Chapter 8: Assessment Prep U

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

the anxious client

Which type of hallucination is the most common? Gustatory Auditory Olfactory Visual

Auditory

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 Incongruent Congruent Restricted

Incongruent

Which statement by the client best demonstrates a healthy relationship with family? My brother and I like to take a walk when he visits." "I want to put on clean clothes for my sister's visit." "I feel better after I visit with my Mom." "My family has always tried their best to help me."

"I feel better after I visit with my Mom."

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..." The client makes eye contact with the nurse but does not respond verbally. "Well, that's certainly the end of that." "Warning, warning, watch your back."

"I might. I'll give it some..."

During assessment of a client with schizophrenia, the nurse notes the client has ideas of reference. Which statement of the client would have led the nurse to conclude this? "My dead friend is putting these ideas in my mind." "My family is taking my thoughts away. I am unable to think now." "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."

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

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." "My dead friend is putting these ideas in my mind." "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."

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

Which client statement indicates the most insight into his or her issue with auditory hallucinations? "I take medication so the voices will stop." "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."

"The voices aren't real but it's hard to ignore them."

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? "You are welcome to share any information that you think would be helpful." "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."

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 Mood Temperament Demeanor

Affect

While conducting an interview with a psychiatric-mental health client, the nurse is observing the client's facial expressions and nonverbal cues. What are these physical manifestations known as? Affect Temperament Demeanor Mood

Affect

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

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 adult attention deficit hyperactivity disorder Clients with post-traumatic stress disorder Clients with depression

Clients with adult attention deficit hyperactivity disorder

A nurse is assessing a hospitalized client who is hearing voices due to psychosis. The client is easily distracted, and this is creating a barrier to completing the assessment. What is the most effective way for the nurse to proceed? Wait for psychiatric medication to take effect. Ask another nurse to attempt the assessment. Complete the assessment in several short interactions. Use observation only to collect client information.

Complete the assessment in several short interactions.

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? A review of systems Evaluation of medication compliance Evaluation of insight and judgment Questions regarding past behaviors

Evaluation of medication compliance

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? Circumstantiality Incoherence Flight of ideas Derailment

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? Comprehensive Secondary Screening Focused

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? Illusion Perseveration Hallucination Fugue state

Hallucination

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 Magical thinking Thought broadcasting Obsession

Ideas of reference

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 client's self-awareness. It will be beneficial to the interaction by increasing the nurse's focus and attention. It will be beneficial to the interaction by increasing the client's focus and attention. It will be detrimental to the interaction by decreasing the nurse's focus and attention.

It will be detrimental to the interaction by decreasing the nurse's focus and attention.

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? Clang association Echolalia Neologism Loose associations

Loose associations

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 Neologisms Ideas of reference Magical thinking

Loose associations

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? Ability to describe the problem Recollection of the problem's related details Fine motor skills Physical appearance

Physical appearance

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. Repeats the phrase, "Mary had a little lamb," whenever feeling stressed. Fails to complete what the client is saying as if distracted. Answers the question, "May we talk?" by responding, "Walk the walk."

Provides long, irrelevant explanations when asked why the client abuses alcohol.

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. Provides long, irrelevant explanations when asked why the client abuses alcohol. 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.

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? Speaking meaningless words Maintenance of an awkward posture for a long time Slowness of body movements Repeated tapping of the foot

Slowness of body movements

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. Write the names of family members. Spell "America" backward. Interpret the meaning of a proverb.

Spell "America" backward.

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 full range of emotional expressions. The client displays a facial expression that is incongruent with mood. The client displays no facial expression. The client displays only one type of facial expression.

The client displays only one type of facial expression.

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 client's right to privacy The amount of lighting in a given location

The client's right to privacy

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 abnormal sensory experiences or misperceptions component The general assessment and motor behavior component The history component

The general assessment and motor behavior component

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? Challenges faced with social networks The number of networks The length and quality of relationships The proximity of the networks to the client

The length and quality of relationships

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 Challenges faced with social networks The proximity of the networks to the client The number of networks

The length and quality of relationships