Deck 8: Assessment

Question 1

When assessing a patient's mental health status, which of the following describe the purpose of the psychosocial assessment? Select all that apply.

A) To assess the client's current emotional state
B) To assess the client's mental capacity
C) To assess the client's behavioral function
D) To assess the client's plan of care
E) To assess the client's physical health status

Answer 1

To assess the client's current emotional state
To assess the client's mental capacity
To assess the client's behavioral function

Question 2

Which of the following factors influencing assessment is under the nurse's control?

A) Client participation and feedback
B) Client's health status
C) Nurse's attitude and approach
D) Client's ability to understand

Answer 2

Nurse's attitude and approach

Question 3

Which of the following are components of the assessment of thought process and content? Select all that apply.

A) What the client is thinking
B) Abstract thinking abilities
C) How the client is thinking
D) Clarity of ideas
E) Self-harm or suicide urges

Answer 3

What the client is thinking
How the client is thinking
Clarity of ideas
Self-harm or suicide urges

Question 4

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) a greater cognitive deficit.
B) A less precise mental status exam.
C) more potential for agitation.
D) no bearing on mental status.

Question 5

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

A) admitting diagnosis.
B) communication skills.
C) perception of the problem.
D) personal needs.

Question 6

A delusion represents a problem in which of the following areas?

A) Memory
B) Motivation
C) Orientation
D) Thinking

Question 7

The nurse asks a patient to list the days of the week in reverse order. The nurse is assessing which of the following?

A) Concentration
B) Memory
C) Orientation
D) Abstract thinking

Question 8

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, A stitch in time saves nine.

A) The client's orientation
B) The client's memory
C) The client's ability to concentrate
D) The client's ability to use abstract thinking

Question 9

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?

A) How would you carry out this plan?
B) Do you have a plan to kill yourself?
C) Are you thinking of killing yourself?
D) How do you plan to kill yourself?

Question 10

The nurse best assesses a patient's memory by asking which of the following questions?

A) Do you have any problems with memory?
B) What did you have for lunch yesterday?
C) Do you know where you are?
D) Who is the current president?

Question 11

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?

A) Blunt affect
B) Restricted affect
C) Broad affect
D) Flat affect

Question 12

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) Delusional thinking
B) Ideas of reference
C) Word salad
D) Hallucination

Question 13

A patient is known to express tangential thinking. The nurse would assess for which of the following when interacting with the patient?

A) Stopping abruptly in the middle of expressing himself
B) Jumping from one idea to another
C) Wandering off the topic and never answering the question
D) Excessive and fast talking about an array of ideas

Question 14

A nurse can best assess a patient's ability to use abstract thinking by asking the patient which of the following questions?

A) What would you do if you found a wallet containing $100 on the sidewalk?
B) What do I mean when I say, 'Don't sweat the small stuff?'
C) What are you going to do next time you hear voices?
D) Can you begin with the number 100 and subtract 7, and then subtract 7 again?

Question 15

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, I pulled over, of course. Which of the following was the nurse trying to assess?

A) The client's judgment
B) The client's insight
C) The client's concentration
D) The client's self-concept

Question 16

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?

A) Where were you when this happened?
B) Why do you think that?
C) Are you sure?
D) That is unbelievable!

Question 17

Which of the following questions is best to ask when assessing the client's judgment?

A) Can you describe your usual daily activities for me?
B) If you found yourself downtown without money or a car, how would you get home?
C) On a scale of 1 to 10, how stressed would you rate yourself?
D) What problem would you like to work on while you're hospitalized?

Question 18

The nurse asks the client, What is similar about a cow and a horse? and What do a bus and an airplane have in common? These questions would best assess which of the following areas?

A) Intellectual function
B) Insight
C) Judgment
D) Memory

Question 19

Which of the following would best assess a client's judgment?

A) Counting by serial sevens
B) Discussing hypothetical situations
C) Interpreting proverbs
D) Spelling words backward

Question 20

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.

A) Body image
B) Cognitive processing
C) Frequently experienced emotions
D) Coping strategies
E) Responsiveness to medications

Question 21

Which of the following are the types of roles that are usually included when assessing roles and relationships? Select all that apply.

A) Family
B) Hobbies
C) Occupation
D) Activities
E) Race
F) Ethnicity

Question 22

Knowing that relationships with others are significant to mental health, the nurse effectively assesses a patient's family relationships through which of the following?

A) Do you feel your family helps you?
B) How many people are in your family?
C) Whom are you closest to in your family?
D) Describe your relationships with your family.

Question 23

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

A) the patient's medications are ineffective.
B) the patient is being kept awake at night due to noise on the unit.
C) the patient's depressed mood is impairing restful sleep patterns.
D) the patient is resisting treatment recommendations to participate in unit activities

Question 24

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?

A) Firmly inform the patient of the dangers of mixing medications with alcohol.
B) Recommend a higher level of care, so the patient can be more closely supervised.
C) Emphasize the importance of truthful information using a nonjudgmental approach
D) Recognize the patient's right to self-determination and avoid addressing the subject.

Question 25

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?

A) Focus on each piece of information obtained from the patient.
B) Look for patterns reflected in the overall assessment.
C) Consider only the abnormal findings in the assessment.
D) Present all data obtained in the treatment team meeting.

Question 26

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?

A) The patient must be able to read to complete the MMPI.
B) The results of the MMPI could be culturally biased.
C) The MMPI assesses a narrow scope of functioning.
D) The MMPI does not have established validity.

Question 27

The client tells the nurse, That new TV anchor is telling the world about me. This is an example of

A) ideas of reference.
B) persecutory delusions.
C) thought broadcasting.
D) thought insertion.

Question 28

During the admission assessment, the nurse asks the client, How are you feeling? The client responds, I 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. The nurse recognizes this response as which of the following?

A) Circumstantial thinking
B) Echolalia
C) Flight of ideas
D) Neologisms

Question 29

A client is admitted to the psychiatric unit and states, I am president of the largest corporation in the world. Everyone comes to me for advice. The client is exhibiting which of the following?

A) Flight of ideas
B) Thought broadcasting
C) Delusion
D) Loose associations

Question 30

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

A) flight of ideas.
B) lack of insight.
C) labile mood.
D) tangential thinking.

Question 31

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?

A) Tangential thinking
B) Ideas of reference
C) Loose associations
D) Word salad

Question 32

Sexuality and self-harm behaviors are often difficult areas for nurses to assess. An effective way for nurses to deal with this discomfort includes

A) recognizing that these areas may also be uncomfortable for the patient to discuss.
B) share feelings of discomfort with the patient.
C) defer assessing these areas to a more experienced nurse.
D) develop a standard question to ask of all patients during this area of assessment

Question 33

Which of the following is the most compelling reason for the nurse to discuss matters of sexuality and suicide?

A) It is required by the law by the federal government and in most states in the union.
B) It is the nurse's professional responsibility to keep safety needs first and foremost.
C) This is commonly required documentation for every encounter with every client.
D) It allows the nurse to gain valuable experience in these kind of difficult discussions.