The Psychosocial Assessment
How should the nurse document Sally's reasoning for being brought into the hospital?
Correct Response: "Client states: 'Its a state secret, and if I tell you, the FBI will have to kill you. I didn't need to come in, but my parents are working with the CIA and they brought me here. They are traitors to the plan.'" Explanation: Asking the client why she came to the hospital allows her to state her perception or understanding of the reason. Writing the client's response in quotes and without interpretation is the clearest and most accurate documentation. The nurse does not have enough information from this one question in order to diagnose the client as psychotic, and while the client's ideas of why she was brought to the hospital may not be grounded in reality, it is still important to document her perception of it. Similarly, the nurse does not yet have enough information to conclude that the client has decompensated or that she is as disordered as she was during her previous admission. The accuracy of the client's response is irrelevant to this portion of the assessment.
Sally tells the nurse she is tired, and doesn't feel like talking anymore. She asks if they can continue talking later after dinner. What is the nurse's best response?
Correct Response: "Of course we can stop now. Thank you for answering all the questions that you have answered. Dinner is in 30 minutes." Explanation: There is no need to complete the psychosocial assessment in one sitting. Many clients cannot tolerate sitting and answering questions for a long period of time, so thanking Sally for her time and agreeing to talk more after dinner will yield the best assessment results. Telling Sally the assessment must be finished now is not accurate. Trying to push Sally to keep going with the assessment either with or without a snack will not facilitate a therapeutic relationship, and it will not help the nurse get the best information possible from Sally.
After asking Sally "Can you tell me what 'the grass is always greener on the other side of the fence means?" Sally says "It means what someone else has always looks better than what you have. You are never satisfied with what you have, and you are always envious of others." How does the nurse document this assessment?
Correct Response: "The client can think abstractly." Explanation: Sally demonstrates being able to correctly interpret the meaning of the saying, so the nurse would document "The client can think abstractly." Because Sally's answer was correct, the nurse would not document that she cannot think abstractly. Concrete thinking is based in fact and would not require interpretation. Although Sally did interpret a common saying, it is more useful for the mental status exam to know that Sally demonstrated abstract thinking.
The weather is warm, and Sally is wearing a pair of shorts, sandals, and a short-sleeved shirt. The clothing has a number of food stains and the nurse notices a strong smell of body odor. Sally's hair is combed but appears unwashed. She is looking at the nurse appropriately without staring, and her facial expressions appropriately reflect the content of her speech. What is the best documentation of these observations?
Correct Response: "The client's clothing is appropriate for the season, but stained with what appears to be food. She is odiferous. Her affect is congruent with speech content." Explanation: Documenting "The client's clothing is appropriate for the season, but stained with what appears to be food. She is odiferous. Her affect is congruent with speech content" is not judgmental and explains what the nurse sees and smells in order to adequately express these observations to other members of the health care team. Documenting "her facial expressions are what one might expect" is unclear because "what one might expect" is subjective. Stating that clothing is meant for a younger person is judgmental, and saying Sally is not staring or "doing anything else inappropriate", does not document information about what she is doing and how she appears. Stating the client has "bad body odor, and her hair is greasy" is subjective and judgmental. Stating her facial expressions are "good" does not indicate why, so other staff members cannot get an accurate understanding of Sally's state during this assessment.
In order to determine Sally's ability to think abstractly, what is the best question the nurse can ask?
Correct Response: "What does 'the grass is always greener on the other side of the fence' mean?" Explanation: By asking the client to interpret a proverb or common saying like "the grass is always greener on the other side of the fence," the nurse can assess the client's ability to think abstractly. Asking the client to state the date and year assesses for orientation to time and place. Asking the client to count back from 100 by 7's or to spell a work backward, assesses the client's ability to concentrate.
An important part of any psychosocial assessment is determining if the client has thoughts of self-harm. What is the best way for the nurse to determine this when assessing Sally?
Correct Response: Ask "Do you have any thoughts of suicide?" Explanation: The best way to assess if a client has thoughts of self-harm is to ask directly, "Do you have any thoughts of suicide?" If the answer is yes, the nurse then asks if the client has a suicide plan. It is not appropriate to wait until the client raises the topic because she may not, and this is important to determine the client's level of safety. Asking questions about if Sally knows anyone who has committed suicide of if she has any religious beliefs or thoughts about suicide are indirect ways to determine Sally's level of risk, potentially keeping the nurse from making an accurate assessment, and a nursing plan to keep Sally safe.
The nurse observes that Sally cannot sit during the interview. She is constantly crossing and uncrossing her legs, periodically standing up, and sitting down again, frequently scanning the room, and moving her fingers as if she is counting up to 10 on them. In what portion of the psychiatric evaluation will the nurse document these observations?
Correct Response: Behavior Explanation: Frequent movement, scanning the room, and using fingers to count are all examples of behavior, and should be documented as such. The client's facial expressions and mannerisms would be documented under the affect section. Evidence of visual or auditory hallucinations may be documented under the perceptual disturbances portion. Thought process and content might include documentation of the ideas Sally expresses.
The nurse tells Sally, "I'm going to name three objects and ask you to say them back to me." The nurse says "table, apple, giraffe," and Sally repeats them. The nurse then tells Sally she is going to continue asking Sally questions, and in 5 minutes, she is going to ask Sally to repeat three objects again. Sally confirms she understands. After 5 minutes of conversation has passed, Sally repeats "table" and "apple", but cannot remember the third word. She takes a guess and comes up with "hippopotamus." What does this technique of questioning assess?
Correct Response: Immediate recall. Explanation: The first step of this line of questioning tests immediate recall and the second step assesses short-term recall. An example of assessing ability to concentrate would be asking the client to spell a moderately long word backward. Asking Sally to repeat the three words 5 minutes later is an example of short-term, not long-term recall. A multistep command would include more concrete instructions rather than questions.
Sally's response to being asked why she was admitter reflects what about her relationship to her psychiatric illness?
Correct Response: Poor insight into her psychiatric illness. Explanation: Sally's inability to recognize her symptoms of mental illness and blaming others or an outside source for her hospitalization is an indication of poor insight into her psychiatric illness. Good insight into one's psychiatric illness would be reflected in a response that demonstrates an ability to understand the reality of her situation without blaming an external source. For instance, if she had stated that she knew she was becoming ill again because she was starting to believe the FBI and CIA were involved in her life, this would show good insight into her illness. Insight is either good or poor; it would not be considered mediocre. She will eventually need better insight in order to recover.
Which aspects would be part of the mental status exam the nurse performs when assessing Sally? Choose all that apply.
Correct Response: ✓ Ability to think abstractly ✓ Ability to concentrate ✓ Memorization ✓ Short-term recall Explanation: The mental status exam will include assessments of the ability to think abstractly; ability to concentrate; memorization; and short-term recall. Past history of psychiatric admission and patterns of speech are assessed during the psychosocial history part of the assessment.
While the nurse is talking with Sally, she is also making observations about Sally's appearance. What will the nurse's observations include?
Correct Response: ✓ Hygiene ✓ Dress ✓ Facial expressions Explanation: Observation is an important part of assessing the client and includes what the nurse can immediately see. This includes hygiene, dress, and facial expressions. Speech patterns, thought content, and thought process are aspects the nurse cannot see, but will assess during her conversations with Sally.
The nurse asks Sally if she is taking any medications, and she responds she has a lot at home. When asked what they are, Sally says they are "junk" that she was prescribed after her last hospitalization. She recalls that she took them for some time, but stopped because they were "stupid and did nothing." What does this conversation allow the nurse to assess about Sally's medication regimen? Choose all that apply.
Correct Response: ✓ Sally's recall of the names of her medications; ✓ Sally's insight into the need for her medications; ✓ The need for teaching about Sally's medications; ✓ The level of compliance Sally exhibits when taking medications. Explanation: Asking questions about Sally's medication regimen allows the nurse to assess if Sally knows the names of her medications; what her understanding is about why she takes these medications; the level of patient teaching Sally may need about medications; and Sally's level of adherence to her medication treatment plan. While a client's religious beliefs may have come up in a conversation such as this, that is not the intention of this assessment, unless the client states a religious or cultural reason for not wanting to adhere to a drug therapy plan. It is out of scope for the nurse to make plans regarding what medications a client should be prescribed, but assessing Sally's understanding and behaviors around medications will help the nurse gather information for the physician to make decisions regarding prescriptions.
The nurse next explains what coping skills are and asks Sally about how she copes when she is upset or overwhelmed. Sally responds that she sometimes stays in bed for days at a time when she is feeling overwhelmed. At other times, she says she will call a friend to talk. Why does the nurse ask Sally about her coping skills? Choose all that apply.
Correct Response: ✓ To assess the need for patient teaching about coping skills; ✓ To assess Sally's ability to utilize effective coping skills. Explanation: An important aspect of the nurse's role in a psychiatric hospital is to teach clients effective coping skills. Upon discharge, all clients will experience stress which can exacerbate mental illness, and the best way to manage stress is with effective coping skills. Asking Sally how she copes allows the nurse to assess the need for patient teaching about coping skills, and to assess Sally's ability to utilize effective coping skills. To assess if Sally has thoughts of self-harm, the nurse would ask directly. Telling Sally she needs to develop better coping skills is nontherapeutic.
The nurse begins to assess Sally's quality of speech. Which categories will the nurse consider when making this assessment? Choose all that apply.
Correct Response: ✓ Tone ✓ Speed ✓ Volume Explanation: Descriptions of the quality of a client's speech may include tone, speed, and volume. The tone of speech conveys the mood of the person speaking. The tone may be pleasant, angry, or irritated. The speed of a client's speech could be described as slow, rapid, or pressured. The volume of speech would be described with words like mute, soft, or loud. Considering the nature and pattern of a client's speech would be an assessment of the speech content rather than its quality.
