Chapter 8 Psych Nursing

16. The client spoke of a current event in the national news and described it as it relates to the client. Then the client spoke of a historical event and described it as it relates to the client. Which of the following questions might the nurse ask to determine if the client is experiencing ideas of reference? A) ìWhere were you when this happened?î B) ìWhy do you think that?î C) ìAre you sure?î D) ìThat is unbelievable!î

Ans: A Feedback: Ideas of reference are the client's inaccurate interpretation that general evens are personally directed to him or her, such as hearing a speech on the news and believing the message had personal meaning. ìWhere were you when this happened,î would relate to the place and might give the nurse more information to validate the client's previous comments. ìWhy do you think that,î may be interpreted as the nurse challenging the client. ìAre you sure,î is a closed-ended question and does not encourage the client to elaborate. ìThat is unbelievable,î is a statement rather than a question and could be interpreted as the nurse's opinion of the information provided by the client.

5. During the assessment, the nurse asks the client to describe his problems. The purpose of this question is to obtain information about the client's A) admitting diagnosis. B) communication skills. C) perception of the problem. D) personal needs.

Ans: C Feedback: The question will elicit information about the client's view or perspective of the problem.

6. A delusion represents a problem in which of the following areas? A) Memory B) Motivation C) Orientation D) Thinking

Ans: D Feedback: A delusion is a fixed false idea or thought. Memory relates to the client's knowledge of past events. Motivation relates to the client's interest in doing things. Orientation relates to the client's perception of reality.

15. A patient reported to the nurse that on his way to the clinic, a policeman in a patrol car turned on his lights and pulled him over. When asked what he did next, the patient stated, ìI pulled over, of course.î Which of the following was the nurse trying to assess? A) The client's judgment B) The client's insight C) The client's concentration D) The client's self-concept

Ans: A Feedback: 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. Self-concept is the way one views oneself in terms of personal worth and dignity. The nurse assesses the client's ability to concentrate by asking the client to perform certain cognitive tasks. To assess a client's self-concept, the nurse can ask the client to describe himself or herself and what characteristics he or she likes and what he or she would change.

27. The client tells the nurse, ìThat new TV anchor is telling the world about me.î This is an example of A) ideas of reference. B) persecutory delusions. C) thought broadcasting. D) thought insertion.

Ans: A Feedback: The client's inaccurate interpretation that general events are personally directed to him or her is an example of ideas of reference. Persecutory delusions involve the client's belief that ìothersî are planning to harm the client. Thought broadcasting is a delusional belief that others can hear or know what the client is thinking. Thought insertion is a delusional belief that others are putting ideas or thoughts into the client's head.

7. The nurse asks a patient to list the days of the week in reverse order. The nurse is assessing which of the following? A) Concentration B) Memory C) Orientation D) Abstract thinking

Ans: A Feedback: The nurse assesses the client's ability to concentrate by asking the client to perform certain tasks such as repeating the days of the week backward. The nurse directly assesses memory, both recent and remote, by asking questions with verifiable answers. Orientation refers to the client's recognition of person, place, and time. Abstract thinking is to making associations or interpretations about a situation or comment

18. The nurse asks the client, ìWhat is similar about a cow and a horse?î and ìWhat do a bus and an airplane have in common?î These questions would best assess which of the following areas? A) Intellectual function B) Insight C) Judgment D) Memory

Ans: A Feedback: These questions would elicit information about the client's intellectual function. Insight is the ability to understand the true nature of one's situation and accept some personal responsibility for that situation. Judgment refers to the ability to interpret one's environment and situation correctly and to adapt one's behavior and decisions accordingly. Questions about memory would require that the client identify knowledge of past events.

32. Sexuality and self-harm behaviors are often difficult areas for nurses to assess. An effective way for nurses to deal with this discomfort includes A) recognizing that these areas may also be uncomfortable for the patient to discuss. B) share feelings of discomfort with the patient. C) defer assessing these areas to a more experienced nurse. D) develop a standard question to ask of all patients during this area of assessment

Ans: A Feedback: Two areas that may be uncomfortable or difficult for the nurse to assess are sexuality and self-harm behaviors. The beginning nurse may feel uncomfortable, as if prying into personal matters, when asking questions about a client's intimate relationships and behavior and any self-harm behaviors or thoughts of suicide. Asking such questions, however, is essential to obtaining a thorough and complete assessment. The nurse needs to remember that it may be uncomfortable for the client to discuss these topics as well.

28. During the admission assessment, the nurse asks the client, ìHow are you feeling?î The client responds, ìI was able to purchase gas for 7 cents a gallon less than yesterday, which saved me a total of 84 cents. My car has a 12-gallon gas tank. Usually I am able to put in 11.7 gallons. I am very happy to have saved so much money.î The nurse recognizes this response as which of the following? A) Circumstantial thinking B) Echolalia C) Flight of ideas D) Neologisms

Ans: A Feedback: With circumstantial thinking, the client eventually answers a question but only after giving excessive unnecessary detail. Echolalia is repetition or imitation of what someone else says. Flight of ideas is excessive amount and rate of speech composed of fragmented or unrelated ideas. Neologisms are invented words that have meaning only for the client.

4. A client is being evaluated for dementia. The nurse knows that a client who is able to complete very few tasks is most likely to have A) a greater cognitive deficit. B) A less precise mental status exam. C) more potential for agitation. D) no bearing on mental status.

Ans: A Feedback: The fewer tasks the client competes accurately, the greater the cognitive deficit. The other choices are not true.

1. When assessing a patient's mental health status, which of the following describe the purpose of the psychosocial assessment? Select all that apply. A) To assess the client's current emotional state B) To assess the client's mental capacity C) To assess the client's behavioral function D) To assess the client's plan of care E) To assess the client's physical health status

Ans: A, B, C Feedback: The purpose of the psychosocial assessment is to construct a picture of the client's current emotional state, mental capacity, and behavioral function. This assessment serves as the basis for developing a plan of care to meet the client's needs. The client's physical health status would need to be completed as another assessment or an extended assessment.

21. Which of the following are the types of roles that are usually included when assessing roles and relationships? Select all that apply. A) Family B) Hobbies C) Occupation D) Activities E) Race F) Ethnicity

Ans: A, B, C, D Feedback: The number and type of roles may vary, but they usually include family, occupation, and hobbies or activities.

20. The nurse plans to assess a patient's self-concept in the admission assessment knowing that self-concept influences which of the following? Select all that apply. A) Body image B) Cognitive processing C) Frequently experienced emotions D) Coping strategies E) Responsiveness to medications

Ans: A, C, D Feedback: Self-concept is the way one views oneself in terms of personal worth and dignity. The client's description of self in terms of physical characteristics gives the nurse information about the client's body image. Also included in an assessment of self- concept are the emotions that the client frequently experiences and whether or not the client is comfortable with those emotions. The nurse also must assess the client's coping strategies. Cognitive processing and response to medications are biologically based.

3. Which of the following are components of the assessment of thought process and content? Select all that apply. A) What the client is thinking B) Abstract thinking abilities C) How the client is thinking D) Clarity of ideas E) Self-harm or suicide urges

Ans: A, C, D, E Feedback: The components of the assessment of thought process and content include content (what the client is thinking), process (how the client is thinking), clarity of ideas, self-harm, or suicide urges. Abstract thinking abilities are an element of the abnormal sensory experiences or misperception assessment.

25. The nurse has completed the psychosocial assessment. Which of the following is the best approach toward analysis of the data to identify nursing diagnoses and develop an appropriate plan of care? A) Focus on each piece of information obtained from the patient. B) Look for patterns reflected in the overall assessment. C) Consider only the abnormal findings in the assessment. D) Present all data obtained in the treatment team meeting.

Ans: B Feedback: After completing the psychosocial assessment, the nurse analyzes all the data that he or she has collected. Data analysis involves thinking about the overall assessment rather than focusing on isolated bits of information. The nurse looks for patterns or themes in the data that lead to conclusions about the client's strengths and needs and to a particular nursing diagnosis. No one statement or behavior is adequate to reach such a conclusion.

26. The nurse reviews results of the Minnesota Multiphasic Personality Inventory (MMPI) recorded in a patient record. While considering the usefulness of these data, the nurse is mindful that the MMPI has which limitation? A) The patient must be able to read to complete the MMPI. B) The results of the MMPI could be culturally biased. C) The MMPI assesses a narrow scope of functioning. D) The MMPI does not have established validity.

Ans: B Feedback: Both intelligence tests and personality tests are frequently criticized as being culturally biased. It is important to consider the client's culture and environment when evaluating the importance of scores or projections from any of these tests. Objective personality tests compare the client's answers with standard answers or criteria and obtain a score or scores. The MMPI provides scores on 10 clinical scales such as hypochondriasis, depression, hysteria, and paranoia; four special scales such as anxiety and alcoholism; three validity scales to evaluate the truth and accuracy of responses.

33. Which of the following is the most compelling reason for the nurse to discuss matters of sexuality and suicide? A) It is required by the law by the federal government and in most states in the union. B) It is the nurse's professional responsibility to keep safety needs first and foremost. C) This is commonly required documentation for every encounter with every client. D) It allows the nurse to gain valuable experience in these kind of difficult discussions.

Ans: B Feedback: It is the nurse's professional responsibility to keep the client's safety needs first and foremost, and this includes overcoming any personal discomfort in talking about suicide. This is not required by any laws nor is it commonly required documentation for every encounter with every client. The nurse needs to gain experience in these kind of difficult discussions, but that is not a compelling reason for the nurse to discuss it if not warranted.

17. Which of the following questions is best to ask when assessing the client's judgment? A) ìCan you describe your usual daily activities for me?î B) ìIf you found yourself downtown without money or a car, how would you get home?î C) ìOn a scale of 1 to 10, how stressed would you rate yourself?î D) ìWhat problem would you like to work on while you're hospitalized?î

Ans: B Feedback: Judgment refers to the ability to interpret one's environment and situation correctly and to adapt one's own behavior and decisions accordingly. This question will elicit information about the client's problem-solving and decision-making abilities. The other choices do not assess the concept of judgment

19. Which of the following would best assess a client's judgment? A) Counting by serial sevens B) Discussing hypothetical situations C) Interpreting proverbs D) Spelling words backward

Ans: B Feedback: The client's judgment can be elicited by asking the client to discuss hypothetical situations, which would indicate one's ability to interpret one's environment and situation correctly and to adapt one's behavior and decisions accordingly. Counting by serial sevens and spelling words backward would assess the client's ability to concentrate. Interpreting proverbs would assess the client's abstract thinking.

14. A nurse can best assess a patient's ability to use abstract thinking by asking the patient which of the following questions? A) ìWhat would you do if you found a wallet containing $100 on the sidewalk?î B) ìWhat do I mean when I say, 'Don't sweat the small stuff?'î C) ìWhat are you going to do next time you hear voices?î D) ìCan you begin with the number 100 and subtract 7, and then subtract 7 again?î

Ans: B Feedback: The nurse assesses the client's ability to use abstract thinking, which is to make associations or interpretations about a situation or comment. The nurse usually can do so by asking the client to interpret a common proverb. If the client can explain the proverb correctly, his or her abstract thinking abilities are intact. 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. The nurse assesses the client's ability to concentrate by asking the client to perform certain tasks such as ìserial sevens.î

23. A nurse assesses that a depressed patient is lethargic during the day and does not actively participate in unit activities. The notes from the night shift document that the patient did not sleep well. The most probable interpretation of these data is A) the patient's medications are ineffective. B) the patient is being kept awake at night due to noise on the unit. C) the patient's depressed mood is impairing restful sleep patterns. D) the patient is resisting treatment recommendations to participate in unit activities

Ans: C Feedback: Emotional problems often affect some areas of physiologic function. Emotional problems can greatly affect eating and sleeping patterns. Therefore, the nurse must assess the client's usual patterns of eating and sleeping and then determine how those patterns have changed.

30. In the space of 5 minutes, the client has been laughing and euphoric, then angry, and then crying for no reason that is apparent to the nurse. This behavior would be best described as A) flight of ideas. B) lack of insight. C) labile mood. D) tangential thinking.

Ans: C Feedback: Moods that shift rapidly, displaying a range of emotions, are termed labile. Flight of ideas is manifested by excessive amount and rate of speech composed of fragmented or unrelated ideas. Lack of insight would be manifested by the lack of the ability to understand the true nature of one's situation and accept some personal responsibility for that situation. Tangential thinking would be manifested by wandering off the topic and never providing the information requested.

24. A nurse suspects that a patient is abusing alcohol while taking prescribed medications. The nurse plans to educate the patient on the dangers of mixing medicine with alcohol. Which of the following would be the most effective way for the nurse to approach this subject with the patient? A) Firmly inform the patient of the dangers of mixing medications with alcohol. B) Recommend a higher level of care, so the patient can be more closely supervised. C) Emphasize the importance of truthful information using a nonjudgmental approach D) Recognize the patient's right to self-determination and avoid addressing the subject.

Ans: C Feedback: Noncompliance with prescribed medications is an important area. If the client has stopped taking medication or is taking medication other than as prescribed, the nurse must help the client feel comfortable enough to reveal this information. The nurse also explores the client's use of alcohol and over-the-counter or illicit drugs. Such questions require nonjudgmental phrasing; the nurse must reassure the client that truthful information is crucial in determining the client's plan of care

31. Throughout the assessment, the client displays disorganized thinking, jumping from one idea to another with no clear relationship between the thoughts. The nurse would assess the client as having which of the following? A) Tangential thinking B) Ideas of reference C) Loose associations D) Word salad

Ans: C Feedback: The client displayed ideas that were loosely associated to one another. Tangential thinking is manifested by wandering off the topic and never providing the information requested. Ideas of reference are the client's inaccurate interpretation that general events are personally directed to him or her. Word salad is a flow of unconnected words that convey no meaning to the listener.

29. A client is admitted to the psychiatric unit and states, ìI am president of the largest corporation in the world. Everyone comes to me for advice.î The client is exhibiting which of the following? A) Flight of ideas B) Thought broadcasting C) Delusion D) Loose associations

Ans: C Feedback: The client has a delusion (a fixed false belief not based in reality) about his superiority over others. Flight of ideas is excessive amount and rate of speech composed of fragmented or unrelated ideas. Thought broadcasting is a delusional belief that others can hear or know what the client is thinking. Loose associations are disorganized thinking that jumps from one idea to another with little or no evident relation between the thoughts.

13. A patient is known to express tangential thinking. The nurse would assess for which of the following when interacting with the patient? A) Stopping abruptly in the middle of expressing himself B) Jumping from one idea to another C) Wandering off the topic and never answering the question D) Excessive and fast talking about an array of ideas

Ans: C Feedback: Tangential thinking is wandering off the topic and never providing the information requested. Thought blocking is stopping abruptly in the middle of a sentence or train of thoughts, sometimes unable to continue the idea. Loose associations are disorganized thinking that jumps from one idea to another with little or no evident relation between the thoughts. Flight of ideas is excessive amount and rate of speech composed of fragmented or unrelated ideas.

9. The nurse is assessing suicide potential in a patient who has expressed hopelessness. In what order does the nurse question the patient about suicidal thoughts? A. ìHow would you carry out this plan?î B. ìDo you have a plan to kill yourself?î C. ìAre you thinking of killing yourself?î D. ìHow do you plan to kill yourself?î

Ans: C, B, D, A Feedback: Suicide assessment should be performed through direct questioning. First, the nurse would need to know if the patient has ideations: ìAre you thinking about killing yourself?î; then if the patient has a plan, ìDo you have a plan to kill yourself?î If the patient has a plan, then the nurse would ask about method: ìHow do you plan to kill yourself?î If the patient has ideations, a plan, a method, then does the patient have access to that method the nurse asks, ìHow would you carry out this plan? Do you have access to the means to carry out the plan?î

11. A patient shows no facial expression when engaging in a game with peers during an outing at a park. The nurse uses which of the following terms when documenting the patient's affect? A) Blunt affect B) Restricted affect C) Broad affect D) Flat affect

Ans: D Feedback: Common terms used in assessing affect include blunted affect: showing little or a slow- to-respond facial expression; broad affect: displaying a full range of emotional expressions; flat affect: showing no facial expression; inappropriate affect: displaying a facial expression that is incongruent with mood or situation, often silly or giddy regardless of circumstances; restricted affect: displaying one type of expression, usually serious or somber.

10. The nurse best assesses a patient's memory by asking which of the following questions? A) ìDo you have any problems with memory?î B) ìWhat did you have for lunch yesterday?î C) ìDo you know where you are?î D) ìWho is the current president?î

Ans: D Feedback: The nurse directly assesses memory, both recent and remote, by asking questions with verifiable answers such as ìWhat is the name of the current president?î The nurse may not be able to verify the accuracy of the client's responses to questions such as ìDo you have any memory problems?î or ìWhat did you do yesterday?î Orientation refers to the client's recognition of person, place, and time.

22. Knowing that relationships with others are significant to mental health, the nurse effectively assesses a patient's family relationships through which of the following? A) ìDo you feel your family helps you?î B) ìHow many people are in your family?î C) ìWhom are you closest to in your family?î D) ìDescribe your relationships with your family.î

Ans: D Feedback: The nurse must assess the relationships in the client's life, the client's satisfaction with those relationships, or any loss of relationships. Open-ended questions and statements elicit more descriptive responses from the patient than direct questions.

8. When the nurse asks the client to restate the following in his or her own words, which sensorium and intellectual process is the nurse attempting to identify? The nurse states, ìA stitch in time saves nine.î A)The client's orientation B)The client's memory C)The client's ability to concentrate D)The client's ability to use abstract thinking

Ans:D Feedback: When the nurse states, ìA stitch in time saves nine,î and asks the client to restate it in his or her own words, the nurse is assessing the client's ability to use abstract thinking. The client's orientation is recognizing person, place, and time. The client's memory, both recent and remote, can be assessed by asking the client questions that have verifiable answers. The client's ability to concentrate can be assessed by asking the client to perform certain tasks including spelling the word ìworldî backward.

12. The patient states that he is 14 trillion years old and created the world. The nurse documents this statement as an example of which type of thinking displayed by the patient? A) Delusional thinking B) Ideas of reference C) Word salad D) Hallucination

Ans: A Feedback: A delusion is a fixed false belief not based in reality. Ideas of reference are client's inaccurate interpretation that general events are personally directed to him or her, such as hearing a speech on the news and believing the message had personal meaning. Word salad is flow of unconnected words that convey no meaning to the listener. Hallucinations are false sensory perceptions or perceptual experiences that do not really exist.

2. Which of the following factors influencing assessment is under the nurse's control? A) Client participation and feedback B) Client's health status C) Nurse's attitude and approach D) Client's ability to understand

Ans: C Feedback: The factors that influence assessment include client participation and feedback, client's health status, client's ability to understand, client's previous experiences, and misconceptions about health care. The only one of these that is under the control of the nurse is the nurse's attitude and approach.