PNU 128 Videbeck PrepU Chapter 8: Assessment

When initiating an assessment, the nurse should use which type of questioning?

Open-ended questions

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

Which type of hallucination is the most common?

Auditory

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

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 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?

"Have you had a bad experience in the hospital before?"

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?

"Sometimes I feel like the world would be better off if I were dead."

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 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."

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

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

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

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

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

Asking the client to complete serial sevens assesses what?

Concentration

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

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

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"?

Incongruent

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

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

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

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

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.

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?

Slowness of body movements

Which tools would a nurse use to objectively assess a client's personality? Select all that apply.

Tennessee Self-Concept Scale (TSCS) Milton Clinical Multiaxial Inventory (MCMI) Psychological Screening Inventory (PSI)

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.

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 is not wearing a hearing aid. The nurse and the client speak different primary languages. The client has a cognitive impairment. The client is experiencing pain.

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

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

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.

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

the anxious client