PrepU Chapter 8

The nurse assesses a client with a history of bipolar disorder. The client tells the nurse that 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

A group of nursing students is reviewing material about assessing mental status. The students demonstrate a competent understanding of this assessment when they identify which as a component of cognitive functioning?

Orientation

When the mental health nurse asks the client, "Do you recall what month and year this is?" the nurse is assessing which part of the mental status examination?

Orientation

Which of the nurse's assessment questions would best identify whether the client has insight into the illness?

"Do you think that your illness prevents you from functioning well?"

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 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?"

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?" "What do you do when you have a problem?"

Which client statement best demonstrates a healthy relationship with family?

"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..."

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."

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

"What did you eat for breakfast today?"

The nurse is preparing to perform a psychosocial assessment of a client with schizophrenia. The client has a history of extreme aggression. What is the optimal setting for conducting an interview with the client?

A physician's intake room with other medical personnel nearby.

During an admission assessment, the nurse asks a client the meaning of the proverb, "People in glass houses should not throw stones." Which clinical feature is the nurse assessing?

Abstract reasoning

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

Abstract thinking

Which must be addressed to establish a trusting working relationship before proceeding with the assessment?

Client's feelings and perceptions

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

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?

Complete the assessment in several short interactions.

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

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

Which type of affect is represented by showing no facial expression?

Flat

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

What is the most significant benefit of using Beck's Depression Inventory to the practice of evidence-based nursing practice?

It is a standardized, reliable depression tool.

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.

Antisocial personality disorders are assessed with which tool?

Milton Clinical Multiaxial Inventory (MCMI)

Which characteristics should the nurse implement when conducting a psychosocial assessment?

Personal

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

During the assessment of a psychiatric client, the nurse documents "oriented x 3" on the client's assessment sheet. What does this indicate?

The client knows the correct date.

The nurse asks the client to explain the meaning of the proverb "a stitch in time saves nine." Which explanation given by the client indicates concrete thinking?

You should not forget to sew up holes in your clothes.

Which client behavior would the nurse document as being an automatism?

drumming one's fingers on the table top

Which type of hallucination is the most common?

Auditory

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

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, but who doesn't feel like that from time to time?"

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."

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 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."

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?"

Which question asked by the nurse indicates that the nurse is assessing the judgment of the client?

"What would you do if you found $10 on the side of the road?"

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

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 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.

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 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

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?

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

Under which component of the psychosocial assessment should the nurse document observations concerning the client's cultural considerations?

History

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

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?

Ideas of reference

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?

Incongruent

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

The Rorschach test is designed to provide what type of information about the client?

Preferred coping styles

Which would not be included as a purpose of the psychosocial assessment?

Previous compliance with treatment regimen

The nurse has been asked to assess a 54-year-old client's memory. Which technique would allow the nurse to evaluate recent memory?

Provide the client with three words and ask the client to recall the words several minutes later.

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

Which must the nurse consider a priority in the assessment of mental status?

Safety

A client with a psychiatric disorder is scheduled to undergo a personality test. Which explanations can the nurse provide when the client asks why the test must be completed? Select all that apply.

Self-concept Impulse control Defense mechanisms

Considering the nature of its content, which areas may be the most uncomfortable or difficult for the nurse to assess?

Sexuality

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

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 a psychosocial assessment of a client with a mental illness. What information should the nurse gather while taking the history? Select all that apply.

The age of the client The spiritual beliefs of the client

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

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

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.

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.

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

Thought process

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.

Which parts of the psychosocial assessment can be obtained by observing the client? (Select all that apply.)

hygiene and grooming posture unusual movements

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

During an assessment of a client with bipolar disorder, the nurse observes the client laughing loudly, then sobbing immediately after. How should the nurse most accurately describe this observation?

labile mood

The nurse is assessing a client who is depressed. The nurse asks the client, "What is your current address?" What is the nurse trying to assess?

memory

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

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

the anxious client