Chapter 8: 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?" "Are you feeling better today?" "How did your problems begin?" "Is there something wrong with you?" "When was your last visit in the psychiatric facility?"
"How did your problems begin?" "How can we help you?" 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.
Which statement by the client best demonstrates a healthy relationship with family? My brother and I like to take a walk when he visits." "I want to put on clean clothes for my sister's visit." "My family has always tried their best to help me." "I feel better after I visit with my Mom."
"I feel better after I visit with my Mom." Explanation: The relationship with others is important to mental health. Feeling better after having contact with a particular person demonstrates a healthy relationship. While all the options present positive statements, only the correct option is obviously positive in the result of the interaction.
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? The client makes eye contact with the nurse but does not respond verbally. "I might. I'll give it some..." "Well, that's certainly the end of that." "Warning, warning, watch your back."
"I might. I'll give it some..." Explanation: 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.
A psychiatric-mental health nurse is assessing a client. Which statement by a client would the nurse recognize as evidence of an absence of insight? "I just feel these days like I'm in this black pit and there's no way I can get out of it." "If things don't improve for me, I'll probably end up on the street." "I don't think any of those psychiatrists or psychologists or whatever have any clue what they're doing." "Sometimes I feel like the world would be better off if I were dead."
"Sometimes I feel like the world would be better off if I were dead." Explanation: Insight is characterized as an awareness of one's circumstances; it includes awareness of thoughts, feelings, and behaviors and ability in relation to the thoughts, feelings, and behaviors of others. Presuming that all people feel the world would benefit from their absence suggests a lack of insight. Anger at the perceived incompetence of care providers, apathy about one's bleak future, and expressions of despondency certainly warrant further assessment and treatment, but they do not necessarily indicate a lack of insight.
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? "I am sure you know what I am thinking. Everybody knows what I am thinking." "The news of the terrorist attack is directed to me. The terrorists are trying to warn me." "My family is taking my thoughts away. I am unable to think now." "My dead friend is putting these ideas in my mind."
"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.
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? "I am sure you know what I am thinking. Everybody knows what I am thinking." "My dead friend is putting these ideas in my mind." "The news of the terrorist attack is directed to me. The terrorists are trying to warn me." "My family is taking my thoughts away. I am unable to think now."
"The news of the terrorist attack is directed to me. The terrorists are trying to warn me." Explanation: 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.
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? "I am sure you know what I am thinking. Everybody knows what I am thinking." "The news of the terrorist attack is directed to me. The terrorists are trying to warn me." "My dead friend is putting these ideas in my mind." "My family is taking my thoughts away. I am unable to think now."
"The news of the terrorist attack is directed to me. The terrorists are trying to warn me." Explanation: 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." "The voices are telling me to hurt myself." "I can't remember a time when I didn't hear voices." "I take medication so the voices will stop."
"The voices aren't real but it's hard to ignore them." Explanation: 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.
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?" "Can you tell me what you have eaten in the last 24-hours?" "How are an apple and orange the same?" "What did you do last evening?"
"When did you get your first job?" Explanation: 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 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? An isolated room outside the hospital premises. A conference hall in the hospital. A table in the hospital cafeteria. A physician's intake room with other medical personnel nearby.
A physician's intake room with other medical personnel nearby. Explanation: 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. The client should not be interviewed in a place like the cafeteria, as it has a lot of distractions. Since the client is aggressive and could hurt oneself or the nurse, the nurse should not be alone or isolated as assistance might be needed during the interviewing. It would be inappropriate for the nurse to conduct the interview in the conference room alone. It would be inappropriate for the nurse to conduct the interview outside the premises of the facility.
If the client provides a literal explanation of a proverb and cannot interpret its meaning, which thought process is lacking? Abstract thinking Concrete thinking Concentration Memory
Abstract thinking Explanation: The question asks which ability is lacking, or absent, in the client who can provide only the literal meaning of a proverb. This client is exhibiting concrete thinking but not abstract thinking, making abstract thinking the correct answer. To evaluate reasoning, the nurse can ask the client to interpret a common proverb such as "A stitch in time saves nine." The client demonstrates abstract thinking by being able to state the metaphorical meaning of the proverb (i.e., "a little planning ahead saves a lot of time and trouble later on"). Concrete thinking occurs when a client gives a literal translation. Concentration relates to the ability to stay on task. 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. Objective Defensive Accepting Judgmental Brief
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.
While conducting an interview with a psychiatric-mental health client, the nurse is observing the client's facial expressions and nonverbal cues. What are these physical manifestations known as? Affect Temperament Demeanor Mood
Affect 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. Among other signs, the nurse will assess consistency between mood and affect (e.g., the client says, "I feel pretty good" but have a somber affect).
A psychiatric-mental health nurse is assessing a client. Which statement by a client would the nurse recognize as evidence of an absence of insight?
Appetite and sleep Explanation: 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).
When completing a physical assessment of an individual's response to stress, the nurse should observe and inquire about what? Appetite and sleep Judgement and insight Concentration Mood
Appetite and sleep Explanation: 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 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 months later. Ask the client to recall events that have occurred over the past few weeks. Ask the client to recall events from childhood. Provide the client with three words and ask the client to recall the words several minutes later.
Ask the client to recall events that have occurred over the past few weeks. Explanation: 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. Reference:
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? Reviewing the client's culture for possible influence Assessing the client's developmental level Observing the client's overall hygiene Asking whether the client often feels cold
Asking whether the client often feels cold Explanation: Dress is typically appropriate for occasion and weather, and dress varies considerably from person to person. Some older adults may wear excess clothing because of slowed metabolism and loss of subcutaneous fat resulting in cold intolerance. The nurse needs to determine this first before performing any other assessments.
The nurse is performing a psychosocial assessment of a client with a mental illness. What information should the nurse gather from the client while taking the history? Select all that apply. Chronological age View on personal attributes Spiritual beliefs Cultural considerations Eating habits
Chronological age Cultural considerations Spiritual beliefs In a psychosocial assessment, the history should include the client's age and their cultural and spiritual beliefs. The eating habits of the client are a part of the physiologic and self-care considerations during the assessment. The support systems of the client are assessed in the roles and relationships part of the assessment.
The nurse is assessing a client with psychiatric disorder. The nurse finds that when asked a question, the client gives excessive and unnecessary details followed by the answer. This is indicative of which impairment of thought content? Flight of ideas Loose associations Circumstantial thinking Thought broadcasting
Circumstantial thinking When a client gives excessive and unnecessary details and then gives the answer, this is termed circumstantial thinking. Flight of ideas is characterized by an excessive amount and rate of speech composed of fragmented or unrelated ideas. Loose association is characterized by jumping from one idea to another with little or no evident relation between the thoughts. Thought broadcasting is when the client has the delusional belief that others can hear or know what the client is thinking.
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 post-traumatic stress disorder Clients with depression Clients with adult attention deficit hyperactivity disorder Clients with antisocial personality disorder
Clients with adult attention deficit hyperactivity disorder Explanation: 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.
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 mosteffective way for the nurse to proceed? Complete the assessment in several short interactions. Use observation only to collect client information. Wait for psychiatric medication to take effect. Ask another nurse to attempt the assessment.
Complete the assessment in several short interactions. Explanation: 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? Orientation Concentration Insight Judgment
Concentration Explanation: 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.
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? Questions regarding past behaviors A review of systems Evaluation of insight and judgment Evaluation of medication compliance
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 has been asked to complete a mental status examination of a psychiatric-mental health client. Which is a necessary component of this assessment? Questions regarding past behaviors Evaluation of medication compliance A review of systems 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.
While talking with a schizophrenic client, the nurse observes that the client is looking straight ahead, maintains no eye contact, and shows no facial expression, 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? Constricted Blunted Labile Flat
Flat Explanation: 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? Neologisms Perseveration Flight of ideas Circumstantiality
Flight of ideas Explanation: 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 Derailment Circumstantiality Incoherence
Flight of ideas Explanation: 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? Comprehensive Screening Secondary Focused
Focused Explanation: 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 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? Obsession Magical thinking Thought broadcasting Ideas of reference
Ideas of reference Explanation: 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? Illusion Hallucination Ideas of reference Religious delusion
Ideas of reference Explanation: 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.
What is the most significant benefit of using Beck's Depression Inventory in evidence-based nursing practice? It is easily graded by the nurse. It has 21 focused questions to be asked of the client. It identifies a client's level of depression. It is a standardized, reliable depression tool.
It is a standardized, reliable depression tool. Explanation: 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. It will be beneficial to the interaction by increasing the nurse's focus and attention. It will be beneficial to the interaction by increasing the client's focus and attention. It will be detrimental to the interaction by decreasing the client's self-awareness.
It will be detrimental to the interaction by decreasing the nurse's focus and attention. Explanation: 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.
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? Ideas of reference Neologisms Magical thinking 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 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? Echolalia Neologism Clang association Loose associations
Loose associations Explanation: 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.
When assessing a client who has been referred to the outpatient mental health clinic with symptoms of depression, the psychiatric nurse should closely observe the client's affect and which assessment component? Ability to describe the problem Fine motor skills Physical appearance Recollection of the problem's related details
Physical appearance Explanation: 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.
Which would not be included as a purpose of the psychosocial assessment? Behavioral function Current emotional state Mental capacity Previous compliance with treatment regimen
Previous compliance with treatment regimen Explanation: 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 psychiatric nurse correctly identifies the client's form of communication as circumstantiality when the client does what? Answers the question, "May we talk?" by responding, "Walk the walk." Repeats the phrase, "Mary had a little lamb," whenever feeling stressed. Provides long, irrelevant explanations when asked why the client abuses alcohol. Fails to complete what the client is saying as if distracted.
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.
Which must the nurse consider a priority in the assessment of mental status? Safety Wellness Hygiene Behavior
Safety Explanation: 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.
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. Explain the perception of inkblot cards. Interpret the meaning of a proverb. Write the names of family members.
Spell "America" backward. Explanation: 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 Motor behavior History Roles and relationships
Suicidal ideation Explanation: 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 Tennessee Self-Concept Scale The Thematic Apperception Test The Psychological Screening Inventory The Rorschach Test
The Rorschach Test Explanation: The 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 a facial expression that is incongruent with mood. The client displays only one type of facial expression. The client displays no facial expression. The client displays a full range of emotional expressions.
The client displays only one type of facial expression. Explanation: 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.
The nurse is performing an assessment of a client with psychiatric illness. The nurse documents that the client has a restricted affect. Which behavior of the client is indicative of restricted affect? Choose the best answer. The client displays a full range of emotional expressions. The client displays only one type of facial expression. The client displays no facial expression. The client displays a facial expression that is incongruent with mood.
The client displays only one type of facial expression. Explanation: 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.
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's father died in a tragic automobile accident when the client was 10 years old. The client is unable to continue school work and has been sitting on the client's bed for 3 days. The client used cocaine up until 1 week ago. The client has been receiving good grades in college and has a grade point average of 3.8.
The client is unable to continue school work and has been sitting on the client's bed for 3 days. Explanation: 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.
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 test environment was not appropriate The client did not understand the test instructions The client's cognitive deficit is significant The test needs to be readministered
The client's cognitive deficit is significant Explanation: The fewer tasks the client competes accurately, the greater the cognitive deficit. None of the other options provide a plausible conclusion.
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 that the client is depersonalizing the death of the spouse. The nurse should redirect the assessment toward mental status assessment. The nurse should recognize the incongruity between content and behavior and find ways of exploring further. The nurse should recognize that the grieving process is highly individual, and responses need not match societal or cultural norms.
The nurse should recognize the incongruity between content and behavior and find ways of exploring further. Explanation: 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 reviewing material about assessing mental status. The nurse demonstrates a competent understanding of this assessment by identifying which area as a component of cognition? mood abstract reasoning posture speech
abstract reasoning Explanation: To assess the client's cognition, that is, the ability to think and know, the nurse uses memory, calculation, and reasoning tests to identify specific areas of impairment. The cognitive areas include (1) attention and concentration, (2) abstract reasoning and comprehension, (3) memory, and (4) insight and judgment. Mood, speech, and posture are not components of a cognitive assessment.
Which client behavior would the nurse document as being an automatism? staring off into space frequently repeating his or her statements asking that the question be repeated drumming one's fingers on the table top
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. Reference:
When considering where to conduct a psychosocial assessment, the nurse can effectively interview which client in the unit's conference room? the aggressive client the anxious client the suicidal client the paranoid client
the anxious client Explanation: 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.
