Chapter 8: Assessment

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 client was born and educated in Japan. The client moved to the United States two years ago. The client wears Western clothing and eats fast food. Which answer describes what the client has modeled?

acculturation

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

Which client statement best demonstrates a healthy relationship with family?

"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 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?"

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

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?

Affect

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 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

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

Asking the client to complete serial sevens assesses what?

Concentration

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

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

Thought process

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..."

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

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

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

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

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

"What did you eat for breakfast today?"

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

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

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? -How did your problems begin?

A nurse is completing a history for a client who recently suffered emotional stress over the death of a family member. What would the nurse expect the client who is diagnosed with conversion disorder to reveal? Select all that apply.

-difficulty swallowing or feeling "a lump in the throat" -double vision -tremors and difficulty walking

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 that have occurred over the past few weeks.

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

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

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 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?

Hallucination

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.

When the nurse asks the client, "If you found a stamped addressed envelope on the ground, what would you do?" the nurse is assessing which component of the assessment?

Judgment

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

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.

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.

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

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 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.

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.

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?

self-concept