PrepU for Videbeck's Psychiatric-Mental Health Nursing, 7 Edition Chapter 8

When the mental health nurse asks the client, "Do you recall what month and year this is?" the nurse is assessing which part of the mental status examination?

Orientation

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

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

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

Appetite and sleep

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

A client is being admitted to an inpatient setting. It is important for the nurse to first obtain which information about the client?

Assessment of history

The nurse performs an assessment of a client who presents with symptoms of mental illness for the first time. Which is the nurse's priority?

Collect comprehensive data

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 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

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?

Loose associations

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..."

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?

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

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."

Which question would be best for the nurse to ask in order to assess recent memory?

"What did you eat for breakfast today?"

The nurse is performing a psychosocial assessment of a client. Which questions should the nurse ask to assess the client's self-concept? Select all that apply.

"What do you do when you have a problem?" "How do you think you look today?"

When assessing orientation, the nurse completes the assessment by asking which questions? Select all that apply.

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

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?"

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 physician's intake room with other medical personnel nearby.

Asking the client to complete serial sevens assesses what?

Ability to concentrate

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

Abstract thinking

When the nurse asks, "How would you carry out this plan?" the nurse is questioning which component of a suicide assessment?

Access

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?

Affect

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

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

Client's feelings and perceptions

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

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.

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?

Evaluation

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?

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?

Flight of ideas

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?

Flight of ideas

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?

Focused

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 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.

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

Antisocial personality disorders are assessed with which tool?

Milton Clinical Multiaxial Inventory (MCMI)

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.

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

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

The nurse is looking to assess the client's ability to concentrate. Which task should the nurse ask the client to perform

Spell "America" backward.

During an assessment, which would be the most important question topic?

Suicidal ideation

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 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.

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.

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 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 client's right to privacy

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.

When considering where to conduct a psychosocial assessment, the nurse can effectively interview which client in the unit's conference room?

the anxious client

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.

The nurse assesses a client with a history of bipolar disorder. The client tells the nurse that 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

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

drumming one's fingers on the table top

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