prep u chapter 8

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."

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:

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

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

A 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

A psychiatric-mental health nurse is beginning a client interview. Which question made by the nurse would be best in the beginning of the interview?

"How did you come to this clinic today?"

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

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

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."

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."

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?"

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?

''What thoughts have you had about hurting your brother?"

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

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

Abstract thinking

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

Appetite and sleep

The nurse notes that an older adult client is wearing layers of clothing on a warm, fall day. Which would be the priority assessment at this time?

Asking whether the client often feels cold

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

Circumstantial thinking

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

Client's feelings and perceptions

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.

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

Asking the client to complete serial sevens assesses what?

Concentration

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

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

Flight of ideas

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?"

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.

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

It is a standardized, reliable depression tool.

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? You Selected:

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

A nurse is conducting an interview with a psychiatric-mental health client and notices the client is using made-up words. This is known as what?

Neologisms

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

Preferred coping styles

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

Previous compliance with treatment regimen

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

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

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?

Tell me the reason that you are not taking your medication."

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 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.

The nurse finds that the client is constantly rubbing the hands. Under which component of psychosocial assessment should the nurse document this finding?

The general assessment and motor behavior component

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

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

A nurse is 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

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

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.

accepting objective

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

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

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

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

While talking with a schizophrenic client, the nurse observes that the client is looking straight ahead, maintains no eye contact, and shows no facial expression, even though the client is telling the nurse about a very emotional episode the client just experienced with a roommate. When describing the client's affect, the nurse documents it as what?

flat

A nurse 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

Under which component of the psychosocial assessment should the nurse document observations concerning the client's cultural considerations?

history

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

ideas of reference

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

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

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

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

A nurse coming on duty reviews the chart from the previous nurse. What assessment finding(s) are evident in the client? Select all that apply.

thought broadcasting inappropriate affect loose associations