Chapter 8

A nurse documents that "the client describes the recent breakup of a dating relationship with an emotionless tone and a flat facial expression." In which section of the mental status exam would the nurse have documented this statement? blocking feelings affect mood

affect

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

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?"

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

"When did you get your first job?"

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.

If the client provides a literal explanation of a proverb and cannot interpret its meaning, which thought process is lacking? Abstract thinking Concrete thinking Concentration Memory

Abstract thinking

the client provides a literal explanation of a proverb and cannot interpret its meaning, which thought process is lacking? Abstract thinking Concrete thinking Concentration Memory

Abstract thinking

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

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

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.

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

The general assessment and motor behavior component

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."

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."

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.

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

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

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

Which type of hallucination is the most common? Auditory Visual Gustatory Olfactory

Auditory

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..."

During assessment of a client with schizophrenia, the nurse notes the client has ideas of reference. Which statement of the client would have led the nurse to conclude this? "My dead friend is putting these ideas in my mind." "My family is taking my thoughts away. I am unable to think now." "I am sure you know what I am thinking. Everybody knows what I am thinking." "The news of the terrorist attack is directed to me. The terrorists are trying to warn me."

"The news of the terrorist attack is directed to me. The terrorists are trying to warn me."

When assessing orientation, the nurse completes the assessment by asking which questions? Select all that apply. "What is your name?" "Can you tell me where you are?" "What day of the week is it?" "What did you eat for breakfast today?" "Would you count from 1 to 10 backward, please?"

"What day of the week is it?" "Can you tell me where you are?" "What is your name?"

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 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

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? A review of systems Evaluation of insight and judgment Questions regarding past behaviors Evaluation of medication compliance

Evaluation of insight and judgment

While talking with a schizophrenic client, the nurse observes that the client is looking straight ahead, maintains no eye contact, and moves facial muscles very little, 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

A nurse assesses a 29-year-old client in the outpatient mental health clinic. The nurse notes the client is speaking very quickly and jumping from topic to topic very rapidly. There is some connection between ideas, but they are difficult to follow. Which term most accurately describes this thought process? Derailment Flight of ideas Circumstantiality Incoherence

Flight of ideas

A young adult client is brought to the outpatient mental health clinic by the client's father. The client was diagnosed with schizophrenia 6 months ago and has been taking medication since. The father reports the client continues to hear voices despite adhering to the medication. Which term best describes the client's abnormality of perception? Illusion Hallucination Fugue state Perseveration

Hallucination

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

During an initial assessment, a client exhibits pressured speech and points to patterns on the wallpaper stating, "This is the writing about the tsunami. Thousands of people died because I read the writing." Which term should the nurse use to document this observation? Illusion Religious delusion Hallucination Ideas of reference

Ideas of reference

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? Blunted Incongruent Flat Labile

Incongruent

A client with psychosis who was recently admitted to a psychiatric unit says to the nurse, "The car is red. Are you ready for lunch? My head is hurting. Dogs bark loud." The client is exhibiting which type of speech? Echolalia Clang association Neologism Loose associations

Loose associations

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

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 Ability to describe the problem Recollection of the problem's related details Fine motor skills

Physical appearance

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 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. Fails to complete what the client is saying as if distracted. Answers the question, "May we talk?" by responding, "Walk the walk." Repeats the phrase, "Mary had a little lamb," whenever feeling stressed.

Provides long, irrelevant explanations when asked why the client abuses alcohol.

Which must the nurse consider a priority in the assessment of mental status? Wellness Behavior Safety Hygiene

Safety

Considering the nature of its content, which areas may be the most uncomfortable or difficult for the nurse to assess? Sexuality Mood Motor behavior Roles and relationships

Sexuality

he nurse is looking to assess the client's ability to concentrate. Which task should the nurse ask the client to perform? Spell "America" backward. Interpret the meaning of a proverb. Explain the perception of inkblot cards. Write the names of family members.

Spell "America" backward.

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 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.

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

The client knows the correct date.

Of the following clinical information, which one would be the most important in determining whether the client would be diagnosed with a mental disorder? The client is unable to continue school work and has been sitting on the client's bed for 3 days. The client has been receiving good grades in college and has a grade point average of 3.8. The client used cocaine up until 1 week ago. The client's father died in a tragic automobile accident when the client was 10 years old.

The client is unable to continue school work and has been sitting on the client's bed for 3 days.

A nurse is performing a psychosocial assessment of a client in the psychiatric unit. The nurse finds that the client is unable to understand the questions. Which explanations should the nurse consider? Select all that apply. The client may have a hearing disability. The client may not be highly educated. The client may have a low socioeconomic status. The client may not be paying attention to the nurse. The client may not understand the nurse's language.

The client may have a hearing disability. The client may not understand the nurse's language.

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

When conducting a psycho-social assessment, the nurse inquires about the client's social supports. In order to effectively do this, which does the nurse need to explore? The number of networks Challenges faced with social networks The proximity of the networks to the client The length and quality of relationships

The length and quality of relationships

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

Which aspect of the mental status exam refers to information about how the client's thoughts connect to one another? Orientation Behavior Mood Thought process

Thought process

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