Psych Prep U on Assessment

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?" Open-ended questions are those questions that require a detailed descriptive answer. Questions like "how can we help you" and "how did your problems begin" cannot be answered in a word or a sentence, but require a detailed explanation. Open-ended questions need to be asked in order to understand the client's perception of the situation. Questions like "are you feeling better today," "is there something wrong with you," and "when was your last visit in the psychiatric facility" require a very precise answer. These are the examples of closed-ended questions. These questions do not allow the client to give more information.

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?" Self-concept is the way one views oneself. It includes perception of body image, coping skills, social image, and academic and occupational image. By asking "how do you think you look today," the nurse is trying to understand the client's body image. By asking "what do you do when you have a problem," the nurse is trying to understand the client's method of coping with problems. Thus, these questions indicate that the nurse is assessing the self-concept of the client. By asking "which country do you live in," the nurse is assessing the memory of the client. By asking "are you thinking about killing yourself," the nurse is assessing if the client has suicidal ideation. By asking "what time is it," the nurse is assessing the client's orientation.

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..." Blocking refers to a sudden stoppage in the spontaneous flow or stream of thinking or speaking for no apparent external or environmental reason. Clanging involves perceived similarities in meaning between words of similar sound ("morning"; "warning"). Mutism is the absence of a verbal response.

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." Ideas of reference are the inaccurate perception of the client that general events are personally directed to him or her. Thinking that the news of the terrorist is a warning to the client indicates that the client has ideas of reference. The delusion that other people (dead friend) are putting thoughts in the client's mind is referred to as thought insertion. The delusion that others are taking the client's thoughts away is referred to as thought withdrawal. The delusion that others know what the client is thinking is referred to as thought broadcasting.

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." Initially, clients perceive hallucinations as real experiences, but later in the illness, they may recognize them as hallucinations. Insight is the ability to understand the true nature of one's situation and accept some personal responsibility for that situation. The correct option is the only one that demonstrates these abilities.

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?" Asking the client to give the client's name, identify the client's location, and name the day of the week assess orientation. Asking the client to relate what the client ate for breakfast assesses short memory, and asking the client to count backward assesses intellectual abilities, neither of which is a reflection of orientation.

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?" Judgment is the ability to understand one's environment and situation correctly and to adapt one's behavoir and decisions accordingly. To determine if the client is able to make just decisions, the nurse should present a hypothetical scenario like "what would you do if you found $10 on the side of the road?" Questions such as "in which country do you live" should be asked while assessing the memory of the client. Questions such as "could you please repeat the days of the week backward" should be asked while assessing the client's ability to concentrate. Questions such as "could you please explain the meaning of the proverb 'barking dogs seldom bite'?" should be asked by the nurse while assessing the abstract thinking abilities of the client.

The nurse is preparing to assess a client's remote memory. Which questions would be most appropriate for the nurse to ask?

"When did you get your first job?" Asking the client about when he or she got his or her first job gives information about the client's remote memory or past events. Asking about what the client ate in the past 24 hours or what he or she did last evening provides information about the client's recent memory. Asking how an apple and orange are similar tests abstract reasoning.

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." The client does not want the family to know information regarding their condition. The client's wishes must be upheld unless there is the threat of harm, in which case information can be shared without the client's consent. In this context, however, that is not the case. The nurse's best response is to ask the family to share anything that they think would inform the assessment and treatment of the client.

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. Interviews for psychosocial assessment should ideally be conducted in an environment that is quiet and free from distractions. Since the client is aggressive, the nurse should perform the interview with other health care personnel in the immediate area. They would be of help in case the situation becomes heightened for either the nurse or client. Thus, for this client, the interview should be performed in a physician's intake room or conference room with other medical personnel nearby.

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

Abstract thinking To evaluate abstract thinking, the nurse can ask the client to interpret a common proverb such as "a stitch in time saves nine." Concrete thinking occurs when a client gives literal translations. Concentration relates to the ability to stay on task while memory is recall of past events.

The nurse is preparing to perform a psychosocial assessment of the client. Which describes the most effective approach taken by the nurse? Select all that apply.

Accepting Objective While performing a psychosocial assessment, the nurse should have an accepting and objective or straightforward approach with the client. If the nurse expresses personal opinions to the client or is judgmental, the client may be reluctant to share sensitive information. The nurse should not be emotionally unstable as this would hinder the nurse's ability for proper assessment. If the nurse asks short and crisp questions, the client may think the nurse is hurried and is not interested in listening. This behavior may prevent the client from providing complete information to the nurse.

When the nurse asks, "How would you carry out this plan?" the nurse is questioning which component of a suicide assessment?

Access A question with regard to suicide assessment and access would include "How would you carry out this plan?"

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 Affect refers to a person's emotional expression (in this case, the manner in which the client talks about the client's experiences). Feelings are emotional states or perceptions. Blocking is the interruption of thoughts. Moods are prolonged emotional states expressed by the 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 Affect refers to the physical manifestations of the client's mood and is assessed by observing the client's facial expression in conjunction with other nonverbal clues.

When completing a physical assessment of an individual's response to stress, the nurse should observe and inquire about what?

Appetite and sleep Biologic data are essential for analyzing an individual's physical responses to stress, coping efforts, and adaptation. Nurses should pay particular attention to alterations in vegetative functions (e.g., appetite and eating patterns, sleep, energy level, and sexual activity).

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.

Which type of hallucination is the most common?

Auditory

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 Clients with attention deficit hyperactivity disorder have reduced attention span, which in turn causes disorganization in their thought processes. These clients may be unable to answer open-ended questions that require a detailed explanation. Thus, the nurse should try to include the maximum number of closed-ended questions in the assessment. Disordered thought is not commonly seen in depression, post-traumatic stress disorder, or antisocial personality disorder. More open-ended questions should be asked of these clients in order to understand their perception of their illness.

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 Assessment is the first standard of practice during which the nurse collects comprehensive data from the client. Diagnosis is arrived at after analyzing the data obtained. Outcome identification is done after diagnosing the client's illness. Planning an alternative to attain an outcome is performed after establishing outcome identification.

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. Clients exhibiting psychotic thought processes or impaired cognition may have an insufficient attention span or may be unable to comprehend the questions being asked. The nurse may need several contacts with such clients to complete the assessment. Observing the client is a very important aspect of the assessment, however, it is not the only part. The nurse must interact with the client and engage in verbal communication in order to complete a full assessment. Psychiatric medication can take a period of time to have an effect. The assessment should be completed in a timely manner. In addition, understanding how a client presents when in a psychotic state can assist in planning for future acute psychiatric presentations. It is within each nurse's scope to complete the assessment. The nurse has not been ineffective in this case, the client's condition at the present moment is not favorable for conducting the assessment all at once.

Asking the client to complete serial sevens assesses what?

Concentration Asking the client to complete serial sevens is assessing the client's ability to concentrate. Orientation refers to the client's recognition of person, place, and time. 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 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?

Data collection Data collection refers to the objective data that nurses observe and the subjective data that clients report. Assessment more specifically refers to a health care provider's interpretation and prioritization of collected data.

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 Evaluation is the assessment of a client's progress after an identified plan has been implemented. Planning is done after diagnosis and just before implementing therapeutic strategies. Assessment is the initial data collection from the client. Professional practice evaluation is the evaluation of nursing care against professional standards.

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 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.

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 The client's affect, or facial expression, would be described as "flat." Labile affect is the abnormal fluctuation or variability of one's expressions, such as repeated, rapid, or abrupt shifts. Constricted affect relates to a reduction in one's expressive range and intensity of affective responses. Blunted affect is a severe reduction or limitation in the intensity of one's affective responses to a situation

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 Flight of ideas is the expression of multiple, unrelated ideas in a string of statements. Neologisms are new words, circumstantiality is when the client speaks about topics that are loosely related with each other, and perseveration is the repetition of words or ideas over and over.

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 This represents flight of ideas, because the ideas are connected in some logical way. Derailment, or loosening of associations, has more disconnection within clauses. Circumstantiality is characterized by the patient speaking "around" the subject and using excessive detail, though thoughts are meaningfully connected. Incoherence lacks meaningful connection and often has odd grammar or word use. Although severe flight of ideas can produce this condition, evidence is not present in this vignette.

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 focused assessment includes the collection of specific data regarding a particular problem as determined by the client, a family member, or a crisis situation. A comprehensive assessment is broader in scope, while a screening assessment aims to identify the presence or absence of health problems.

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 A hallucination is a subjective sensory perception in the absence of real external stimuli. The client can hear, see, smell, taste, or feel something that does not exist in reality. In this case, the client's sister died and cannot be speaking to the client, although in the client's mind the client can hear her. This is an example of an auditory hallucination, but hallucinations can occur with any of the five senses

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?" If the client is reluctant to engage with the nurse for the assessment, it is likely due to a previous unsatisfactory experience with the health care system. A sign that the client is reluctant is that the client was brought to hospital by a family member. The nurse must address the client's feelings and perceptions to establish a trusting working relationship before proceeding with the assessment.

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

History The assessment information concerning culture is documented under the History component of the psychosocial assessment.

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 Ideas of reference include beliefs that external events have personal significance. Magical thinking includes the belief that thinking about something will make it happen. Thought broadcasting includes the belief that thoughts are known by others. Obsessions include unwanted repetitive thoughts.

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 The client falsely believes that she is responsible for catastrophic events unrelated to her. The nurse would document "ideas of reference" and quote the patient's statements. Believing that the wallpaper contains secrets is not a misperception of a real stimulus or an illusion. The client believes she is responsible for the events she is describing. Hallucinations are false sensory perceptions. In a hallucination, the client sees, smells, hears, tastes, or feels something for which there are no external stimuli. While the ideas of reference would be considered a delusion, no religious or spiritual theme is involved with the patient's false beliefs.

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 The correct answer is incongruent affect or lack of harmony between one's voice and movements with one's speech or verbalized thoughts. Blunted affect is a severe reduction or limitation in the intensity of one's affective responses to a situation. Flat affect describes absence or near absence of any signs of affective responses. Labile affect is the abnormal fluctuation of one's expressions.

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. Evidence-based practice promotes the use of standardized, valid, and reliable tools, guidelines, and protocols in mental health, based on aggregate data. Tools based on the majority of the population presume similarity and stability over time. While the other options are true statements about this screening tool, none are associated with evidence based practice.

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. Anxiety on the nurse's part is one of many factors that can influence outcomes. It is widely recognized that as anxiety increases, the person's ability to focus narrows. Nurses who begin interviews in a highly anxious state may find it difficult to focus on thorough data collection or interpretation

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 The nurse may assess a client's judgment by asking the client hypothetical questions, such as "If you found a stamped addressed envelope on the ground, what would you do?"

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 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 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 Looseness of association is a disturbance of thinking shown by speech in which ideas shift from one unrelated or minimally unrelated subject to another. Echolalia is the parrot-like repetition of overheard words or phrases. Clang association is a type of thinking in which the sound of a word (rhyming) substitutes for logic during communication. Neologism describes the use of a new word or combination of several words coined or self-invented by a person and not readily understood by others.

Antisocial personality disorders are assessed with which tool?

Milton Clinical Multiaxial Inventory (MCMI) Only the Milton Clinical Multiaxial Inventory (MCMI) is designed to assess specifically for personality disorders.

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

Open-ended questions

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 Cognitive abilities include orientation, concentration, recent and remote memory, abstract reasoning, judgment, visual perception, and constructional ability. Posture, speech, and thought processes are components of a comprehensive mental status examination.

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

Personal The nurse must conduct the assessment professionally, in a nonjudgmental way, and matter-of-factly while not allowing personal feelings to influence the interview.

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 When assessing a client suspected of being depressed, the psychiatric nurse pays close attention to the client's affect and physical appearance. An ability to describe a problem, recall details, and use fine motor skills are not typically the first things to pay attention to when assessing a client suspected of being depressed.

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

Preferred coping styles The Rorschach test involves 10 stimulus cards of inkblots; client describes perceptions of inkblots; narrative interpretation discusses areas such as coping styles, interpersonal attitudes, characteristics of ideation. The other options are examples of Beck's Depression Inventory, Milton Clinical Multiaxial Inventory, and the Tennessee self-Concept Scale.

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

Previous compliance with treatment regimen The previous amount of compliance with the treatment regimen would not be included as a purpose of the psychosocial assessment. Current emotional state, behavioral function, and mental capacity are included in the psychosocial assessment.

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. Immediate memory refers to the ability to retain information presented within the last several minutes. Nurses may ask clients to repeat three words and then recall those three words several minutes later. Recent memory refers to the client's ability to recall information from within the past few weeks, while remote memory involves recall of events from many years ago

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. With circumstantiality, the person gives much unnecessary detail that delays meeting a goal, stating a point, or answering a question. This impairment may be found in clients who abuse substances. The other options provided do not provide unnecessary details and thus are not examples of circumstantiality

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 Insight is defined as self-understanding, or the extent of one's understanding about the origin, nature, and mechanisms of one's attitudes, behavior, and/or condition. Thus, asking a client how schizophrenia has affected his or her life is an example of assessing reflective thinking. Critical thinking (determining the meaning and significance of what is observed or expressed), intellectual ability (a person's ability to use facts comprehensively), and concrete thinking (seeing each situation as unique and lacking the ability to generalize from the similarities between situations) are not the

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

Safety The most important priority in conducting a mental health assessment interview is determination of the client's safety toward self, toward others, and from others.

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 Personality tests reflect the client's personality in areas like self concept, impulse control, and defenses used. The cognitive abilities and the intellectual functioning of the client are assessed using intelligence tests.

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 Slowing of thought processes and bodily movements is referred to as psychomotor retardation. Repeated tapping of foot is referred to as automatism which is often caused due to anxiety. Speaking words that are only meaningful to the client and nobody else is referred to as neologisms. Maintenance of an awkward posture for a long time is an abnormal behavior and is referred to as waxy flexibility.

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 To assess the concentration of the client, the nurse should ask the client to spell "America" backward. This activity requires a good amount of concentration. Interpretation of a proverb or idiom is the task used to determine the use of abstract thinking by the client. Explaining the perception of inkblot cards is the Rorschach test and is useful to understand the coping styles, interpersonal attitudes, and characteristics of ideation of the client. Asking the client to write the names of family members is a task useful for assessing the memory of the client.

During an assessment, which would be the most important question topic?

Suicidal ideation The client's safety is a priority. Asking clients clearly and directly about suicidal ideation is essential.

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 he Rorschach Test is a projective personality test. It includes the use of 10 stimulus cards with inkblots. The client has to describe perceptions of inkblots. This test is useful to understand the coping styles, interpersonal attitudes, and characteristics of ideation. The Thematic Apperception Test uses 20 stimulus cards with pictures. The client tells a story about the picture. The Tennessee Self-Concept Scale and the Psychological Screening Inventory are objective personality tests. The Tennessee Self-Concept Scale includes 100 true-false questions that provide information on 14 scales related to self-concept. The Psychological Screening Inventory consists of 103 true-false questions. The result of the test indicates whether the client needs psychological help.

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 restricted affect indicates that the client displays only one type of facial expression, usually a serious expression. Displaying no facial expression is referred to as a flat affect. Displaying a full range of emotional expressions is indicative of a broad affect. Displaying a facial expression that is incongruent with mood is referred to as inappropriate affect.

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 The fewer tasks the client competes accurately, the greater the cognitive deficit. None of the other options provide a plausible conclusion.

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. Disturbance in functional status, or activities of daily living, is the most important factor in determining whether or not a mental disorder is present. Other data in the answers listed could be present even in the absence of mental disorder.

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 The client's right to privacy is an essential setting consideration. It is an ethical responsibility of the nurse as well as a legal right of the client. Nurses must make critical clinical judgments about the optimal setting that maintains privacy while also ensuring safety

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 Constant rubbing of the hands is a type of unusual movement or mannerism. This finding should be documented under general assessment and motor behavior. This abnormal motor behavior is not documented in the history, mood and affect, or abnormal sensory experiences or misperceptions.

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 Social assessment also includes identification of the person's social network. The nurse should elicit the information about the size and extent of the network, both relatives and nonrelatives, and the length and quality of the 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. An apparent disconnect between content and the client's behavior should prompt the nurse to explore the matter more deeply. While grieving is indeed an individual process, it would be imprudent for the nurse to deny the incongruity between the topic and the behavior. The client's statement heightens the relevance of mental status in the assessment, but the priority would be to explore the matter more deeply and ask follow-up questions. It would be presumptuous to conclude that the client is depersonalizing the spouse's death.

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 the client makes specific threats or has a plan to harm another person, health care providers are legally obligated to warn the target of the threats. Legally this is called duty to warn. Although the nurse must document the session thoroughly and can meet with the client again the next day, this should not be the nurse's first action. The nurse should eventually review coping strategies for anxiety and set new therapeutic goals; however, duty to warn is the priority.

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. When a client always gives a literal translation of a comment or situation, it indicates that the client uses concrete thinking. The literal translation of the proverb "a stitch in time saves nine" is that "you should not forget to sew up holes in your clothes." Thus, this statement of the client indicates concrete thinking. The statement "one should always stitch before nine o'clock" indicates that the client has not even understood the literal meaning of the proverb. As for "fixing things on time would prevent bigger problems in future" and "If you solve one problem, you will prevent nine problems in future," both are correct explanations of the proverb. If the client gives these explanations, then the client uses abstract thinking.

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

drumming one's fingers on the table top An automatism is a repeated purposeless behaviors often indicative of anxiety, such as drumming fingers, twisting locks of hair, or tapping the foot. None of the other options are generally associated with an expression of anxiety.

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 The client has a flat affect yet tells the nurse that their mood is "really happy." In this situation, the nurse would accurately describe the mood and affect as incongruent. A congruent mood and affect would mean the client's facial expression and demeanor match the subjective report of the mood. A restricted affect refers to displaying one type of expression, usually serious or somber. A broad affect refers to the display of a full range of emotional expression.

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 When the client exhibits unpredictable and rapid mood swings from euphoria to crying with no apparent stimuli, the mood is labile (rapidly changing). Limited judgement would describe a decreased ability of the client to interpret the environment and situation correctly to adapt behavior and decisions accordingly. A lack of insight refers to the client's inability to understand the true nature of their situation, for example, to recognize and accept the limitations caused by the symptoms of a psychiatric disorder. Flat affect refers to showing no facial expression.

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

The nurse is seeing a client who has been experiencing symptoms of depression over the past month. Recent stress includes the death of the client's mother, for whom the client was a primary caregiver. Which components of the psychosocial assessment apply to this aspect of the client's situation? (Select all that apply.)

roles and relationships self-concept history For this client, there has been a recent major loss of significant relationships and of the role of caregiver. As a result of the loss of the client's role as caregiver, the client's personal view of self or personal qualities/attributes will also be altered. The history includes the recent death of the client's mother as well as the fact that the client has lost the role of primary caregiver. This part of the assessment can to helpful in understanding the nature of the client's depressive symptoms.

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

the anxious client The nurse should not choose an isolated location such as a conference room for the interview, if the client is unknown to the nurse or has a history of any threatening behavior either to themselves or to others. The anxious client by diagnosis does not present a threat and so is the one best suited for the nurse to use the conference room for the interview.