse's best response? "Have you had a bad experience in the hospital before?" "What makes you think you're not sick?" "What kind of help do you think you need?" "You don't think I know what I'm doing?"
"Have you had a bad experience in the hospital before?" If the client is reluctant to engage with the nurse for the assessment, it is likely due to a previous unsatisfactory experience with the health care system. A sign that the client is reluctant is that the client was brought to hospital by a family member. The nurse must address the client's feelings and perceptions to establish a trusting working relationship before proceeding with the assessment.
A nurse is performing a psychosocial assessment of the client. Which questions asked by the nurse can be identified as open ended? Select all that apply. "How can we help you?" "Are you feeling better today?" "How did your problems begin?" "Is there something wrong with you?" "When was your last visit in the psychiatric facility?"
"How can we help you?" "How did your problems begin?" 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 statement by the client best demonstrates a healthy relationship with family? "I feel better after I visit with my Mom." "I want to put on clean clothes for my sister's visit." My brother and I like to take a walk when he visits." "My family has always tried their best to help me."
"I feel better after I visit with my Mom." The relationship with others is important to mental health. Feeling better after having contact with a particular person demonstrates a healthy relationship. While all the options present positive statements, only the correct option is obviously positive in the result of the interaction.
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? "Warning, warning, watch your back." "I might. I'll give it some..." "Well, that's certainly the end of that." The client makes eye contact with the nurse but does not respond verbally.
"I might. I'll give it some..." Blocking refers to a sudden stoppage in the spontaneous flow or stream of thinking or speaking for no apparent external or environmental reason. Clanging involves perceived similarities in meaning between words of similar sound ("morning"; "warning"). Mutism is the absence of a verbal response.
The nurse is assessing a client's abstract reasoning. Which statement made by the nurse to the client would elicit the most acccurate information regarding this clinical feature? "People in glass houses should not throw stones." "Can you tell me what you ate for breakfast this morning?" "Are you hearing voices that tell you to do certain things?" "Can you tell me what day of the week it is?"
"People in glass houses should not throw stones." The nurse assesses the client's ability to use abstract thinking, which is to make associations or interpretations about a situation or comment. The nurse can usually do so by asking the client to interpret a common proverb such as "a stitch in time saves nine." If the client can explain the proverb correctly, their abstract thinking abilities are intact. If the client provides a literal explanation of the proverb and cannot interpret its meaning, abstract thinking abilities are lacking. Asking the client what they ate for breakfast this morning is assessing short-term memory. Hearing voices would assess the presence of hallucinations and altered thought process. The nurse will test for orientation by asking what day of the week it is.
A psychiatric-mental health nurse is assessing a client. Which statement by a client would the nurse recognize as evidence of an absence of insight? "I don't think any of those psychiatrists or psychologists or whatever have any clue what they're doing." "Sometimes I feel like the world would be better off if I were dead." "If things don't improve for me, I'll probably end up on the street." "I just feel these days like I'm in this black pit and there's no way I can get out of it."
"Sometimes I feel like the world would be better off if I were dead." Insight is characterized as an awareness of one's circumstances; it includes awareness of thoughts, feelings, and behaviors and ability in relation to the thoughts, feelings, and behaviors of others. Presuming that all people feel the world would benefit from their absence suggests a lack of insight. Anger at the perceived incompetence of care providers, apathy about one's bleak future, and expressions of despondency certainly warrant further assessment and treatment, but they do not necessarily indicate a lack of insight.
Which client statement indicates the most insight into his or her issue with auditory hallucinations? "The voices are telling me to hurt myself." "I can't remember a time when I didn't hear voices." "The voices aren't real but it's hard to ignore them." "I take medication so the voices will stop."
"The voices aren't real but it's hard to ignore them." Initially, clients perceive hallucinations as real experiences, but later in the illness, they may recognize them as hallucinations. Insight is the ability to understand the true nature of one's situation and accept some personal responsibility for that situation. The correct option is the only one that demonstrates these abilities.
A client diagnosed with major depressive disorder has been not taking their medications as prescribed. What statement made by the nurse is most therapeutic to assess the medication noncompliance? "Are you having side effects with the medication?" "Why are you not taking your medication?" "You should take your medication to feel better." "Tell me the reason that you are not taking your medication."
"Tell me the reason that you are not taking your medication." Noncompliance with prescribed medications is an important subject for the nurse to assess. The nurse must remain nonjudgmental in their approach to inquire the honest reason that the client is noncompliant. Open-ended questions or statements are helpful to seek understanding and not to convey judgment. Therefore, the nurse's statement, "Tell me the reason that you are not taking your medication" allows the client to explain the reason that they are noncompliant. The nurse's question, "Are you having side effects with the medication?" is close-ended and making assumptions, which could provide false information from the client. The nurse's question, "Why are you not taking your medication?" is nontherapeutic and could cause defensiveness in the client. The nurse's statement, "You should take your medication to feel better" is giving advice, which is not therapeutic for the client.
A client is admitted to the psychiatric-mental health unit. What question made by the nurse indicates intellectual functioning is being assessed? "What do you do when you have a problem?" "If you could change one thing about yourself, what would it be?" "What is similar about an apple and an orange?" "If you found a stamped addressed envelope on the ground, what would you do?"
"What is similar about an apple and an orange?" The client's intellectual function can be assessed by asking the client to identify the similarities between pairs of objects. Therefore, the nurse's question, "What is similar about an apple and an orange?" assesses the client's intellectual functioning. The nurse's question, "What do you do when you have a problem?" assesses the client's coping ability. The nurse's question, "If you could change one thing about yourself, what would it be?" assesses the client's self-concept. The nurse's question, "If you found a stamped addressed envelope on the ground, what would you do?" assesses the client's judgment.
A client diagnosed with bipolar disorder is currently in a manic state. The client states, "I hate my brother! He stole my car and my partner!" What is the nurse's priority statement that should be made to the client? "Have you used any illicit drugs or alcohol within the past month?" "What thoughts have you had about hurting your brother?" "Tell me about your brother stealing your car and partner." "Have you expressed your anger with your brother?"
"What thoughts have you had about hurting your brother?" If a client is angry, hostile, or making threatening remarks about a family member, spouse, or anyone else, the nurse must ask whether the client has thoughts or plans about hurting that person. Therefore, the priority question is to ask the client, "What thoughts have you had about hurting your brother?". The other statements made by the nurse including, "Have you used any illicit drugs or alcohol within the past month?", "Tell me about your brother stealing your car and partner", and "Have you expressed your anger with your brother?", can be assessed after the safety risk of harming others is addressed.
The nurse reviews the nurse's note shown for a newly admitted hospitalized client. Based on the chart findings, what is the nurse's priority assessment question? "What thoughts of suicide have you had?" "How long have you been depressed?" "How are you caring for yourself at home?" "What medications or over-the-counter medications are you taking?"
"What thoughts of suicide have you had?" The nurse must determine whether the depressed or hopeless client has suicidal ideation or a lethal plan. Assessing the risk for harm is always a priority and the nurse should ask directly if the client is having thoughts of suicide. The client's chart indicates the client is at high risk for suicide with the current depression, history of post-traumatic stress disorder, and family history of suicide. Therefore, the nurse should begin the assessment by asking, "What thoughts of suicide have you had?". The nurse's questions, "How long have you been depressed?", "How are you caring for yourself at home?", and "What medications or over-the-counter medications are you taking?" can be assessed after the risk of suicide is addressed.
The nurse is performing a mental health status examination for a client. Which question asked by the nurse indicates that the nurse is assessing the judgment of the client? "In which country do you live?" "Could you please repeat the days of the week backward?" "What would you do if you found $10 on the side of the road?" "Could you please explain the meaning of proverb 'barking dogs seldom bite'?"
"What would you do if you found $10 on the side of the road?" Judgment is the ability to understand one's environment and situation correctly and to adapt one's behavoir and decisions accordingly. To determine if the client is able to make just decisions, the nurse should present a hypothetical scenario like "What would you do if you found $10 on the side of the road?" Questions such as "In which country do you live?" should be asked while assessing the memory of the client. Questions such as "Could you please repeat the days of the week backward?" should be asked while assessing the client's ability to concentrate. Questions such as "Could you please explain the meaning of the proverb 'barking dogs seldom bite'?" should be asked by the nurse while assessing the abstract thinking abilities of the client.
A hospitalized client diagnosed with bipolar disorder is currently manic. What question made by the nurse would assess the client's physiologic functioning? "Are you having thoughts of harming yourself or others?" "How do you handle it when someone makes you feel angry?" "When was the last time that you slept for more than 5 hours at a time?" "Are you close with your family?"
"When was the last time that you slept for more than 5 hours at a time?" When conducting a psychosocial assessment, the nurse must include physiologic functioning because mental illness can affect the client's eating and sleeping habits. The nurse's question, "When was the last time that you slept for more than 5 hours at a time?" is assessing the client's physiological functioning, because sleeping and eating can be impaired with clients diagnosed with bipolar disorder. The nurse's question, "Are you having thoughts of harming yourself or others?" is assessing the suicide and homicide risk of the client. The nurse's question, "How do you handle it when someone makes you feel angry?" is assessing the client's coping ability. The nurse's question, "Are you close with your family?" is assessing the client's social roles and relationships.
The nurse is caring for a hospitalized client who is suspicious and guarded. The client tells the nurse that the client does not want anyone to tell the family about the client's condition. What is the nurse's best response when the family calls the hospital unit to inquire about the client's condition? "You are welcome to share any information that you think would be helpful." "Unfortunately, you are not permitted to call the hospital unit." "I am sorry, the client does not want you included in care." "It would be best if you came to visit the client here."
"You are welcome to share any information that you think would be helpful." The client does not want the family to know information regarding their condition. The client's wishes must be upheld unless there is the threat of harm, in which case information can be shared without the client's consent. In this context, however, that is not the case. The nurse's best response is to ask the family to share anything that they think would inform the assessment and treatment of the client.
The nurse is preparing to perform a psychosocial assessment of a client with schizophrenia. The client has a history of extreme aggression. What is the optimal setting for conducting an interview with the client? A table in the hospital cafeteria. A conference hall in the hospital. An isolated room outside the hospital premises. A physician's intake room with other medical personnel nearby.
A physician's intake room with other medical personnel nearby. Interviews for psychosocial assessment should ideally be conducted in an environment that is quiet and free from distractions. Since the client is aggressive, the nurse should perform the interview with other health care personnel in the immediate area. They would be of help in case the situation becomes heightened for either the nurse or client. Thus, for this client, the interview should be performed in a physician's intake room or conference room with other medical personnel nearby. The client should not be interviewed in a place like the cafeteria, as it has a lot of distractions. Since the client is aggressive and could hurt oneself or the nurse, the nurse should not be alone or isolated as assistance might be needed during the interviewing. It would be inappropriate for the nurse to conduct the interview in the conference room alone. It would be inappropriate for the nurse to conduct the interview outside the premises of the facility.
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. Judgmental Defensive Brief Accepting Objective
Accepting Objective While performing a psychosocial assessment, the nurse should have an accepting and objective or 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.
While conducting an interview with a psychiatric-mental health client, the nurse is observing the client's facial expressions and nonverbal cues. What are these physical manifestations known as? Demeanor Temperament Mood Affect
Affect Affect refers to the physical manifestations of the client's mood and is assessed by observing the client's facial expression in conjunction with other nonverbal clues. Among other signs, the nurse will assess consistency between mood and affect (e.g., the client says, "I feel pretty good" but have a somber affect).
A client describes the recent breakup of a dating relationship when being interviewed by the nurse. Which finding will the nurse determine is the client's affect? Client perception of events that has occurred Placing quotes in nurse's notes of client statement An emotionless tone and flat facial expression Prolonged emotional state of mood of client
An emotionless tone and flat facial expression The correct response is that affect refers to a person's emotional expression (in this case, the manner in which the client talks about the client's experiences). It is the expression the nurse observes as the client's affect. While placing the client statement in quotes is used in documentation, it does not determine affect in this case. Verbalizations are documented in nurse's notes as direct quotes, such as, "I'm just going to end it all." Emotional states or perceptions are expressed as feelings. Moods are prolonged emotional states expressed by the affect.
When completing a physical assessment of an individual's response to stress, the nurse should observe and inquire about what? Appetite and sleep Mood Judgement and insight Concentration
Appetite and sleep Biologic data are essential for analyzing an individual's physical responses to stress, coping efforts, and adaptation. Nurses should pay particular attention to alterations in vegetative functions (e.g., appetite and eating patterns, sleep, energy level, and sexual activity).
The nurse has been asked to assess a 54-year-old client's memory. Which technique would allow the nurse to evaluate recent memory? Provide the client with three words and ask the client to recall the words several minutes later. Ask the client to recall events that have occurred over the past few weeks. Ask the client to recall events from childhood. Provide the client with three words and ask the client to recall the words several months later.
Ask the client to recall events that have occurred over the past few weeks. Immediate memory refers to the ability to retain information presented within the last several minutes. Nurses may ask clients to repeat three words and then recall those three words several minutes later. Recent memory refers to the client's ability to recall information from within the past few weeks, while remote memory involves recall of events from many years ago.
The nurse notes that an older adult client is wearing layers of clothing on a warm, fall day. Which would be the priority assessment at this time? 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 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 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? Flight of ideas Loose associations Thought broadcasting Circumstantial thinking
Circumstantial thinking When a client gives excessive and unnecessary details and then gives the answer, this is termed circumstantial thinking. Flight of ideas is characterized by an excessive amount and rate of speech composed of fragmented or unrelated ideas. Loose association is characterized by jumping from one idea to another with little or no evident relation between the thoughts. Thought broadcasting is when the client has the delusional belief that others can hear or know what the client is thinking.
Which must be addressed to establish a trusting working relationship before proceeding with the assessment? Client's feelings and perceptions Client's behavior Client's compliance Client's willingness to participate
Client's feelings and perceptions The nurse must address the client's feelings and perceptions to establish a trusting working relationship before proceeding with the assessment.
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 depression Clients with post-traumatic stress disorder Clients with antisocial personality disorder Clients with adult attention deficit hyperactivity disorder
Clients with adult attention deficit hyperactivity disorder Clients with attention deficit hyperactivity disorder have reduced attention span, which in turn causes disorganization in their thought processes. These clients may be unable to answer open-ended questions that require a detailed explanation. Thus, the nurse should try to include the maximum number of closed-ended questions in the assessment. Disordered thought is not commonly seen in depression, post-traumatic stress disorder, or antisocial personality disorder. More open-ended questions should be asked of these clients in order to understand their perception of their illness.
The nurse performs an assessment for a client presenting with symptoms of mental illness. Which is the nurse's priority? Prepare a diagnostic statement. Identify a measurable outcome. Collect comprehensive data. Plan alternative to attain outcome.
Collect comprehensive data. Assessment is the first standard of practice, during which the nurse collects comprehensive data from the client. Diagnosis is arrived at after analyzing the data obtained. Outcome identification is done after diagnosing the client's illness. Planning an alternative to attain an outcome is performed after establishing outcome identification.
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 most effective way for the nurse to proceed? Use observation only to collect client information. Wait for psychiatric medication to take effect. Ask another nurse to attempt the assessment. Complete the assessment in several short interactions.
Complete the assessment in several short interactions. Clients exhibiting psychotic thought processes or impaired cognition may have an insufficient attention span or may be unable to comprehend the questions being asked. The nurse may need several contacts with such clients to complete the assessment. Observing the client is a very important aspect of the assessment, however, it is not the only part. The nurse must interact with the client and engage in verbal communication in order to complete a full assessment. Psychiatric medication can take a period of time to have an effect. The assessment should be completed in a timely manner. In addition, understanding how a client presents when in a psychotic state can assist in planning for future acute psychiatric presentations. It is within each nurse's scope to complete the assessment. The nurse has not been ineffective in this case, the client's condition at the present moment is not favorable for conducting the assessment all at once.
Asking the client to complete serial sevens assesses what? Concentration Orientation Judgment Insight
Concentration Serial sevens is a measure of auditory attention/concentration, mental tracking, and computation that requires the examinee, starting at 100, to repeatedly subtract or add seven. 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.
A nurse is caring for a client admitted for self-harm behaviors. The nurse feels strong anger toward the client because the nurse's father committed suicide. What is the nurse's best action to handle their feelings? Discuss their feelings with a more experienced colleague. Suppress their feelings of anger toward the client. Tell the supervisor to change client assignments. Speak to the client about the nurse's feelings.
Discuss their feelings with a more experienced colleague. Self-awareness is crucial when caring for clients. Many clients diagnosed with mental illness can provoke countertransference feelings, which are unconscious feelings toward the client based on the nurse's past experiences, in the nurse. If the countertransference feelings are intense and strong, the nurse will have to express these feelings with a more experienced colleague to lessen the misguided feelings. Suppressing the feelings of anger toward the client would be nontherapeutic, because these feelings would interfere with a therapeutic nurse-client relationship. Telling the supervisor to change client assignments is avoiding their feelings, which is nontherapeutic. Speaking to the client about the nurse's feelings is inappropriate in a therapeutic nurse-client relationship.
Which is the most effective way in which the nurse can assess the progress of a client's mental status based on the expected outcome of the therapeutic plan? Planning Evaluation Assessment Professional practice evaluation
Evaluation Evaluation is the assessment of a client's progress after an identified plan has been implemented. Planning is done after diagnosis and just before implementing therapeutic strategies. Assessment is the initial data collection from the client. Professional practice evaluation is the evaluation of nursing care against professional standards.
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? Labile Constricted Flat Blunted
Flat The client's affect, or facial expression, would be described as "flat." Labile affect is the abnormal fluctuation or variability of one's expressions, such as repeated, rapid, or abrupt shifts. Constricted affect relates to a reduction in one's expressive range and intensity of affective responses. Blunted affect is a severe reduction or limitation in the intensity of one's affective responses to a situation.
During a conversation, the client states, "It's raining outside and raining in my heart. Did you know that St. Valentine used to visit jails? I've never been to jail." The nurse can correctly identify this thought process as what? Perseveration Circumstantiality Neologisms Flight of ideas
Flight of ideas Flight of ideas is the expression of multiple, unrelated ideas in a string of statements. Neologisms are new words, circumstantiality is when the client speaks about topics that are loosely related with each other, and perseveration is the repetition of words or ideas over and over.
A 20-year-old client who has a diagnosis of schizophrenia frequently experiences delusions of persecution. At the prompting of the client's mother, the nurse attempts to determine the character and severity of these delusions on a particular day. In doing so, the nurse is conducting what type of assessment? Comprehensive Focused Screening Secondary
Focused A focused assessment includes the collection of specific data regarding a particular problem as determined by the client, a family member, or a crisis situation. A comprehensive assessment is broader in scope, while a screening assessment aims to identify the presence or absence of health problems.
Under which component of the psychosocial assessment should the nurse document observations concerning the client's cultural considerations? History Thought Process and Content Self-Concept Roles and Relationships
History The assessment information concerning culture is documented under the History component of the psychosocial assessment.
A psychiatric-mental health client informs the nurse that a tornado that hit a neighboring town was the client's fault because the client dislikes a neighbor. This disturbance of thought content is known as what? Ideas of reference Magical thinking Thought broadcasting Obsession
Ideas of reference Ideas of reference include beliefs that external events have personal significance. Magical thinking includes the belief that thinking about something will make it happen. Thought broadcasting includes the belief that thoughts are known by others. Obsessions include unwanted repetitive thoughts.
A client being counseled for anger management has threatened to kill one of their family members by stabbing them. What is the nurse's priority intervention? Teach the client effective coping skills to avoid violence. Remain calm and allow the client to express their feelings. Maintain client confidentiality and do not share this information with the client's family. Inform the health care team and family member of the threats.
Inform the health care team and family member of the threats. When a client makes specific threats or has a plan to harm another person, health care providers are legally obligated to warn the person who is the target of the threats or plan. The legal term for this informing process is duty to warn. This is a situation where the nurse must breach client confidentiality to protect the threatened person. Therefore, the nurse's priority intervention is to inform the health care team and family member of the threats. Confidentiality must be broken in these situations; therefore, the nurse must not maintain client confidentiality and keep this information from the client's family. The nurse should remain calm and allow the client to express their feelings and teach the client effective coping skills to avoid violence, but these actions should come after the nurse informs the health care team and the threatened family member.
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? Magical thinking Neologisms Loose associations Ideas of reference
Loose associations In some cases a client presents several thoughts that don't make sense in conjunction with one another. This is often seen in clients with acute exacerbations of schizophrenia and is described as loose association.
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? Judgment Insight Self-concept Orientation
Judgment 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?"
The Rorschach test is designed to provide what type of information about the client? Presence of depression Presence of a personality disorder Status of self-concept Preferred coping styles
Preferred coping styles The Rorschach test involves showing the client 10 stimulus cards of ink blots. The client describes perceptions of ink blots. The practitioner's narrative interpretation discusses areas such as coping styles, interpersonal attitudes, and characteristics of ideation. Beck Depression Inventory (BDI) assesses for depression. Milton Clinical Multiaxial Inventory (MCMI and MCMI-II) assesses personality traits and personality disorders. The Tennessee Self-Concept Scale (TSCS) provides information on 14 scales related to self-concept.
Which would not be included as a purpose of the psychosocial assessment? Previous compliance with treatment regimen Current emotional state Behavioral function Mental capacity
Previous compliance with treatment regimen 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.
When asking a client to "tell me how having schizophrenia has affected your life," the nurse is assessing the client's capacity for what? Reflective insight Critical thinking Intellectual thought Concrete thinking
Reflective insight 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.
Which must the nurse consider a priority in the assessment of mental status? Wellness Behavior Safety Hygiene
Safety 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.
The nurse is caring for a client who has recently developed psychomotor retardation. Based on this information, which behavior would the nurse expect to see in this client? Slowness of body movements Repeated tapping of the foot Speaking meaningless words Maintenance of an awkward posture for a long time
Slowness of body movements Slowing of thought processes and bodily movements is referred to as psychomotor retardation. Repeated tapping of foot is referred to as automatism which is often caused due to anxiety. Speaking words that are only meaningful to the client and nobody else is referred to as neologisms. Maintenance of an awkward posture for a long time is an abnormal behavior and is referred to as waxy flexibility.
The nurse is performing an assessment of a client with a psychiatric illness. The nurse has 10 cards with different inkblot shapes. Which test is the nurse about to perform? The Rorschach Test The Thematic Apperception Test The Tennessee Self-Concept Scale The Psychological Screening Inventory
The Rorschach Test The Rorschach Test is a projective personality test. It includes the use of 10 stimulus cards with inkblots. The client has to describe perceptions of inkblots. This test is useful to understand the coping styles, interpersonal attitudes, and characteristics of ideation. The Thematic Apperception Test uses 20 stimulus cards with pictures. The client tells a story about the picture. The Tennessee Self-Concept Scale and the Psychological Screening Inventory are objective personality tests. The Tennessee Self-Concept Scale includes 100 true-false questions that provide information on 14 scales related to self-concept. The Psychological Screening Inventory consists of 103 true-false questions. The result of the test indicates whether the client needs psychological help.
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 test needs to be readministered The test environment was not appropriate The client did not understand the test instructions
The client's cognitive deficit is significant The fewer tasks the client competes accurately, the greater the cognitive deficit. None of the other options provide a plausible conclusion.
The nurse is assessing a newly admitted client and is determining their orientation status. How will the nurse best document that the client is oriented? The client correctly states their name and date. The client identifies a picture of a house and car. The client knows their mother's name. The client is able to add 2 numbers together.
The client correctly states their name and date. 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 the client's hometown and 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. Being able to identify a picture and a house does not describe orientation status.
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 no facial expression. The client displays only one type of facial expression. The client displays a full range of emotional expressions. The client displays a facial expression that is incongruent with mood.
The client displays only one type of facial expression. A restricted affect indicates that the client displays only one type of facial expression, usually a serious expression. Displaying no facial expression is referred to as a flat affect. Displaying a full range of emotional expressions is indicative of a broad affect. Displaying a facial expression that is incongruent with mood is referred to as inappropriate affect.
During an assessment of a client with bipolar disorder, the nurse observes the client laughing loudly, then sobbing immediately after. How will the nurse most accurately document this observation? The client is experiencing lability of mood. The client has limited judgement. The client lacks insight. The client demonstrates a flat affect.
The client is experiencing lability of mood. When the client exhibits unpredictable and rapid mood swings from euphoria to crying with no apparent stimuli, their mood is labile (rapidly changing). Limited judgement would describe a decreased ability of the client to interpret the environment and situation correctly to adapt behavior and decisions accordingly. A lack of insight refers to the client's inability to understand the true nature of their situation; for example, to recognize and accept the limitations caused by the symptoms of a psychiatric disorder. Flat affect refers to showing no facial expression.
The nurse is performing a mental status assessment for a client with schizophrenia. The client begins talking in unconnected words that convey no meaning to the nurse. How will the nurse document this in the assessment? The client has thought insertion. The client is having auditory hallucinations. The client is experiencing tangential thinking. The client is speaking in a word salad.
The client is speaking in a word salad. The client is demonstrating a word salad, which is a flow of unconnected words that convey no meaning to the listener. Tangential thinking is when the client begins wandering off the topic and never provides the information requested. There is no evidence at the present time that the client is having auditory hallucinations since the nurse has not asked the questions that would elicit this information. Thought insertion is a delusional belief that others are putting ideas or thoughts into the client's head—that is, the ideas are those of others and not the client.
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 amount of lighting in a given location The client's right to a stress-free environment The client's right to privacy The amount of distracters in a given location
The client's right to privacy The client's right to privacy is an essential setting consideration. It is an ethical responsibility of the nurse as well as a legal right of the client. Nurses must make critical clinical judgments about the optimal setting that maintains privacy while also ensuring safety.
The nurse 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. The nurse should recognize that the grieving process is highly individual, and responses need not match societal or cultural norms. The nurse should redirect the assessment toward mental status assessment. The nurse should recognize that the client is depersonalizing the death of the spouse.
The nurse should recognize the incongruity between content and behavior and find ways of exploring further. 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 client'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 the client is depersonalizing the spouse's death.
A nurse is seeing a client for a weekly therapeutic session in an outpatient psychiatric clinic. The client discloses to the nurse that the client often has thoughts about killing a neighbor. What should be the nurse's first response? Warn the client's neighbor and report to the authorities. Document the session thoroughly and meet with the client again the next day. Review the client's history to determine presence of past of violent behavior. Review coping strategies for anxiety and set new therapeutic goals.
Warn the client's neighbor and report to the authorities. When the client makes specific threats or has a plan to harm another person, health care providers are legally obligated to warn the target of the threats. Legally this is called duty to warn. Although the nurse must document the session thoroughly and can meet with the client again the next day, this should not be the nurse's first action. The nurse should eventually review coping strategies for anxiety and set new therapeutic goals; however, duty to warn is the priority.
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? One should always stitch before nine o'clock. You should not forget to sew up holes in your clothes. Fixing things on time would prevent bigger problems in future. If you solve one problem, you will prevent nine problems in future.
You should not forget to sew up holes in your clothes. 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 explanations of the proverb. If the client gives these explanations, then the client uses abstract thinking.
A nurse is conducting a mental status examination on a client diagnosed with severe depression. The nurse asks the client to repeat the days of the week backward. What component of the examination is the nurse assessing in the client? sensory-perception alterations memory ability to concentrate abstract thinking
ability to concentrate The nurse asking the client to repeat the days of the week backward is assessing the client's ability to concentrate. Abstract thinking can be assessed by asking the client to interpret a common proverb or analogy. Sensory-perceptual alterations can be assessed by assessing for the presence of hallucinations. Memory can be assessed by asking the client to recall their previous day's activities or asking for the client to recall the state's capital.
A nurse is reviewing material about assessing mental status. The nurse demonstrates a competent understanding of this assessment by identifying which area as a component of cognition? abstract reasoning posture speech mood
abstract reasoning To assess the client's cognition, that is, the ability to think and know, the nurse uses memory, calculation, and reasoning tests to identify specific areas of impairment. The cognitive areas include (1) attention and concentration, (2) abstract reasoning and comprehension, (3) memory, and (4) insight and judgment. Mood, speech, and posture are not components of a cognitive assessment.
A psychiatric-mental health nurse is conducting an interview with a client experiencing psychosis. The client cannot organize their thoughts, and they are having difficulty answering the assessment questions. How should the nurse proceed to interview the client? ask open-ended questions ask the family members the assessment questions end the interview ask focused, close-ended questions
ask focused, close-ended questions If the client cannot organize their thoughts or has difficulty answering open-ended questions, the nurse may need to use more direct questions to obtain information. The questions need to be clear, simple, and focused on one specific behavior or symptom. Open-ended questions can be confusing and too broad, asking the family members the assessment questions would not be client-focused or appropriate, and ending the interview is premature. Therefore, the nurse should ask focused, closed-ended questions to this client.
A client with a history of aggressive behaviors is admitted to the psychiatric-mental health unit. The nurse needs to conduct an interview to gather data for the client's care. What preparation should be made by the nurse before interviewing the client? asking another nurse to be present in the interview conducting the interview in an isolated area conducting the interview in the milieu gathering information only from the medical records
asking another nurse to be present in the interview The nurse should conduct the psychosocial assessment in an environment that is comfortable, private, and safe for both the client and the nurse. An environment that is quiet with few distractions allows the client to give their full attention to the interview. Conducting the interview in a conference room is best. The nurse should not choose an isolated location for the interview, particularly if the client is unknown to the nurse or has a history of any threatening behavior. The nurse must ensure the safety of themselves and the client, even if that means another person is present during the assessment. Therefore, the client with a history of aggressive behaviors requires the nurse to take extra safety precautions and ask another nurse to be present during the interview. Conducting the interview in an isolated area would increase the potential safety risk to the nurse. Conducting the interview in the milieu would be too distracting and stimulating for the client, which would not be desired. Gathering information only from the medical record would not be a comprehensive psychosocial assessment, because information needs to be elicited from the client.
A client diagnosed with depressive disorder is receiving bibliotherapy. The client is recommended a book to read for the purpose of expressing feelings stimulated by parallel experiences with the characters. Which term will the nurse identify that is being used to help promote healing in the client? anxiety reduction catharsis problem solving insight
catharsis Through reading, clients can enrich their lives in different ways. Catharsis is the expression of feelings stimulated by parallel experiences. Problem solving is the development of solutions to problems in the literature from practical ideas about problem solving. Insight refers to increased self-awareness and understanding as the reader explores personal meaning from what is read. Anxiety reduction is the use of self-help written materials that can reduce concerns about a diagnosed problem and treatment. The purpose for the client is to express feelings stimulated by parallel experiences; therefore, catharsis is the purpose of the bibliotherapy for the client, not anxiety reduction, problem solving, or insight.
A nurse is caring for a client who has automatic thought patterns that interfere with the client's ability to function optimally. What type of intervention would the nurse anticipate be initiated with the client? behavior relaxation cognitive conflict resolution
cognitive Cognitive interventions aim to change or reframe an individual's automatic thought patterns that have developed over time and that interfere with the individual's ability to function optimally. Behavior therapy interventions focus on reinforcing or promoting desirable behaviors or altering undesirable ones. Relaxation interventions promote comfort, reduce anxiety, alleviate stress, ease pain, and prevent aggression. Relaxation interventions range from simple deep breathing to biofeedback to hypnosis. Conflict resolution interventions include a process of helping an individual or family identify a problem underlying a disagreement and developing alternative possibilities for solving the conflict. The client in the scenario is having automatic thought patterns that interfere with the client's ability to function optimally. Therefore, the nurse would anticipate cognitive interventions to be initiated with the client, not behavior, relaxation, or conflict resolution.
A psychiatric-mental health nurse is gathering psychosocial assessment data from a client experiencing anxiety. Upon assessment, the client is restless and cannot concentrate on answering the questions from the nurse. What is the priority intervention from the nurse before proceeding in the interview? assessing the client's support system decreasing the client's anxiety level rescheduling the interview assessing the client's coping ability
decreasing the client's anxiety level The client's health status may affect the client's psychosocial assessment. If the client is anxious, the nurse may have difficulty eliciting the client's full participation in the assessment. The nurse needs to recognize these feelings and deal with them before continuing the full assessment. Therefore, the first intervention by the nurse would be to decrease the client's anxiety level. The nurse may need to reschedule the interview, but the priority intervention is to decrease the client's anxiety level before attempting to reschedule. After the client is calmer and can concentrate, the nurse may assess the client's support system and coping ability.
The nurse assesses a client with a history of bipolar disorder. The client tells the nurse that an intelligence agency has surveillance equipment set up in the client's bathroom. The nurse is observing which thought process or content? delusional thinking circumstantial thinking tangential thinking loose associations
delusional thinking A delusion is a false fixed idea not based in reality. The information that the client has told the nurse in addition to the history of bipolar disorder indicates the client is expressing delusional thinking. Circumstantial thinking refers to when a client can respond to a question asked only after giving an excessive amount of detail. Tangential thinking refers to when the client wanders off topic when being asked a question in the assessment. With this type of thinking, the client never really provides the information that was originally requested. Loose associations refers to disorganized thinking that jumps from one idea to another with little or no evident relation between thoughts.
Which client behavior would the nurse document as being an automatism? drumming one's fingers on the table top frequently repeating his or her statements asking that the question be repeated staring off into space
drumming one's fingers on the table top An automatism is a repeated purposeless behaviors often indicative of anxiety, such as drumming fingers, twisting locks of hair, or tapping the foot. None of the other options are generally associated with an expression of anxiety.
A client being counseled states to the nurse, "I am so stressed all the time. I live paycheck to paycheck." Which aspect of the client's well-being needs to be assessed further by the nurse? financial occupational environmental spiritual
financial Financial well-being is satisfaction with present and future situations. What the nurse needs to ascertain is not specific dollar amounts but whether the client feels stressed by finances and has enough for basic needs. The client in the situation feels stressed related to finances; therefore, the client's financial well-being needs to be assessed further. Occupational well-being involves personal satisfaction and enrichment derived from one's work. Environmental well-being involves living in pleasant, stimulating environments that support a healthy lifestyle. Spiritual well-being refers to the client's human need for meaning, purpose, and connection to something greater than themselves. The client's statement indicates stress related to their financial well-being, not occupational, environmental, or spiritual well-being.
The nurse is performing an assessment of a client in the behavioral health unit that is in a group session. Another client informs the group that their child died in a house fire and it has been devastating. How will the nurse document the assessment when the previous client begins smiling at the other client's loss? flat affected blunted affect inappropriate affect restricted affect
inappropriate affect 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.
Upon assessment, the nurse notes that they client is using made-up words that have meaning only to the client. How would the nurse document these findings? automatisms neologisms psychomotor retardation waxy flexibility
neologisms Neologisms is a term used when a client invents words that have meaning only to that person. Therefore, the nurse would document the findings as neologisms. Automatisms are repeated purposeless behaviors that often indicate anxiety. Psychomotor retardation is overall slowed movements. Waxy flexibility is the maintenance of posture or position over time even when it is awkward or uncomfortable.
A hospitalized client diagnosed with panic attacks is being assessed by the nurse on shift. Upon assessment, the client states their name correctly and that they are in the hospital. The client believes the year is 5 years ago and that they are hospitalized because their pet died. How would the nurse document the client's orientation status? oriented X 1 oriented X 2 oriented X 3 oriented X 4
oriented X 2 Orientation refers to the client's recognition of person, place, time, and situation. If the client can recall all four of these details accurately, the client's orientation status is documented as oriented X 4, because each category is documented as a point. The client in the scenario knows who they are (person) and that they are in the hospital (place). The client does not know the current year (time) or why the client is in the hospital (situation). Therefore, the nurse would document the assessment findings as oriented X 2. Oriented X 1 would indicate that the client is oriented to person only. Oriented X 3 would indicate that the client is oriented to a combination of three orientation components. Oriented X 4 would indicate that the client is fully oriented to person, place, time, and situation.
A home health nurse is documenting and meeting with their supervisor about the client's home visit. Which phase of the home visit does the nurse identify that includes documentation and reporting? previsit greetings closure postvisit
postvisit The postvisit phase includes documentation, reporting, and follow-up planning. This is also when the nurse meets with the supervisor and presents data from the home visit at the team meeting. The nurse in the scenario is documenting and meeting with the supervisor is in the postvisit phase. The previsit phase includes setting goals for the home visit based on data received from other health care providers or the client. The greeting and closure phases occur during the actual visit. The greetings phase includes greeting the client and family. The closure phase ends the home visit with the client. The previsit, greetings, and closure phases do not encompass documentation and reporting after the client visit.
A client diagnosed with major depressive disorder is admitted to the psychiatric mental-health unit. The client is observed moving slowly while walking and completing activities of daily living. Which physical finding would the nurse document as observed in the client? psychomotor retardation automatisms waxy flexibility neologisms
psychomotor retardation Psychomotor retardation is a term used to describe overall slowed movements in a client. Automatisms is a term used for repeated purposeless behaviors often indicative of anxiety, such as drumming fingers, twisting locks of hair, or tapping the foot. Waxy flexibility is a term used for maintenance of posture or position over time even when it is awkward or uncomfortable. Neologisms is a term used to describe invented words that have meaning only to the client. Therefore, the nurse would document psychomotor retardation as being observed in this client.
A psychiatric-mental health nurse is conducting a mental health examination on a client. The nurse asks the client about a world event that has happened within the last few months. Which aspect of memory is the nurse assessing? immediate short-term long-term recent
recent There are four spheres of memory to check including recall or immediate memory, short-term memory, recent memory, and long-term memory. To check immediate and short-term memory, the nurse gives the client three unrelated words to remember and asks them to recite them right after telling them and at 5- and 15-minute intervals during the interview. To test recent memory, the nurse may question about a holiday or world event within the past few months. The nurse tests long-term or remote memory by asking about events that occurred years ago. Therefore, the nurse is assessing recent memory in the client by asking about a world event that has happened within the past few months, not immediate, short-term, or long-term memory.
A client diagnosed with bipolar disorder is currently in a manic state. During the psychosocial assessment, the client wanders from the topic and does not provide the information requested. How should the nurse document the client's thought process? tangential thinking circumstantial thinking flight of ideas thought broadcasting
tangential thinking The thought process of a client refers to how the client thinks. Tangential thinking is a term used to describe when a client wanders from the topic of conversation and never provides the information requested. Circumstantial thinking is when a client eventually answers a question but only after giving excessive unnecessary detail. Flight of ideas is when a client has an excessive amount and rate of speech composed of fragmented or unrelated ideas. Thought broadcasting is a delusional belief that others can hear or know what the client is thinking. Therefore, the client who wanders off the topic and never provides the requested information to the nurse would have tangential thinking.
When considering where to conduct a psychosocial assessment, the nurse can effectively interview which client in the unit's conference room? the anxious client the paranoid client the suicidal client the aggressive client
the anxious client The nurse should not choose an isolated location such as a conference room for the interview, if the client is unknown to the nurse or has a history of any threatening behavior either to themselves or to others. The anxious client by diagnosis does not present a threat and so is the one best suited for the nurse to use the conference room for the interview.