ch8:assessment
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..." "Warning, warning, watch your back." The client makes eye contact with the nurse but does not respond verbally. "Well, that's certainly the end of that."
"I might. I'll give it some..." 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.
Which of the nurse's assessment questions would best identify whether the client has insight into the illness? "Do you ever hear voices or see things that other people do not see?" "Do you think that your illness prevents you from functioning well, and if so, how?" "Has anyone ever spoken to you about having a mental illness?" "Has anything like this happened to you before?"
"Do you think that your illness prevents you from functioning well, and if so, how?" Insight is defined as self-understanding about the origin, nature, and mechanisms of one's attitudes and behavior; it can often be ascertained by asking whether the client believes oneself to be in need of treatment and how the client perceives oneself to have limitations in function as a result of the illness. Asking the client if anyone has ever spoken to the client in the past about having a mental illness does not provide information about the client's insight, but it can assess the client's memory. Asking the client if "anything like this has" happened to the client before assesses the client's memory. Asking the client if the client hears voices that others do not hear assesses for the presence of auditory hallucinations. Reference:
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? "What kind of help do you think you need?" "Have you had a bad experience in the hospital before?" "What makes you think you're not sick?" "You don't think I know what I'm doing?"
"Have you had a bad experience in the hospital before?" If the client is reluctant to engage with the nurse for the assessment, it is likely due to a previous unsatisfactory experience with the health care system. A sign that the client is reluctant is that the client was brought to hospital by a family member. The nurse must address the client's feelings and perceptions to establish a trusting working relationship before proceeding with the assessment.
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?" "When was your last visit in the psychiatric facility?" "Is there something wrong with you?" "How did your problems begin?"
"How can we help you?" "How did your problems begin?" Open-ended questions are those questions that require a detailed descriptive answer. Questions like "how can we help you" and "how did your problems begin" cannot be answered in a word or a sentence, but require a detailed explanation. Open-ended questions need to be asked in order to understand the client's perception of the situation. Questions like "are you feeling better today," "is there something wrong with you," and "when was your last visit in the psychiatric facility" require a very precise answer. These are the examples of closed-ended questions. These questions do not allow the client to give more information.
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. "How do you think you look today?" "Which country do you live in?" "What do you do when you have a problem?" "Are you thinking about killing yourself?" "Could you tell me what time it is?"
"How do you think you look today?" "What do you do when you have a problem?" Self-concept is the way one views oneself. It includes perception of body image, coping skills, social image, and academic and occupational image. By asking "how do you think you look today," the nurse is trying to understand the client's body image. By asking "what do you do when you have a problem," the nurse is trying to understand the client's method of coping with problems. Thus, these questions indicate that the nurse is assessing the self-concept of the client. By asking "which country do you live in," the nurse is assessing the memory of the client. By asking "are you thinking about killing yourself," the nurse is assessing if the client has suicidal ideation. By asking "what time is it," the nurse is assessing the client's orientation.
Which statement by the client best demonstrates a healthy relationship with family? "My family has always tried their best to help me." "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."
"I feel better after I visit with my Mom." The relationship with others is important to mental health. Feeling better after having contact with a particular person demonstrates a healthy relationship. While all the options present positive statements, only the correct option is obviously positive in the result of the interaction.
A psychiatric-mental health nurse is assessing a client. Which statement by a client would the nurse recognize as evidence of an absence of insight? "I don't think any of those psychiatrists or psychologists or whatever have any clue what they're doing." "If things don't improve for me, I'll probably end up on the street." "I just feel these days like I'm in this black pit and there's no way I can get out of it." "Sometimes I feel like the world would be better off if I were dead."
"Sometimes I feel like the world would be better off if I were dead." Insight is characterized as an awareness of one's circumstances; it includes awareness of thoughts, feelings, and behaviors and ability in relation to the thoughts, feelings, and behaviors of others. Presuming that all people feel the world would benefit from their absence suggests a lack of insight. Anger at the perceived incompetence of care providers, apathy about one's bleak future, and expressions of despondency certainly warrant further assessment and treatment, but they do not necessarily indicate a lack of insight.
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." "I am sure you know what I am thinking. Everybody knows what I am thinking." "My family is taking my thoughts away. I am unable to think now." "My dead friend is putting these ideas in my mind."
"The news of the terrorist attack is directed to me. The terrorists are trying to warn me." Ideas of reference are the inaccurate perception of the client that general events are personally directed to him or her. Thinking that the news of the terrorist is a warning to the client indicates that the client has ideas of reference. The delusion that other people (dead friend) are putting thoughts in the client's mind is referred to as thought insertion. The delusion that others are taking the client's thoughts away is referred to as thought withdrawal. The delusion that others know what the client is thinking is referred to as thought broadcasting.
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." 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.
Which question would be best for the nurse to ask in order to assess recent memory? "What did you eat for breakfast today?" "When is your birthday?" "Why are you at the health care clinic today?" "How are an orange and an apple different?"
"What did you eat for breakfast today?" 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.
When assessing orientation, the nurse completes the assessment by asking which questions? Select all that apply. "Would you count from 1 to 10 backward, please?" "What is your name?" "What day of the week is it?" "Can you tell me where you are?" "What did you eat for breakfast today?"
"What is your name?" "What day of the week is it?" "Can you tell me where you are?" Asking the client to give the client's name, identify the client's location, and name the day of the week assess orientation. Asking the client to relate what the client ate for breakfast assesses short memory, and asking the client to count backward assesses intellectual abilities, neither of which is a reflection of orientation.
The nurse is preparing to assess a client's remote memory. Which questions would be most appropriate for the nurse to ask? "What did you do last evening?" "When did you get your first job?" "Can you tell me what you have eaten in the last 24-hours?" "How are an apple and orange the same?"
"When did you get your first job?"
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 Temperament Mood Demeanor
Affect 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).
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? "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."
"You are welcome to share any information that you think would be helpful." The client does not want the family to know information regarding their condition. The client's wishes must be upheld unless there is the threat of harm, in which case information can be shared without the client's consent. In this context, however, that is not the case. The nurse's best response is to ask the family to share anything that they think would inform the assessment and treatment of the client.
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? Temperament Affect Mood Demeanor
Affect 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).
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. Judgmental Accepting Defensive Objective Brief
Accepting Objective While performing a psychosocial assessment, the nurse should have an accepting and objective or straightforward approach with the client. If the nurse expresses personal opinions to the client or is judgmental, the client may be reluctant to share sensitive information. The nurse should not be emotionally unstable as this would hinder the nurse's ability for proper assessment. If the nurse asks short and crisp questions, the client may think the nurse is hurried and is not interested in listening. This behavior may prevent the client from providing complete information to the nurse.
When completing a physical assessment of an individual's response to stress, the nurse should observe and inquire about what? Concentration Appetite and sleep Judgement and insight Mood
Appetite and sleep 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 from childhood. Provide the client with three words and ask the client to recall the words several months later. 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 that have occurred over the past few weeks. 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 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? Assessing the client's developmental level Reviewing the client's culture for possible influence Asking whether the client often feels cold Observing the client's overall hygiene
Asking whether the client often feels cold Dress is typically appropriate for occasion and weather, and dress varies considerably from person to person. Some older adults may wear excess clothing because of slowed metabolism and loss of subcutaneous fat resulting in cold intolerance. The nurse needs to determine this first before performing any other assessments.
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? Evaluation Planning Assessment Diagnosis
Assessment 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 willingness to participate Client's feelings and perceptions Client's behavior Client's compliance
Client's feelings and perceptions 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 antisocial personality disorder Clients with depression Clients with adult attention deficit hyperactivity disorder Clients with post-traumatic stress disorder
Clients with adult attention deficit hyperactivity disorder 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.
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? Ask another nurse to attempt the assessment. Complete the assessment in several short interactions. Wait for psychiatric medication to take effect. Use observation only to collect client information.
Complete the assessment in several short interactions. 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? Insight Judgment Concentration Orientation
Concentration 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.
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? Professional practice evaluation Planning Evaluation Assessment
Evaluation Evaluation is the assessment of a client's progress after an identified plan has been implemented. Planning is done after diagnosis and just before implementing therapeutic strategies. Assessment is the initial data collection from the client. Professional practice evaluation is the evaluation of nursing care against professional standards.
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 Questions regarding past behaviors A review of systems Evaluation of medication compliance
Evaluation of insight and judgment 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.
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 medication compliance A review of systems Evaluation of insight and judgment Questions regarding past behaviors
Evaluation of insight and judgment 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.
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? Blunted Flat Labile Constricted
Flat The client's affect, or facial expression, would be described as "flat." Labile affect is the abnormal fluctuation or variability of one's expressions, such as repeated, rapid, or abrupt shifts. Constricted affect relates to a reduction in one's expressive range and intensity of affective responses. Blunted affect is a severe reduction or limitation in the intensity of one's affective responses to a situation.
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? Perseveration Circumstantiality Neologisms Flight of ideas
Flight of ideas Flight of ideas is the expression of multiple, unrelated ideas in a string of statements. Neologisms are new words, circumstantiality is when the client speaks about topics that are loosely related with each other, and perseveration is the repetition of words or ideas over and over.
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? Incoherence Flight of ideas Derailment Circumstantiality
Flight of ideas This represents flight of ideas, because the ideas are connected in some logical way. Derailment, or loosening of associations, has more disconnection within clauses. Circumstantiality is characterized by the patient speaking "around" the subject and using excessive detail, though thoughts are meaningfully connected. Incoherence lacks meaningful connection and often has odd grammar or word use. Although severe flight of ideas can produce this condition, evidence is not present in this vignette.
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 Comprehensive Screening Secondary
Focused A focused assessment includes the collection of specific data regarding a particular problem as determined by the client, a family member, or a crisis situation. A comprehensive assessment is broader in scope, while a screening assessment aims to identify the presence or absence of health problems.
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? Fugue state Hallucination Perseveration Illusion
Hallucination A hallucination is a subjective sensory perception in the absence of real external stimuli. The client can hear, see, smell, taste, or feel something that does not exist in reality. In this case, the client's sister died and cannot be speaking to the client, although in the client's mind the client can hear her. This is an example of an auditory hallucination, but hallucinations can occur with any of the five senses.
Under which component of the psychosocial assessment should the nurse document observations concerning the client's cultural considerations? Roles and Relationships History Self-Concept Thought Process and Content
History The assessment information concerning culture is documented under the History component of the psychosocial assessment.
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 Obsession Magical thinking Thought broadcasting
Ideas of reference Ideas of reference include beliefs that external events have personal significance. Magical thinking includes the belief that thinking about something will make it happen. Thought broadcasting includes the belief that thoughts are known by others. Obsessions include unwanted repetitive thoughts.
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? Hallucination Illusion Religious delusion Ideas of reference
Ideas of reference The client falsely believes that she is responsible for catastrophic events unrelated to her. The nurse would document "ideas of reference" and quote the patient's statements. Believing that the wallpaper contains secrets is not a misperception of a real stimulus or an illusion. The client believes she is responsible for the events she is describing. Hallucinations are false sensory perceptions. In a hallucination, the client sees, smells, hears, tastes, or feels something for which there are no external stimuli. While the ideas of reference would be considered a delusion, no religious or spiritual theme is involved with the patient's false beliefs.
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"? Broad Restricted Congruent Incongruent
Incongruent 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? Blunted Labile Incongruent Flat
Incongruent 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.
What is the most significant benefit of using Beck's Depression Inventory in evidence-based nursing practice? It is a standardized, reliable depression tool. It is easily graded by the nurse. It has 21 focused questions to be asked of the client. It identifies a client's level of depression.
It is a standardized, reliable depression tool. Evidence-based practice promotes the use of standardized, valid, and reliable tools, guidelines, and protocols in mental health, based on aggregate data. Tools based on the majority of the population presume similarity and stability over time. While the other options are true statements about this screening tool, none are associated with evidence based practice.
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 Ideas of reference Loose associations Neologisms
Loose associations 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.
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? Neologism Clang association Echolalia Loose associations
Loose associations Looseness of association is a disturbance of thinking shown by speech in which ideas shift from one unrelated or minimally unrelated subject to another. Echolalia is the parrot-like repetition of overheard words or phrases. Clang association is a type of thinking in which the sound of a word (rhyming) substitutes for logic during communication. Neologism describes the use of a new word or combination of several words coined or self-invented by a person and not readily understood by others.
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 Clangs Word themes Broadcasting
Neologisms Clients with thought disorders (e.g., schizophrenia) may rhyme (clang associations) or use made-up words (neologisms).
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 Recollection of the problem's related details Ability to describe the problem Fine motor skills
Physical appearance 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.
Which would not be included as a purpose of the psychosocial assessment? Behavioral function Previous compliance with treatment regimen Current emotional state Mental capacity
Previous compliance with treatment regimen The previous amount of compliance with the treatment regimen would not be included as a purpose of the psychosocial assessment. Current emotional state, behavioral function, and mental capacity are included in the psychosocial assessment.
The psychiatric nurse correctly identifies the client's form of communication as circumstantiality when the client does what? Repeats the phrase, "Mary had a little lamb," whenever feeling stressed. Answers the question, "May we talk?" by responding, "Walk the walk." Fails to complete what the client is saying as if distracted. Provides long, irrelevant explanations when asked why the client abuses alcohol.
Provides long, irrelevant explanations when asked why the client abuses alcohol. 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.
Which tools would a nurse use to objectively assess a client's personality? Select all that apply. Psychological Screening Inventory (PSI) Rorschach test Tennessee Self-Concept Scale (TSCS) Milton Clinical Multiaxial Inventory (MCMI) Thematic apperception test (TAT)
Psychological Screening Inventory (PSI) Tennessee Self-Concept Scale (TSCS) Milton Clinical Multiaxial Inventory (MCMI) The Tennessee Self-Concept Scale (TSCS), the Milton Clinical Multiaxial Inventory (MCMI), and the Psychological Screening Inventory (PSI) are designed as objective measures of personality in which the nurse compares the client's answers with standard answers or criteria and obtains a score or scores. The thematic apperception test (TAT) and the Rorschach test are projective measures of personality; these are unstructured and are usually conducted by the interview method.
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? Maintenance of an awkward posture for a long time Speaking meaningless words Slowness of body movements Repeated tapping of the foot
Slowness of body movements Slowing of thought processes and bodily movements is referred to as psychomotor retardation. Repeated tapping of foot is referred to as automatism which is often caused due to anxiety. Speaking words that are only meaningful to the client and nobody else is referred to as neologisms. Maintenance of an awkward posture for a long time is an abnormal behavior and is referred to as waxy flexibility.
The nurse is looking to assess the client's ability to concentrate. Which task should the nurse ask the client to perform? Explain the perception of inkblot cards. Interpret the meaning of a proverb. Spell "America" backward. Write the names of family members.
Spell "America" backward. To assess the concentration of the client, the nurse should ask the client to spell "America" backward. This activity requires a good amount of concentration. Interpretation of a proverb or idiom is the task used to determine the use of abstract thinking by the client. Explaining the perception of inkblot cards is the Rorschach test and is useful to understand the coping styles, interpersonal attitudes, and characteristics of ideation of the client. Asking the client to write the names of family members is a task useful for assessing the memory of the client.
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 Thematic Apperception Test The Tennessee Self-Concept Scale The Psychological Screening Inventory The Rorschach Test
The Rorschach Test The Rorschach Test is a projective personality test. It includes the use of 10 stimulus cards with inkblots. The client has to describe perceptions of inkblots. This test is useful to understand the coping styles, interpersonal attitudes, and characteristics of ideation. The Thematic Apperception Test uses 20 stimulus cards with pictures. The client tells a story about the picture. The Tennessee Self-Concept Scale and the Psychological Screening Inventory are objective personality tests. The Tennessee Self-Concept Scale includes 100 true-false questions that provide information on 14 scales related to self-concept. The Psychological Screening Inventory consists of 103 true-false questions. The result of the test indicates whether the client needs psychological help.
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 a facial expression that is incongruent with mood. The client displays only one type of facial expression. The client displays no facial expression. The client displays a full range of emotional expressions.
The client displays only one type of facial expression. 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 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 a full range of emotional expressions. The client displays only one type of facial expression. The client displays a facial expression that is incongruent with mood.
The client displays only one type of facial expression. 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.
A nurse is meeting an older adult client for the first time. What may hinder the nurse's ability to effectively carry out the psychiatric assessment? (Select all that apply.) The client has a cognitive impairment. The client is not wearing a hearing aid. The client is experiencing pain. The client is slow to respond to questions. The nurse and the client speak different primary languages.
The client has a cognitive impairment. The client is not wearing a hearing aid. The client is experiencing pain. The nurse and the client speak different primary languages. The client's ability to hear and understand what the nurse is saying are factors in the accurate collection of data. In addition, when a client is experiencing pain, the information the nurse obtains may reflect the pain rather than an accurate assessment of the client's situation. If a client is slow to respond to questions asked, this should not hinder the assessment. The nurse needs to modify the assessment by tolerating silence or long pauses before questions are answered. Symptoms of psychiatric disorders such as depression or psychosis can cause slower cognitive processing leading to latency in response.
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 test needs to be readministered The client did not understand the test instructions The test environment was not appropriate The client's cognitive deficit is significant
The client's cognitive deficit is significant The fewer tasks the client competes accurately, the greater the cognitive deficit. None of the other options provide a plausible conclusion.
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 a stress-free environment The amount of distracters in a given location The amount of lighting in a given location The client's right to privacy
The client's right to privacy The client's right to privacy is an essential setting consideration. It is an ethical responsibility of the nurse as well as a legal right of the client. Nurses must make critical clinical judgments about the optimal setting that maintains privacy while also ensuring safety.
The nurse finds that the client is constantly rubbing the hands. Under which component of psychosocial assessment should the nurse document this finding? The mood and affect component The history component The abnormal sensory experiences or misperceptions component The general assessment and motor behavior component
The general assessment and motor behavior component Constant rubbing of the hands is a type of unusual movement or mannerism. This finding should be documented under general assessment and motor behavior. This abnormal motor behavior is not documented in the history, mood and affect, or abnormal sensory experiences or misperceptions.
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 proximity of the networks to the client The length and quality of relationships Challenges faced with social networks The number of networks
The length and quality of relationships Social assessment also includes identification of the person's social network. The nurse should elicit the information about the size and extent of the network, both relatives and nonrelatives, and the length and quality of the 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 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. 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 the incongruity between content and behavior and find ways of exploring further. 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.
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? Review the client's history to determine presence of past of violent behavior. Document the session thoroughly and meet with the client again the next day. Warn the client's neighbor and report to the authorities. Review coping strategies for anxiety and set new therapeutic goals.
Warn the client's neighbor and report to the authorities. When the client makes specific threats or has a plan to harm another person, health care providers are legally obligated to warn the target of the threats. Legally this is called duty to warn. Although the nurse must document the session thoroughly and can meet with the client again the next day, this should not be the nurse's first action. The nurse should eventually review coping strategies for anxiety and set new therapeutic goals; however, duty to warn is the priority.
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? mood speech posture abstract reasoning
abstract reasoning 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.
The nurse assesses a client with a history of bipolar disorder. The client tells the nurse 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 loose associations circumstantial thinking tangential thinking
delusional thinking A delusion is a false fixed idea not based in reality. The information that the client has told the nurse in addition to the history of bipolar disorder indicates the client is expressing delusional thinking. Circumstantial thinking refers to when a client can respond to a question asked only after giving an excessive amount of detail. Tangential thinking refers to when the client wanders off topic when being asked a question in the assessment. With this type of thinking, the client never really provides the information that was originally requested. Loose associations refers to disorganized thinking that jumps from one idea to another with little or no evident relation between thoughts.
Which client behavior would the nurse document as being an automatism? staring off into space frequently repeating his or her statements asking that the question be repeated drumming one's fingers on the table top
drumming one's fingers on the table top 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.
During the assessment of a client who has a pattern of eating-disordered behavior, the nurse asks, "What would you change about your body, if you could?" The nurse is assessing which component of the psychosocial assessment? sensory-perceptual alterations roles and relationships self-concept thought process and content
self-concept By asking the question "What would you change about your body, if you could?" the nurse is assessing self-concept. The client's description of self in terms of physical characteristics gives the nurse information about the client's body image which is also a part of self concept. Sensory-perceptual alterations refer to a change in the client's perception of the world. Often this results in hallucinations or a false sensory perception or perceptual experience that does not really exist. When assessing roles and relationships, the nurse would ask questions such as "Do you feel close to your family?" or "Do you have a significant other?" to determine the existence and quality of the client's sources of support and/or stress. Thought process and content refers to how the client thinks and what they actually say. The aim of this component of the assessment is to determine if the client's ability to think is impaired or intact.
When considering where to conduct a psychosocial assessment, the nurse can effectively interview which client in the unit's conference room? the paranoid client the suicidal client the aggressive client the anxious client
the anxious client The nurse should not choose an isolated location such as a conference room for the interview, if the client is unknown to the nurse or has a history of any threatening behavior either to themselves or to others. The anxious client by diagnosis does not present a threat and so is the one best suited for the nurse to use the conference room for the interview.
