PrepU Chapter 9 Questions
The patient has difficulty when the nurse asks him to say "No ifs, ands, or buts." The nurse understands that this may indicate a form of a) aphasia b) dysarthria c) mania d) disorientation
aphasia
A client states reports feeling like a burden to the family and totally worthless. Which response would be appropriate for the nurse to make to this client? a) "I'm sure that you aren't worthless." b) "Have you thought of killing yourself?" c) "Where does your family live?" d) "Everyone feels that way every now and then."
"Have you thought of killing yourself?" Explanation: Feelings of worthlessness and being a burden could indicate that the client is depressed and at risk for suicide. The nurse should ask if the client has ever thought of suicide. Asking about the family does not address the client's statement. Stating that the client isn't worthless or that everyone feels that way now and then minimizes the client's statement and does not assess if the client is experiencing suicide ideation.
Which of the following assessment questions is most likely to allow the nurse to assess a client's judgment? a) "Do you ever feel like you're hearing or seeing something that others can't see or hear?" b) "What do you think is responsible for your change in mood over the last several weeks?" c) "How do you plan to meet your responsibilities at work?" d) "In the past, what activities have you found help improve your mood?"
"How do you plan to meet your responsibilities at work?" Explanation: Asking the client to explain his or her response to financial, interpersonal, or logistical challenges can yield insight into the client's judgment. Asking the client to explain the cause of mood changes can help the clinician gauge the client's insight but not judgement, while asking about seeing and hearing things addresses perception, specifically hallucinations. Asking about previous successful coping strategies can be useful but does not assess judgment.
When assessing the client's ability to make sound judgments, what question should the nurse ask? a) "How many dimes are in one dollar?" b) "Can you keep track of your finances on an ongoing basis?" c) "How do you plan to pay rent if you lose your job?" d) "Do you eat breakfast?"
"How do you plan to pay rent if you lose your job?" Explanation: The nurse can usually assess judgment by noting the client's responses to family situations, jobs, use of money, and interpersonal conflicts. Asking if the client eats breakfast or can manage money are simple yes/no questions that are less likely to reveal data than asking for the client's plan of action in a hypothetical situation such as job loss. Asking how many dimes are in a dollar is a knowledge question.
A nurse is conducting an initial interview with a client who has paranoid delusions. What statement by the nurse can help to establish rapport as well as alleviate some of the suspicion the client may experience? a) "I will be asking you some questions, and they shouldn't be hard to answer." b) "Don't worry about the questions. Just answer to the best of your ability." c) "I will be asking you a series of questions that I ask of all of my clients." d) "I am going to ask you a series of questions, and I need you to answer me truthfully
"I will be asking you a series of questions that I ask of all of my clients." Explanation: It is important to establish rapport and trust prior to beginning the interview process. If there is not time to establish this rapport and trust, the nurse can begin the interview by letting the client know that the questions are being asked of all clients who are interviewed. Questions in mental health are designed to elicit information about various mental health risks and problems.
The nurse is caring for a woman who presents to the Emergency Department with complaints of abdominal pain, as well as cuts and bruises on the arms. Which comment by the patient describes intimidation? a) "He says I'm stupid even though I have a doctoral degree in history." b) "I have not seen my parents in 6 months; they live only 30 minutes away." c) "If my husband wants me to know something, he has the kids tell me." d) "My husband hits the kitchen wall with his fist just inches from my head."
"My husband hits the kitchen wall with his fist just inches from my head." Explanation: Intimidation makes the victim afraid through the use of looks, action, or gestures. Emotional abuse refers to the victim being put down or made to feel bad about them self. A perpetrator uses children to relay messages to exert power or control the victim. Isolation refers to controlling what victims do or read, whom they see or talk to, or where they go.
As part of the mental status examination, a nurse assesses the cognitive abilities of a client. Which question should the nurse ask to assess the judgment ability in the client? a) "When were you last hospitalized?" b) "When did you get your first job?" c) "What do you do if you have pain?" d) "How is an apple different from an orange?"
"What do you do if you have pain?" Explanation: To assess judgment ability in a client, the nurse should ask the client what he or she does when in pain. Asking about the first job and the last hospitalization helps in assessing remote memory. Asking the client about the difference between an apple and an orange elicits abstract reasoning.
When assessing an older adult about possible mistreatment, which of the following questions would be most appropriate to use initially? a) "Are you alone often at home?" b) "Did you ever signs papers you didn't understand?" c) "Have you ever been abused?" d) "What is a typical day in your life like?"
"What is a typical day in your life like?" Explanation: The nurse would begin to assess an older adult for possible mistreatment by asking the client to tell the nurse about a typical day in his or her life. Then the nurse would ask questions related to signing papers or being alone at home. Asking the client if he or she was ever abused would be nontherapeutic and block further communication. The client may be fearful about the ramifications of reporting the abuse if it is occurring
Which of the following would be most important for a nurse to keep in mind when assessing a client for possible physical abuse? a) Abuse rarely occurs in women younger than age 25 years. b) The abuse may start any time during a relationship. c) The abuse is often part of the presenting problem. d) Physical abuse usually involves only about 5% of women.
/"X vbcsaAaaS:::::::::::: The abuse may start any time during a relationship. Explanation: With physical abuse, it is important to remember that it can start at any time during a relationship. The abuse may not be part of the presenting problem for which the client is being seen, but may be cause or etiology of the presenting problem. Consistent risk factors for women at risk have not been identified. Therefore, both abused and non-abused women require routine screening by health care providers. The recommendation is that all female clients age 14 and older be screened for abuse when seen in emergency departments, urgent care centers, or primary health care clinics.
A nurse assesses a client who was physically assaulted by her boyfriend. The nurse learns that the client was stabbed in the thigh with a knife. After marking the area of injury on the body map, what score should the nurse document for this abuse? a) 6 b) 4 c) 5 d) 7
6 Explanation: The nurse should document the abuse score as 6, which indicates use of a weapon or a wound from a weapon. Beating up and severe contusion is given a score of 4, and head injury and internal injury is given a score of 5. A score of 7 is not possible on this scale.
During the mental status assessment of a new client, the nurse has asked the client to describe some of the similarities and differences between a tennis ball and a soccer ball. Despite adequate time and cuing, the client is unable to state any similarities or differences. The nurse should document what assessment finding? a) A lack of spatial orientation b) A deficit in abstract reasoning c) A deficit in practical intelligence d) An inability to follow directions accurately
A deficit in abstract reasoning Explanation: Asking a client to describe similarities and/or differences between two objects that are alike allows the nurse to assess the client's abstract reasoning. This is not synonymous with intelligence and does not providing insight into the client's ability to follow directions. This task is unrelated to spatial orientation.
A nursing instructor is discussing mental health assessments with students. In what situations would the instructor tell the students an acute mental health assessment is necessary? a) Any time a client is severely depressed b) When a client is assessed as delirious c) A situation in which the admitted client is diagnosed with schizophrenia d) A situation that involves danger of harm to self or others
A situation that involves danger of harm to self or others Explanation: An acute mental health assessment includes questions about harm to self or others. Acute situations include a risk for injury that accompanies psychotic states, depression, dementia, or delirium. It is important to ask the safety questions first and leave the presenting problem last. Clients with schizophrenia do not always present with risk for harm to self or others. A client with severe depression is not necessarily at risk of harm to self or others nor is a delirious client.
Which type of elder abuse involves leaving an older adult and no longer providing care for the individual? a) Abandonment b) Physical c) Emotional d) Neglect
Abandonment Explanation: The six types of elder abuse are physical (injury by hitting, kicking, pushing, slapping, burning, and so on), sexual (unconsented sexual act), emotional (harm of self-worth or emotional well-being), neglect (failure to meet the older adult's basic needs of shelter, food, and so on), abandonment (leaving an older adult alone and no longer providing care), and financial (illegally misusing money, property, or assets).
A nurse is examining a 16-year-old girl who is visibly distraught. The client has a bruise on her face and tells the nurse that her boyfriend got rough with her recently. On further questioning, the client tells the nurse that her boyfriend raped her. Which of the following is the priority nursing intervention at this point? a) Conduct a forensic interview b) Assess the client for signs of psychological abuse c) Determine whether the boyfriend was abused as a child d) Apply ice to the bruise on the client's face to reduce swelling
Conduct a forensic interview Explanation: If a nurse discovers signs of sexual abuse, including rape, on assessing a client, the nurse should conduct a forensic interview to gather data for potential legal proceedings. The other answers are of lesser priority than conducting a forensic interview.
When depression goes undiagnosed, what consequences occur eight times more frequently than in the general population? a) Bankruptcy b) Comorbidity c) Death d) Polyhedonia
Death Explanation: Failure to diagnose depression can have fatal consequences—suicide rates among patients with major depression are eight times higher than in the general population.
A older adult client is brought to the clinic by the client's daughter who voices concerns about changes in her parent's mental status. What behavior would the nurse look for to formulate a plan of care for dementia in this client? a) Defers to family members to answer questions directed to the client b) Appears oriented c) Uses appropriate and comprehensible words d) Repeatedly and apparently unintentionally follows instructions
Defers to family members to answer questions directed to the client Explanation: Some cues that a client may have dementia include seeming disoriented, being a "poor historian," deferring to a family member to answer questions directed to the client, repeatedly and apparently unintentionally failing to follow instructions, having difficulty finding the right words or using inappropriate or incomprehensible words, and having difficulty following conversations.
The nurse has completed the objective and subjective assessment of a client who required care after an incident of intimate partner violence. How should the nurse document the client's injuries? a) Describe the location of the injuries in detailed prose. b) Ask the client to write out a description of his or her injuries. c) Make a video recording of the client's skin surfaces. d) Document using an injury map.
Document using an injury map. Explanation: An injury map provides a clear, visual record of a client's injuries. This is superior in detail to verbal description, and video recordings are not typically used. The client should not be asked to write a description of his or her injuries.
A 36-year-old woman has been a client of a fertility clinic for 2 years and has now scheduled an appointment, believing that she is pregnant. The nurse who provides care at the clinic should screen the woman for intimate partner violence (IPV) at what time? a) During the woman's first prenatal visit to the clinic b) At a point when the woman states she is comfortable with being screened c) As soon as an appointment can be scheduled with the woman's partner d) Once the woman begins her second trimester of pregnancy
During the woman's first prenatal visit to the clinic Explanation: Screening for pregnant mothers should be started at the initial prenatal visit and continued periodically and postnatally. The partner should not be present during screening.
Which of the following is the most important skill a nurse needs when conducting a mental status assessment? a) Thorough assessment skills b) Effective listening skills c) Rapid interpretive skills d) Well-developed writing skills
Effective listening skills Explanation: Rapid interpretation, well-honed writing skills, and thorough assessment skills are moot without empathic and focused listening
The nurse is caring for a woman in the prenatal clinic who comments that she just cannot seem to get things "right" anymore at home and that her husband says she knows so little about life. Which type of abusive or controlling behavior is the woman describing? a) Intimidation b) Emotional abuse c) Minimizing d) Blaming
Emotional abuse Explanation: Emotional abuse refers to the victim being put down or made to feel bad about them. The perpetrator makes light of abuse and says abuse did not occur through minimizing and blaming. Intimidation makes the victim afraid through the use of looks, action, or gestures
A nurse has been asked to complete a mental status examination of a psychiatric-mental health client. Which of the following is included in this assessment? a) Questions regarding past behaviors b) A review of systems c) Evaluation of medication compliance d) Evaluation of insight and judgment
Evaluation of insight and judgment Explanation: The mental status examination is a central aspect of the psychiatric assessment process that assesses current cognitive and affective functioning through data collection on appearance, behavior, level of consciousness, speech, thought content and processes, cognitive ability, mood and affect, insight, and judgment. This assessment relies almost exclusively on observation rather than inquiry and is expected to change during treatment.
A nurse is conducting a mental status assessment of a 70-year-old male client who is being treated for depression. When assessing the client's facial expression and eye contact, the nurse should consider which of the following? a) Facial expression should be disregarded if the client has a diagnosed mental illness. b) The nurse should inform the client that his facial expression is being assessed. c) Reduced eye contact is an age-related physiological change. d) Eye contact is strongly influenced by cultural norms.
Eye contact is strongly influenced by cultural norms. Explanation: Eye contact and facial expressions, such as smiling, differ widely between cultures. Reduced eye contact is not an age-related physiological change. Informing the client that his facial expression is being assessed will likely confound the assessment results. Mental illness does not preclude assessment of eye contact and facial expression
A nurse has interviewed a client with a mental health disorder who does not speak English. The nurse enlists assistance from an interpreter. What is important for the nurse and interpreter to do after concluding the interview? a) Go into a private conference area and question the interpreter about the communication style and context of the client. b) Have the interpreter stay with the client while the nurse completes her documentation. c) Have the interpreter wait in the cafeteria while the nurse notifies the physician about the results of the interview. d) Encourage the interpreter to discuss the interaction with other members of the client's cultural community.
Go into a private conference area and question the interpreter about the communication style and context of the client. Explanation: After the interview, the nurse and interpreter should walk out of sight of the client and, in a private area, discuss the communication style and context of the interview. The nurse should establish if the client made sense, if sentences were structured properly and completely, if the client had difficulty with self-expression, if the client was oriented to reality, and if the nurse should be aware of any cultural practices or beliefs.
The nurse is assisting a female client who is being physically abused about a safety plan. The client prefers to return home. Which of the following would the nurse need to do first? a) Notify the neighbors about the abuse b) Give the client the number of a shelter c) Have the client complete a danger assessment d) Tell her to have her bags packed
Have the client complete a danger assessment Explanation: If a client says that she prefers to return home, ask her if it is safe for her do so and have her complete a danger assessment tool. After doing so, the nurse would then help her devise a safety plan including having a bag packed, and giving her contact information for shelters and groups. The client would be urged to tell neighbors about the abuse and ask them to call the police if they hear a disturbance. This would not be something the nurse would do
The nurse needs to assess the visual, perceptual, and constructional ability of a client. Which of the following assessments should the nurse use? a) Ask the client to pick up a pencil with the left hand, move it to the right, and then hand it to her b) Ask the client today's date c) Have the client draw the face of a clock d) Perform the SLUMS exam
Have the client draw the face of a clock Explanation: Having the client draw the face of a clock is one way to assess visual, perceptual, and constructional ability. The SLUMS exam tests cognitive function. Giving directions to the client to perform a series of tasks, such as picking up and manipulating a pencil, is an assessment of concentration. Asking the client today's date is an assessment of orientation
A nurse who provides care on a medical unit utilizes the Alcohol Use Disorders Identification Test (AUDIT) as part of the standard admission protocol. After obtaining a score of 9 from a recently admitted client, the nurse should recognize the possibility of which of the following? a) Hazardous and harmful alcohol use b) Alcoholism c) Imminent liver disease d) Acute pancreatitis
Hazardous and harmful alcohol use Explanation: Total scores of 8 or more on the AUDIT are recommended as indicators of hazardous and harmful alcohol use, as well as possible alcohol dependence. A score of 9 does not necessarily suggest liver disease, pancreatitis, or alcoholism.
A nurse is assigned to care for a client who has been physically abused by her stepfather. The nurse finds that client has an abuse score of 5 in her documents. Which of the following descriptions corresponds to the abuse score? a) Head injury and internal injury b) Beating up and severe contusions c) Threat of abuse by weapons d) Punching and kicking
Head injury and internal injury Explanation: Head injury and internal injury are rated a score of 5. An abuse score of 4 corresponds to beating up and severe contusions. Punching and kicking are given a score of 3. Threat of abuse by weapons is given a score of 1.
The nurse is caring for a woman who presents to the Emergency Department with complaints of abdominal pain, as well as cuts and bruises on the arms. While observing the interaction between the husband and wife, the nurse observes the husband shaking his fist at the wife. Which type of abusive or controlling behavior did the nurse observe? a) Coercion b) Emotional abuse c) Isolation d) Intimidation
Intimidation Explanation: Intimidation makes the victim afraid through the use of looks, action, or gestures. Emotional abuse refers to the victim being put down or made to feel bad about them. A perpetrator makes or carries out threats to do something to hurt victims through coercion. Isolation refers to controlling what victims do or read, whom they see or talk to, or where they go
A client arrives at the clinic accompanied by her husband. When the client is in the examination room she says to the nurse, "He loves me so much. He only lets me go out when he is with me because he says other men look at me." What type of behavior is this husband exhibiting? a) Isolation b) Privilege c) Coercion d) Intimidation
Isolation Explanation: Isolation is when someone is controlling what victims do or read, whom they see or talk to, or where they go, limiting their involvement outside of the home; it is a way of using jealousy to justify actions.
A nurse asks a client the following question: "What do you do if you have pain?" The nurse is assessing which of the following aspects of cognitive function? a) Abstract reasoning b) Memory c) Orientation d) Judgment
Judgment Explanation: Asking a client about what he or she does or would do if he or she has pain evaluates a client's judgment. Asking about the client's name, time, and place evaluates his or her orientation. Asking a client to compare and contrast things evaluates abstract reasoning. Asking the client about recent and past events evaluates memory
You are conducting an interview with a client suffering from schizophrenia. She says to you, "bunnies are cute as a button, buttons are on my shirt, shirts can be bought in a store." What is this type of thought process known as? a) Magical thinking b) Neologisms c) Ideas of reference d) Loose associations
Loose associations Explanation: In some cases a client presents several thoughts that don't make sense in conjunction with one another. This is often seen in clients with acute exacerbations of schizophrenia and is described as loose association
A victim of intimate partner violence tells a nurse, "I don't know how I'd live if I left my husband. And what about my children? I have no skills and haven't worked since I was a teenager." When developing the plan of care for this client, which nursing diagnosis would most likely apply? a) Anxiety related to the physical escalation of the violence b) Impaired parenting related to family violence c) Risk for violence related to inadequate coping abilities d) Low self-esteem related to lack of confidence in ability
Low self-esteem related to lack of confidence in ability Explanation: The client's statements indicate that her self-esteem is low due to her feelings of not being able to survive outside the violent relationship. The client may be anxious, but this anxiety would most likely be related to her low self-esteem, not to the escalation of the violence. Although impaired parenting might apply, the client's statements are more reflective of her feelings of low self-esteem, which would, in turn, contribute to her feelings about whether she was a good parent. The partner, not the client, would most likely have a nursing diagnosis of risk for violence.
During the health-history interview, which of the following components of cognitive function can the nurse quickly assess? a) Calculation and language b) Judgment and behaviour c) Memory and attention d) Abstract thinking and perceptions
Memory and attention Explanation: While gathering the health history, it is possible to quickly discern the client's level of alertness and orientation, mood, attention, and memory. As the history unfolds, the nurse will learn about the client's insight and judgment and any recurring or unusual thoughts or perceptions. Calculation, behaviour, and abstract thinking are less likely to emerge during this phase of assessment
A gerontologic nurse is assessing the speech of an older adult client. Which of the following would the nurse characterize as an expected assessment finding? a) Moderate pace b) Loud tone c) Rapid speech d) Repetition
Moderate pace Explanation: Normally, in older adults, responses may be slowed, but speech should be clear and moderately paced. Slow, repetitive speech is characteristic of depression or Parkinson's disease. Loud, rapid speech may occur in manic phases of bipolar disorder
A nurse reviews the documentation of the nurse on the previous shift and finds that the client was obtunded. The nurse anticipates that the client will respond to stimulation in what manner? a) Opens eyes to a loud voice and answers with confusion b) Opens eyes, answers the question, and falls back to sleep c) Does not respond even to painful stimuli d) Awakens only to a vigorous shake or painful stimuli
Opens eyes to a loud voice and answers with confusion Explanation: The obtunded client opens the eyes to a loud voice and answers with confusion. If the client opens eyes, answers the question, and falls back to sleep, the client is said to be lethargic. If the client awakens to a vigorous shake or painful stimuli, he is in the stupor stage. If the client is unresponsive even to painful stimuli, the client is in a coma.
A client expresses to the nurse visiting her home that her husband has threatened to kill her. The nurse understands that threats of harm and intimidation are which type of abuse? a) Psychosocial b) Physical c) Sexual d) Economic
Psychosocial Explanation: Threat to harm and intimidation are examples of psychosocial abuse. Economic abuse includes forging signatures. Physical abuse includes direct physical violence with harm inflicted. Sexual abuse includes fondling.
The nurse is conducting a health history of a patient at the local community mental health clinic. Which assessment tool would the nurse administer to determine the suicide risk for the patient? a) CAGE Questionnaire b) SAD PERSONAS c) HOPE Assessment d) Mini-Mental Status Exam
SAD PERSONAS Explanation: The nurse uses the SAD PERSONAS to assess the suicide risk for a patient. The nurse uses the CAGE Questionnaire to assess substance use. The HOPE Assessment tool assesses spiritual beliefs. The Mini-Mental Status Exam assesses cognitive function.
Susanne is a 27-year-old woman who has had headaches, muscle aches, and fatigue for the last 2 months. The nurse has completed a thorough history, examination, and laboratory workups, the results of which are normal. What would the next action be? a) Screening for depression b) Telling the client nothing has been found c) A referral to a neurologist d) A referral to a rheumatologist
Screening for depression Explanation: Although the nurse may consider referrals to help with diagnosis and treatment of this client, screening is a time-efficient way to recognize depression. This will allow her to be treated more expediently. The nurse may tell the client that no answer is clear yet, but also that he or she will not stop investigating until the client has gotten the help she needs. Research has shown that health care providers routinely fail to screen for depression
The nurse is assessing an older adult client's mental status. Consistently, the client pauses after the nurse poses a question, but then the client provides a response that is correct or appropriate. How should the nurse best interpret this characteristic of the client? a) The client may be trying to anticipate the nurse's desired response. b) The client is displaying a sign of early Alzheimer's disease. c) Slight delays in mental processing are normal in older adults. d) The client may be experiencing an early sign of delirium.
Slight delays in mental processing are normal in older adults. Explanation: Slight delays in information processing are considered to be an age-related change and are not necessarily pathologic. There is no indication that the client may be trying to anticipate the nurse's desired response.
The patient states, "I don't know why God as abandoned me; I am a good person." The nurse suspects the patient is at risk for: a) Psychosis b) Suicide c) Confabulation d) Delusions
Suicide Explanation: The patient who does not experience a sense of hope for the future may be at risk for suicide. Confabulation refers to making up answer to cover for not knowing. Psychosis occurs when the patient has difficulty distinguishing reality from internal perceptions. Delusions are false beliefs the person holds despite lack of supportive evidence.
An older adult client scores a 15 on a Mini-Mental Status Examination (MMSE). What does this score tell the nurse about the client? a) The client's score is in the normal range b) The score is borderline, so another examination is needed c) The score is inconclusive and the test must be repeated d) The client's score indicates cognitive impairment
The client's score indicates cognitive impairment Explanation: Taking only 5 to 10 minutes to administer makes the MMSE easy to use with elderly clients or clients with poor attention span. A score of 24 to 30 is in the normal range. A score of 23 or lower on the MMSE indicates cognitive impairment.
The nurse begins the physical examination of a newly admitted client by assessing the client's mental status. What is the nurse's best rationale for performing the mental status exam early in the assessment? a) The client's fears about having a serious illness may be alleviated by the results of the exam. b) The exam can provide clues about the validity of the client's responses now and throughout. c) The exam provides data about mental health problems that the client may be afraid to report. d) The client will be less anxious early, providing the nurse with more accurate and reliable data.
The exam can provide clues about the validity of the client's responses now and throughout. Explanation: Assessing mental status at the very beginning of the head-to-toe examination provides clues regarding the validity of the subjective information provided by the client during the history and throughout the exam. Thus, it is best to determine the validity of client responses before completing the entire physical exam only to learn that the client's answers to questions may have been inaccurate. Assessing mental status first will not necessarily lessen a client's anxiety or fears about a serious illness. The exam can provide data about mental health problems. However, this is not the primary reason for performing the exam at the very beginning.
A nurse suspects abuse on a client with a fractured forearm, who does not want to discuss how the fracture happened. What is something the nurse could do to let the client know the client is not alone? a) The nurse can contact a social worker so the woman will be removed from the situation b) The nurse can call the authorities and have the abuser arrested c) The nurse can educate the client about the high prevalence of human violence d) The nurse can ask more questions so the client feels it is necessary to talk about it
The nurse can educate the client about the high prevalence of human violence Explanation: When a nurse asks about violence, some clients decide that the time, setting, or health care professional is not a comfortable fit for them to disclose their story. In such cases, violence-screening questions provide an opportunity for the nurse to let clients know about the high prevalence of human violence so that they do not feel singled out or alone. Contacting a social worker to remove the woman from the situation or calling the authorities to have the abuser arrested is not an appropriate response.
The nurse uses the SAD PERSONAS to assess the suicide risk for a patient. The total score was 3. Which interpretation by the nurse is correct? a) The patient is at high risk for suicide. b) The patient is at low risk for suicide. c) The score suggests suicide may be a problem. d) Further evaluation is needed to make a determination.
The patient is at low risk for suicide. Explanation: Scores on the SAD PERSONAS can range from 0 to 10. Higher scores indicate greater suicide risk. A score of 3 indicates relatively low risk.
The nurse is admitting a 23-year-old woman to the acute care mental health unit. Physical examination reveals vertical cuts on the patient's forearms approximately 6 inches long bilaterally. On the care plan, the nurse enters a nursing diagnosis of Risk for Self-Mutilation. What would be the most immediate nursing intervention for this patient? a) Place in a private room. b) Use only plastic eating utensils. c) Treat medical injuries. d) Place the patient on 1:1 nurse/patient care.
Treat medical injuries. Explanation: For the risk for self-mutilation medical treatment needs to be provided for injuries.
A nurse is interviewing a child who is suspected of being abused. Which of the following would be most appropriate? a) Ask questions that are highly detailed b) Use simple yes and no questions regardless of the child's age c) Use direct, nonleading questions d) Offer the child a reward for answering questions
Use direct, nonleading questions Explanation: When interviewing children, the nurse should use questions that are direct to extract information without being leading. The less information supplied in the questions and the more information provided by the child increases the credibility of the information gathered. Questions need to be formulated based on the child's understanding and developmental stage. Children should not be coerced to answer questions by being offered a reward to do so
The CAGE assessment is used by the nurse to determine if further assessment is needed. The nurse may assess that it is highly likely the client has a problem and would seek additional assessments if the client a) answered "yes" to one of the four CAGE questions. b) answered "no" to three of the four CAGE questions. c) answered "no" to all of the four CAGE questions. d) answered "yes" to three of the four CAGE questions.
answered "yes" to three of the four CAGE questions. Explanation: The CAGE assessment is a quick questionnaire used to determine if an alcohol assessment is needed. If two or more of these questions is answered yes, then further assessment is advised
The nurse notes that a client hesitates when responding to questions. With which part of the mental health assessment is this client having difficulty? a) mood b) insight c) orientation d) attention
attention Explanation: A client having difficulty with attention has difficulty responding to questions. Mood is a sustained emotion that provides information about the client's view of the world. Insight is an awareness that symptoms or behaviors are normal or abnormal. Orientation is an awareness of person, place, and time
Which nursing action is essential in caring for the victim of violence? Select all that apply a) Respect autonomy of the victim b) Minimizing confidentiality c) Validating the abuse experience d) Trivializing the abuse e) Normalizing victimization
• Validating the abuse experience • Respect autonomy of the victim Explanation: The essential nursing action when caring for the victim of violence is validating the abuse experience, maintaining confidentiality, respecting the autonomy of the victim, acknowledging the abuse, and avoiding normalization of the victimization.
A client known to a health clinic arrives wearing soiled clothing with matted hair and streaks of dirt on the face and hands. What should this client's appearance suggest to the nurse? a) obsessive-compulsive disorder b) depression c) mania d) Parkinson's disease
depression Explanation: Grooming and personal hygiene may deteriorate in depression. Mania is characterized by elation and euphoria. There is no particular change in appearance with mania. The client with Parkinson's disease will demonstrate a flat affect. There is no particular change in appearance in Parkinson's disease. Excessive fastidiousness may be seen in obsessive-compulsive disorder
If a nurse suspects that a client is depressed, asking the client about any suicidal thoughts: a) will stimulate thoughts of suicide b) will stimulate clients to act on suicidal ideation c) is important and will not stimulate the thought of suicide d) is important, but not an early priority
is important and will not stimulate the thought of suicide Explanation: Many clinicians avoid the topic of self-harm or suicide because they worry that broaching it will implant the idea in the client's mind. There is little risk that talking about suicide with someone who is not already thinking about it will prompt him or her to do it. Consequently, the issue should be prioritized and directly addressed with clients who are or may be depressed.
An experienced nurse is training a novice nurse on how to perform mental health assessments. The novice nurse asks the colleague exactly what "mental health" means. The experienced nurse responds by citing the 2010 definition of the World Health Organization (WHO), which states that mental health requires which of the following components? Select all that apply. a) An IQ that is 100 or greater b) Ability to cope with the normal stresses of life c) Ability to earn a high school diploma or equivalent d) Ability to work productively e) Ability to make a contribution to one's community f) A state of well-being
• Ability to cope with the normal stresses of life • Ability to work productively • Ability to make a contribution to one's community • A state of well-being Explanation: WHO defines mental health as "a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community." Neither an IQ of 100 or greater nor the ability to earn a high school diploma or equivalent is required for mental health.
Which nursing assessment data cue is supportive of a diagnosis of impaired social interaction? (Select all that apply.) a) Loneliness b) Inaccurate interpretation of surroundings c) Argues with family d) Poor communication skills e) Avoid peers and others
• Argues with family • Poor communication skills • Avoid peers and others Explanation: Assessment data supporting a nursing diagnosis of impaired social interaction include poor communication skills, arguing with family and others, and avoiding peers and others. Inaccurate interpretation of surroundings is supportive of a nursing diagnosis of altered thought processes. Individuals at risk for suicide express loneliness.
