chapter 8-Assessment Flashcards
When assessing a patient's mental health status, which of the following describe the purpose of the psychosocial assessment? Select all that apply.
- To assess the client's current emotional state
- To assess the client's mental capacity
- To assess the client's behavioral function
Which of the following factors influencing assessment is under the nurse's control?
Nurse's attitude and approach
Which of the following are components of the assessment of thought process and content? Select all that apply.
- What the client is thinking
- How the client is thinking
- Clarity of ideas
- Self-harm or suicide urges
A client is being evaluated for dementia. The nurse knows that a client who is able to complete very few tasks is most likely to have
a greater cognitive deficit.
During the assessment, the nurse asks the client to describe his problems. The purpose of this question is to obtain information about the client's
perception of the problem.
A delusion represents a problem in which of the following areas?
The nurse asks a patient to list the days of the week in reverse order. The nurse is assessing which of the following?
When the nurse asks the client to restate the following in his or her own words, which sensorium and intellectual process is the nurse attempting to identify? The nurse states, ìA stitch in time saves nine.î
The client ability to use abstract thinking
The nurse is assessing suicide potential in a patient who has expressed hopelessness. In what order does the nurse question the patient about suicidal thoughts?
C. Are you thinking of killing yourself?
B. Do you have a plan to kill yourself?
D. How do you plan to kill yourself?
A. How would you carry out this plan?
The nurse best assesses a patient's memory by asking which of the following questions?
Who is the current president?i
A patient shows no facial expression when engaging in a game with peers during an outing at a park. The nurse uses which of the following terms when documenting the patient's affect?
The patient states that he is 14 trillion years old and created the world. The nurse documents this statement as an example of which type of thinking displayed by the patient?
A patient is known to express tangential thinking. The nurse would assess for which of the following when interacting with the patient?
Wandering off the topic and never answering the question
A nurse can best assess a patient's ability to use abstract thinking by asking the patient which of the following questions?
What do I mean when I say, 'Don't sweat the small stuff?
A patient reported to the nurse that on his way to the clinic, a policeman in a patrol car turned on his lights and pulled him over. When asked what he did next, the patient stated, ìI pulled over, of course.î Which of the following was the nurse trying to assess?
The client judgement
The client spoke of a current event in the national news and described it as it relates to the client. Then the client spoke of a historical event and described it as it relates to the client. Which of the following questions might the nurse ask to determine if the client is experiencing ideas of reference?
Where were you when this happened?
Which of the following questions is best to ask when assessing the client's judgment?
If you found yourself downtown without money or a car, how would you get home?i
The nurse asks the client, ìWhat is similar about a cow and a horse?î and ìWhat do a bus and an airplane have in common?î These questions would best assess which of the following areas?
Which of the following would best assess a client's judgment?
Discussing hypothetical situations
The nurse plans to assess a patient's self-concept in the admission assessment knowing that self-concept influences which of the following? Select all that apply.
- Body image
- Frequently experienced emotions
- Coping strategies
Which of the following are the types of roles that are usually included when assessing roles and relationships? Select all that apply.
Knowing that relationships with others are significant to mental health, the nurse effectively assesses a patient's family relationships through which of the following?
Describe your relationships with your family.
A nurse assesses that a depressed patient is lethargic during the day and does not actively participate in unit activities. The notes from the night shift document that the patient did not sleep well. The most probable interpretation of these data is
the patient's depressed mood is impairing restful sleep patterns.
A nurse suspects that a patient is abusing alcohol while taking prescribed medications. The nurse plans to educate the patient on the dangers of mixing medicine with alcohol. Which of the following would be the most effective way for the nurse to approach this subject with the patient?
Emphasize the importance of truthful information using a nonjudgmental approach
The nurse has completed the psychosocial assessment. Which of the following is the best approach toward analysis of the data to identify nursing diagnoses and develop an appropriate plan of care?
Look for patterns reflected in the overall assessment.
The nurse reviews results of the Minnesota Multiphasic Personality Inventory (MMPI) recorded in a patient record. While considering the usefulness of these data, the nurse is mindful that the MMPI has which limitation?
The results of the MMPI could be culturally biased.
The client tells the nurse, ìThat new TV anchor is telling the world about me.î This is an example of
ideas of references
During the admission assessment, the nurse asks the client, ìHow are you feeling?î The client responds, ìI was able to purchase gas for 7 cents a gallon less than yesterday, which saved me a total of 84 cents. My car has a 12-gallon gas tank. Usually I am able to put in 11.7 gallons. I am very happy to have saved so much money.î The nurse recognizes this response as which of the following?
A client is admitted to the psychiatric unit and states, ìI am president of the largest corporation in the world. Everyone comes to me for advice.î The client is exhibiting which of the following?
In the space of 5 minutes, the client has been laughing and euphoric, then angry, and then crying for no reason that is apparent to the nurse. This behavior would be best described as
Throughout the assessment, the client displays disorganized thinking, jumping from one idea to another with no clear relationship between the thoughts. The nurse would assess the client as having which of the following?
Sexuality and self-harm behaviors are often difficult areas for nurses to assess. An effective way for nurses to deal with this discomfort includes
recognizing that these areas may also be uncomfortable for the patient to discuss.
Which of the following is the most compelling reason for the nurse to discuss matters of sexuality and suicide?
It is the nurse's professional responsibility to keep safety needs first and foremost.
Which of the following is an example of an open-ended question?
What concerns you most about your health?
Which of the following is an example of a closed-ended question?
Where are you employed?
Assessment data about the client’s speech patterns are categorized in which of the following areas?
General appearance and motor behavior
When the nurse is assessing whether or not the client’s ideas are logical and make sense, the nurse is examining which of the following?
The client’s belief that a news broadcast has special meaning for him or her is an example of
ideas of references
The client who believes everyone is out to get him or her is experiencing a(n)
To assess the client’s ability to concentrate, the nurse would instruct the client to do which of the following?
Repeat the days of the week backward.
The client tells the nurse “I never do anything right. I make a mess of everything. Ask anyone, they’ll tell you the same thing.” The nurse recognizes these statements as examples of
Assessment of sensorium and intellectual processes includes which of the following?
Assessment of suicidal risk includes which of the following?
- Intend to die