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?

"A labile mood is seen with this type of reaction." Explanation: 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?

"Asking clients if they are having suicidal thoughts may put that idea into their head." Explanation: 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?" Explanation: 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? You Selected:

"Has there been a recent change in your social roles?" Explanation: 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 has entered a hospital client's room and asked the client if the client plans to attend the morning's scheduled group life-skills session. Which response should signal the presence of thought blocking to the nurse?

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

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

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

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?

"What would you do if you found $10 on the side of the road?" Explanation: 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.

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

"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.

The nurse is performing an assessment for a client and attempting to determine the client's ability to concentrate. Which question will the nurse ask the client to elicit this information?

"Will you spell the word 'world' backward?" Explanation: "Will you spell the word 'world' backward?" is a question that is asked to determine if the client has the ability to concentrate. "What is the name of the current president?" is a question asked to determine the memory of a client. "What does 'A stitch in time saves nine' mean?" would be asked if the client has the ability to think abstractly. Determining if the client is having suicidal ideation determines if there is a safety risk.

While conducting an interview with a psychiatric-mental health client, the nurse is observing the client's facial expressions and nonverbal cues. What are these physical manifestations known as?

Affect Explanation: 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?

An emotionless tone and flat facial expression Explanation: 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 Explanation: 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?

Ask the client to recall events that have occurred over the past few weeks. Explanation: 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 is conducting an admission interview with a psychiatric-mental health client. The nurse uses observational skills to identify that the client has a flat affect. The nurse is engaging in which part of the nursing process?

Assessment Explanation: Assessment is the step of the nursing process in which data are collected and analyzed. Observations of the client's mood and affect are part of this step. The other steps of the nursing process are diagnosis, planning, implementation, and evaluation.

Which must be addressed to establish a trusting working relationship before proceeding with the assessment?

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.

The nurse is preparing a psychosocial assessment for use with clients with various mental health conditions. For which group of clients should the nurse include mostly closed-ended questions?

Clients with adult attention deficit hyperactivity disorder Explanation: 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?

Collect comprehensive data. Explanation: 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?

Complete the assessment in several short interactions. Explanation: 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 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.

A nurse has been asked to complete a mental status examination of a psychiatric-mental health client. Which is a necessary component of this assessment?

Evaluation of insight and judgment Explanation: The mental status examination is a central aspect of the psychiatric assessment process that assesses current cognitive and affective functioning through data collection on appearance, behavior, level of consciousness, speech, thought content and processes, cognitive ability, mood and affect, insight, and judgment. This assessment relies almost exclusively on observation rather than inquiry and is expected to change during treatment.

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

Incongruent Explanation: The client has a flat affect yet tells the nurse that his or her mood is "really happy." In this situation, the nurse would accurately describe the mood and affect as incongruent. A congruent mood and affect would mean the client's facial expression and demeanor match the subjective report of the mood. A restricted affect refers to displaying one type of expression, usually serious or somber. A broad affect refers to the display of a full range of emotional expression.

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. The nurse would correctly document this mood as what?

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 being counseled for anger management has threatened to kill one of their family members by stabbing them. What is the nurse's priority intervention?

Inform the health care team and family member of the threats. Explanation: 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.

A psychiatric-mental health nurse is feeling highly anxious before conducting an interview with a client. The nurse's experience of anxiety will impact the client assessment in which way?

It will be detrimental to the interaction by decreasing the nurse's focus and attention. Explanation: Anxiety on the nurse's part is one of many factors that can influence outcomes. It is widely recognized that as anxiety increases, the person's ability to focus narrows. Nurses who begin interviews in a highly anxious state may find it difficult to focus on thorough data collection or interpretation.

As the nurse is conducting an interview with a client with a diagnosis of schizophrenia, the client states, "Bunnies are cute as a button, buttons are on my shirt, shirts can be bought in a store." Which is a term used to describe this thought process?

Loose associations Explanation: 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 assessing a client who has been referred to the outpatient mental health clinic with symptoms of depression, the psychiatric nurse should closely observe the client's affect and which assessment component?

Physical appearance 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 Rorschach test is designed to provide what type of information about the client?

Preferred coping styles Explanation: 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.

The psychiatric nurse correctly identifies the client's form of communication as circumstantiality when the client does what?

Provides long, irrelevant explanations when asked why the client abuses alcohol. Explanation: With circumstantiality, the person gives much unnecessary detail that delays meeting a goal, stating a point, or answering a question. This impairment may be found in clients who abuse substances. The other options provided do not provide unnecessary details and thus are not examples of circumstantiality.

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 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 performing an assessment of a client with psychiatric illness. The nurse documents that the client has a restricted affect. Which behavior of the client is indicative of restricted affect? Choose the best answer.

The client displays only one type of facial expression. Explanation: 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.

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 is speaking in a word salad. Explanation: 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.

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 Explanation: 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 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. 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 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.

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?

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 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?

ability to concentrate Explanation: 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 Explanation: 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 focused, close-ended questions Explanation: 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 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?

cognitive Explanation: 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 conducting an initial interview with a client admitted for hallucinations and abdominal pain. The client is focused on the pain and cannot concentrate on the assessment questions being asked. What is the initial desired outcome of the client?

client's pain level decreased Explanation: The client's health status can affect the psychosocial assessment. If the client is anxious, tired, or in pain, the nurse may have difficulty eliciting the client's full participation in the assessment. The nurse needs to recognize these situations and deal with them before continuing the full assessment. The client may need to rest, receive medications to alleviate pain, or be calmed before the assessment can continue. The client in the scenario is reporting pain; therefore, the initial outcome would be that the client's pain level is decreased. There is no indication that the client is experiencing anxiety; therefore, having the client's anxiety level decrease is not applicable. The outcomes of completing the assessment and the client's understanding of the importance of the assessment can occur after their pain is decreased.

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?

decreasing the client's anxiety level Explanation: 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.

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

drumming one's fingers on the table top Explanation: 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 is crying while talking about a distressing situation. The nurse states to the client, "That must be very upsetting for you." Which assessment interview behavior is the nurse demonstrating?

exhibiting empathy Explanation: Nurses can enhance the effectiveness of the assessment interview by exhibiting empathy, giving recognition, demonstrating acceptance, restating, reflecting, focusing, using open-ended questions, presenting reality, or making observations. The nurse's behavior of exhibiting empathy is showing empathy to the client and saying statements such as, "That must have been upsetting for you" or "I can understand your hurt feelings." The behavior of demonstrating acceptance is portraying a neutral stance that allows the client to continue. The behavior of restating is when the nurse tries to clarify what the client is trying to say by restating it. The behavior of reflecting is when the nurse presents the client's last statement as a question, which gives the client a chance to expand further on the information. The nurse's statement, "That must be very upsetting for you" is utilizing the behavior of exhibiting empathy. Demonstrating acceptance, restating, and reflecting are not behaviors noted in the interaction.

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 Explanation: 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.

A nurse is conducting a psychosocial assessment on the client and asks about the client's cultural beliefs and practice. What component of the psychosocial framework is the nurse assessing?

history Explanation: Background assessments include the client's history, age and developmental stage, cultural and spiritual beliefs, and beliefs about health and illness. Within the history component of the psychosocial assessment, the nurse should ask about the client's cultural beliefs and practices to avoid making inaccurate assumptions and to identify what is important to the client. The components of mood and affect, self-concept, and roles and relationships do not elicit information about the client's cultural beliefs and practices.

The nurse is caring for a client who states, "the FBI is listening, and they are going to come get me." Although the client is smiling at the nurse, the client is seen pacing the unit and checking the doors. How would the nurse document the client's affect?

inappropriate Explanation: Affect is the outward expression of the client's emotional state. Blunted affect is showing little or a slow-to-respond facial expression. Restricted affect is displaying one type of expression, usually serious or somber. Flat affect is showing no facial expression. Inappropriate affect is displaying a facial expression that is incongruent with mood or situation; the client is often silly or giddy regardless of circumstances. The client in the scenario is experiencing psychosis and their mood is scared. Their affect of smiling is incongruent with the circumstances. Therefore, the nurse should document the client's affect as inappropriate.

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?

inappropriate affect 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.

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?

postvisit Explanation: 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 Explanation: 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 social assessment on a client. Which findings from the client would be documented by the nurse in the social assessment?

spiritual practices Explanation: The social assessment includes functional status; social systems; spirituality; occupation, economic, and legal status; quality of life; social strengths; and wellness attributes. The mental status examination includes general observation of appearance, psychomotor activity, and attitude; orientations; mood; affect; emotions; speech; and thought processes. Therefore, the nurse conducting a social assessment on a client would document their spiritual practices in the medical record. .