Mental Health: Chapter 8: Assessment
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 table in the hospital cafeteria. A conference hall in the hospital. An isolated room outside the hospital premises. 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? Memory Abstract thinking Concentration Concrete thinking
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.
If the client provides a literal explanation of a proverb and cannot interpret its meaning, which thought process is lacking? Memory Abstract thinking Concrete thinking Concentration
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 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? Assessment Planning Diagnosis Evaluation
Assessment Explanation: Assessment is the step of the nursing process in which data are collected and analyzed. Observations of the client's mood and affect are part of this step. The other steps of the nursing process are diagnosis, planning, implementation, and evaluation.
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 post-traumatic stress disorder Clients with depression 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 most effective way for the nurse to proceed? Wait for psychiatric medication to take effect. Complete the assessment in several short interactions. Ask another nurse to attempt the assessment. Use observation only to collect client information
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.
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? Review coping strategies for anxiety and set new therapeutic goals. Review the client's history to determine presence of past of violent behavior. Document the session thoroughly and meet with the client again the next day. Warn the client's neighbor and report to the authorities.
Warn the client's neighbor and report to the authorities. Explanation: 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 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..." "Warning, warning, watch your back." The client makes eye contact with the nurse but does not respond verbally. "Well, that's certainly the end of that."
"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.
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? "The news of the terrorist attack is directed to me. The terrorists are trying to warn me." "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." "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 are telling me to hurt myself." "The voices aren't real but it's hard to ignore them." "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.
When assessing orientation, the nurse completes the assessment by asking which questions? Select all that apply. "Can you tell me where you are?" "Would you count from 1 to 10 backward, please?" "What did you eat for breakfast today?" "What day of the week is it?" "What is your name?"
"What is your name?" "Can you tell me where you are?" "What day of the week is it?" Explanation: 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.
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 . "Is there something wrong with you?" "Are you feeling better today?" "How can we help you?" "When was your last visit in the psychiatric facility?" "How did your problems begin?"
"What would you do if you found $10 on the side of the road?" Explanation: 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 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? "Unfortunately, you are not permitted to call the hospital unit." "It would be best if you came to visit the client here." "You are welcome to share any information that you think would be helpful." "I am sorry, the client does not want you included in care."
"You are welcome to share any information that you think would be helpful." Explanation: 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.
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 Mood Temperament Demeanor
Affect Explanation: 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).
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 Asking whether the client often feels cold Assessing the client's developmental level Observing the client's overall hygiene
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 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? Evaluation Assessment Diagnosis Planning
Assessment Explanation: Assessment is the step of the nursing process in which data are collected and analyzed. Observations of the client's mood and affect are part of this step. The other steps of the nursing process are diagnosis, planning, implementation, and evaluation.
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? Planning Assessment Evaluation Diagnosis
Assessment Explanation: Assessment is the step of the nursing process in which data are collected and analyzed. Observations of the client's mood and affect are part of this step. The other steps of the nursing process are diagnosis, planning, implementation, and evaluation.
Which type of hallucination is the most common? Auditory Gustatory Olfactory Visual
Auditory Explanation: Auditory hallucinations are the most common. Visual hallucinations are the second most common.
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? Assessment Planning Professional practice evaluation Evaluation
Evaluation Explanation: 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.
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 Professional practice evaluation Assessment Planning
Evaluation Explanation: 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 medication compliance Evaluation of insight and judgment A review of systems Questions regarding past behaviors
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.
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? Circumstantiality Perseveration Flight of ideas Neologisms
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 Circumstantiality Derailment 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? Focused Comprehensive Secondary Screening
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 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? Secondary Comprehensive Screening 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.
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 Congruent Broad Restricted
Incongruent Explanation: The client has a flat affect yet tells the nurse that his or her 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.
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? Flat Incongruent Blunted Labile
Incongruent Explanation: 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.
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 beneficial to the interaction by increasing the client's focus and attention. It will be detrimental to the interaction by decreasing the nurse's focus and attention. It will be detrimental to the interaction by decreasing the client's self-awareness. It will be beneficial to the interaction by increasing the nurse's focus and attention.
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.
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 client's self-awareness. 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 client's focus and attention. It will be beneficial to the interaction by increasing the nurse's focus and attention.
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.
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? Orientation Judgment Insight Self-concept
Judgment Explanation: 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 Magical thinking Ideas of reference Neologisms
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 Clang association Neologism 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.
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? Fine motor skills Physical appearance Ability to describe the problem 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? Current emotional state Behavioral function 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
Which would not be included as a purpose of the psychosocial assessment? Mental capacity Behavioral function Previous compliance with treatment regimen Current emotional stat
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? Provides long, irrelevant explanations when asked why the client abuses alcohol. Fails to complete what the client is saying as if distracted. Repeats the phrase, "Mary had a little lamb," whenever feeling stressed. Answers the question, "May we talk?" by responding, "Walk the walk."
Provides long, irrelevant explanations when asked why the client abuses alcohol. Explanation: 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? Wellness Behavior Hygiene Safety
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 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? Repeated tapping of the foot Speaking meaningless words Maintenance of an awkward posture for a long time Slowness of body movements
Slowness of body movements Explanation: 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. 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? Roles and relationships History Motor behavior Suicidal ideation
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 Psychological Screening Inventory The Rorschach Test The Tennessee Self-Concept Scale The Thematic Apperception 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 no facial expression. The client displays a full range of emotional expressions. The client displays only one type of 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.
A nurse is meeting an older adult client for the first time. What may hinder the nurse's ability to effectively carry out the psychiatric assessment? (Select all that apply.) The client is slow to respond to questions. The client is experiencing pain. The client has a cognitive impairment. The client is not wearing a hearing aid. The nurse and the client speak different primary languages.
The client is not wearing a hearing aid. The nurse and the client speak different primary languages. The client has a cognitive impairment. The client is experiencing pain. Explanation: The client's ability to hear and understand what the nurse is saying are factors in the accurate collection of data. In addition, when a client is experiencing pain, the information the nurse obtains may reflect the pain rather than an accurate assessment of the client's situation. If a client is slow to respond to questions asked, this should not hinder the assessment. The nurse needs to modify the assessment by tolerating silence or long pauses before questions are answered. Symptoms of psychiatric disorders such as depression or psychosis can cause slower cognitive processing leading to latency in response.
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 did not understand the test instructions The client's cognitive deficit is significant The test environment was not appropriate 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 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 amount of distracters in a given location The amount of lighting in a given location The client's right to privacy The client's right to a stress-free environment
The client's right to privacy Explanation: 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 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 amount of distracters in a given location The client's right to privacy The client's right to a stress-free environment The amount of lighting in a given location
The client's right to privacy Explanation: 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 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 amount of lighting in a given location The client's right to privacy The client's right to a stress-free environment The amount of distracters in a given location
The client's right to privacy Explanation: 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 abnormal sensory experiences or misperceptions component The mood and affect component The history component The general assessment and motor behavior component
The general assessment and motor behavior component Explanation: 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.
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 The abnormal sensory experiences or misperceptions component The mood and affect component The history component
The general assessment and motor behavior component Explanation: 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.
The nurse finds that the client is constantly rubbing the hands. Under which component of psychosocial assessment should the nurse document this finding? The mood and affect component The abnormal sensory experiences or misperceptions component The general assessment and motor behavior component The history component
The general assessment and motor behavior component Explanation: 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? Challenges faced with social networks The length and quality of relationships The proximity of the networks to the client The number of networks
The length and quality of relationships Explanation: 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 that the client is depersonalizing the death of the spouse. The nurse should recognize the incongruity between content and behavior and find ways of exploring further. The nurse should redirect the assessment toward mental status assessment. 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 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 mood feelings blocking
affect Explanation: 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.
The nurse assesses a client with a history of bipolar disorder. The client tells the nurse that an intelligence agency has surveillance equipment set up in the client's bathroom. The nurse is observing which thought process or content? circumstantial thinking delusional thinking tangential thinking loose associations
delusional thinking Explanation: A delusion is a false fixed idea not based in reality. The information that the client has told the nurse in addition to the history of bipolar disorder indicates the client is expressing delusional thinking. Circumstantial thinking refers to when a client can respond to a question asked only after giving an excessive amount of detail. Tangential thinking refers to when the client wanders off topic when being asked a question in the assessment. With this type of thinking, the client never really provides the information that was originally requested. Loose associations refers to disorganized thinking that jumps from one idea to another with little or no evident relation between thoughts.
The nurse assesses a client with a history of bipolar disorder. The client tells the nurse that an intelligence agency has surveillance equipment set up in the client's bathroom. The nurse is observing which thought process or content? tangential thinking delusional thinking circumstantial thinking loose associations
delusional thinking Explanation: A delusion is a false fixed idea not based in reality. The information that the client has told the nurse in addition to the history of bipolar disorder indicates the client is expressing delusional thinking. Circumstantial thinking refers to when a client can respond to a question asked only after giving an excessive amount of detail. Tangential thinking refers to when the client wanders off topic when being asked a question in the assessment. With this type of thinking, the client never really provides the information that was originally requested. Loose associations refers to disorganized thinking that jumps from one idea to another with little or no evident relation between thoughts.
During the assessment of a client who has a pattern of eating-disordered behavior, the nurse asks, "What would you change about your body, if you could?" The nurse is assessing which component of the psychosocial assessment? roles and relationships thought process and content sensory-perceptual alterations self-concept
self-concept Explanation: By asking the question "What would you change about your body, if you could?" the nurse is assessing self-concept. The client's description of self in terms of physical characteristics gives the nurse information about the client's body image which is also a part of self concept. Sensory-perceptual alterations refer to a change in the client's perception of the world. Often this results in hallucinations or a false sensory perception or perceptual experience that does not really exist. When assessing roles and relationships, the nurse would ask questions such as "Do you feel close to your family?" or "Do you have a significant other?" to determine the existence and quality of the client's sources of support and/or stress. Thought process and content refers to how the client thinks and what they actually say. The aim of this component of the assessment is to determine if the client's ability to think is impaired or intact.
During the assessment of a client who has a pattern of eating-disordered behavior, the nurse asks, "What would you change about your body, if you could?" The nurse is assessing which component of the psychosocial assessment? sensory-perceptual alterations roles and relationships thought process and content self-concept
self-concept Explanation: By asking the question "What would you change about your body, if you could?" the nurse is assessing self-concept. The client's description of self in terms of physical characteristics gives the nurse information about the client's body image which is also a part of self concept. Sensory-perceptual alterations refer to a change in the client's perception of the world. Often this results in hallucinations or a false sensory perception or perceptual experience that does not really exist. When assessing roles and relationships, the nurse would ask questions such as "Do you feel close to your family?" or "Do you have a significant other?" to determine the existence and quality of the client's sources of support and/or stress. Thought process and content refers to how the client thinks and what they actually say. The aim of this component of the assessment is to determine if the client's ability to think is impaired or intact.
When considering where to conduct a psychosocial assessment, the nurse can effectively interview which client in the unit's conference room? the suicidal client the aggressive client the paranoid client the anxious 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.
Which question asked by the nurse indicates that the nurse is assessing the judgment of the client? "Could you please repeat the days of the week backward?" "What would you do if you found $10 on the side of the road?" "Could you please explain the meaning of proverb 'barking dogs seldom bite'?" "In which country do you live?"
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.
