Question 1

An elderly,hard-of-hearing client is observed not participating with conversation and sits quietly in the corner of the room.This client's physical ailment is impacting which psychosocial dimension?

Accepted Answer

The client's physical ailment (hard-of-hearing) is impacting their ability to participate in social interactions with others.

Question 2

The nurse is conducting a class on health promotion and uses the following definition: "The ability to perform daily tasks vigorously and alertly,with energy left over for enjoying leisure-time activities and meeting emergency demands." The nurse is stressing which of the following areas?

Accepted Answer

The definition given by the nurse focuses on the ability to perform daily tasks with energy left over for leisure-time activities and meeting emergency demands, which is a core aspect of physical fitness. This definition does not necessarily encompass emotional health, physical health, or psychologic well-being.

Question 3

The adult caregiver of an elderly client states,"When my mother takes ill,you can predict I'll be sick in about 6 weeks." This statement demonstrates:

Accepted Answer

The statement suggests a strong correlation between the mother's illness and the caregiver's subsequent illness, indicating that the caregiver may be experiencing emotional stress in response to the mother's health problems.

Question 4

The nurse is caring for a client admitted for severe weight loss and depression.The client has recently experienced the loss of three close family members and has withdrawn from all social activities.In developing the plan of care,the nurse would correctly choose which of the following nursing diagnoses?

Accepted Answer

The client's recent loss of three close family members and subsequent withdrawal from social activities suggests that the client is experiencing dysfunctional grieving, which is characterized by difficulty in accepting the reality of the loss, intense emotional pain, and a disruption in normal functioning. Powerlessness, anxiety, and spiritual distress may also be present in this client, but they do not reflect the clients specific situation.

Question 5

The nurse is assessing a client in an outpatient mental health setting.The assessment tool outlines criteria for psychosocial health.The nurse understands that this term may be defined as which of the following?

Accepted Answer

Psychosocial health encompasses multiple dimensions of health including mental, emotional, social, and spiritual. Therefore, the correct definition of psychosocial health is the state of being mentally, emotionally, socially, and spiritually well. Options A, B, and C do not adequately capture the multi-dimensional nature of psychosocial health.

Question 6

The nurse is reviewing the care plan for a client who is being treated for schizophrenia.The client had been hearing voices for quite some time,but now doesn't state or deny that voices are heard.The nurse notes that the established goals have been met-the client is interacting appropriately with staff and family,is well-groomed,and has expressed excitement about the discharge.The nurse is using which step of the nursing process?

Accepted Answer

The nurse is using the evaluation step of the nursing process by reviewing the established goals and determining if they have been met.

Question 7

A client tells the nurse,"I want to make sure my children have every possible opportunity to complete their education." The nurse realizes this client's philosophy on education will influence which aspect of her children's health?

Accepted Answer

The client's philosophy on education will likely influence the children's self-esteem and sense of achievement, as education is often closely tied to these factors. It is less likely to directly impact their immediate needs, lead to ongoing family disturbances, or result in mental illness.

Question 8

The nurse is interviewing a client prior to a physical examination.The client tells the nurse that she has been experiencing a lot of aches,pains,and abdominal discomfort.The nurse may suspect which of the following factors that impact physical health?

Accepted Answer

The client's report of aches, pains, and abdominal discomfort is indicative of physical symptoms that may be related to stress. Factors such as income, ethnicity, and occupation may also impact physical health, but the symptoms described by the client are most likely related to stress.

Question 9

The nurse is admitting a client to a psychiatric facility and is planning to conduct a psychosocial assessment.The nurse would correctly choose which of the following tools to obtain this data?

Accepted Answer

The answer of The nurse is admitting a client to...

Question 10

A client is admitted to the orthopedic unit after breaking an arm after a fall.The client appears disheveled and has a body odor.The family arrives and expresses surprise at the client's appearance.They report that this is not the normal appearance of the client and that they are usually clean and meticulously groomed.Which of the following assessments does the nurse need to complete in order to formulate relevant nursing diagnoses and a plan of care for this patient?

Accepted Answer

The answer of A client is admitted to the orthopedic...

Question 11

The nurse is caring for a woman in the emergency room who is complaining of chest pain.She states that she was walking from her apartment to the grocery store when the pain became very severe.She reported that people were following her.She said she couldn't really see them but she could hear them talking about "grabbing me." While the woman is explaining the event,she alternates between wringing her hands and manipulating the items in her purse over and over.The nurse would obtain what further assessment data in this situation?

Accepted Answer

A focused psychosocial interview would help the nurse gather more information about the woman's mental state, anxiety levels, and any potential hallucinations or paranoia she might be experiencing.

Question 12

The nurse has gathered assessment data on a client admitted for suicidal tendencies.The nurse develops appropriate nursing diagnoses and formulates goals to achieve client outcomes.The nurse is utilizing which step of the nursing process?

Accepted Answer

The nurse is utilizing the planning step of the nursing process by developing appropriate nursing diagnoses and formulating goals to achieve client outcomes.

Question 13

The nurse is completing the psychosocial history on a newly admitted adult client.The client reports trouble concentrating,rapid heartbeats,irritability,and inability to make decisions.The nurse suspects which of the following?

Accepted Answer

The symptoms described by the client, such as trouble concentrating, rapid heartbeats, irritability, and inability to make decisions, are commonly associated with a stress reaction.

Question 14

A 7-year-old client was just admitted to the hospital following an appointment in the pediatric oncology clinic.His mother,who is distraught over his recent leukemic relapse,accompanies the child.She is crying and asking,"What did I do wrong? ...Why does he deserve this? ...Why can't it be me?" The nurse understands that these statements indicate which of the following?

Accepted Answer

The mother's questions reflect a struggle with understanding the situation, questioning the fairness or reason behind her child's illness, which are indicative of spiritual distress. This is characterized by questioning the meaning of suffering, the purpose of life, and questioning one's beliefs in the face of life's challenges.

Question 15

A client with hypertension stops into the clinic for his weekly blood pressure measurement.He tells the nurse that he is in a hurry because he started a new job and has to get back to work.Evidence that this client is responding to the new job in a stressful way would be:

Accepted Answer

Elevated blood pressure is a common physical response to stress. This client's hypertension and rush to get back to work could indicate a stress response to starting a new job. The other vitals (respirations, temperature, heart rate) do not have a clear association with stress.

Question 16

The nurse is caring for a confused client.The nurse informs the client of the date,day of the week,time,and location each time the room is entered.The nurse is utilizing which step of the nursing process?

Accepted Answer

The nurse is implementing a specific intervention, which is providing the client with information about the date, day of the week, time, and location to help with their confusion. This is part of the implementation step of the nursing process, where actions are taken based on the identified nursing diagnoses and the established plan of care.

Question 17

Because of statements made by the client during a physical assessment,the nurse believes the client is at risk for developing a major illness.Which of the following statements would cause the nurse to fear for this client?

Accepted Answer

Statement A indicates a potential for negative or judgmental thinking, which can be associated with stress or mental health issues that might increase the risk for developing a major illness. The other statements indicate positive behaviors or attitudes.

Question 18

The nurse is reviewing the plan of care for a client and notes that the following goal has not been met: "Client will verbalize three positive things about himself." The nurse would correctly choose to do which of the following?

Accepted Answer

The nurse should determine barriers to achieving the goal in order to identify the reason why the goal has not been met and modify the plan of care accordingly. Simply telling the client three things he does well or asking other clients to do so does not necessarily address the underlying issue. Doing nothing as long as the client appears better is not appropriate because the goal has not been met.

Question 19

The nurse is interviewing an overweight teenager who looks downward and speaks softly when answering questions.The nurse identifies a problem with client's self-concept.Which of the following findings would support the nurse's conclusions?

Accepted Answer

Feelings of worthlessness, anxiety, and/or depression are commonly associated with a negative self-concept. The client's downward gaze and soft spoken responses also suggest low self-esteem and lack of confidence. Increased desire to form lasting relationships and inability to maintain stable employment may be associated with other issues, but do not necessarily indicate a problem with self-concept. Decreased ability to form attachments with other people may be associated with attachment-related disorders, but does not indicate a problem with self-concept specifically.

Question 20

While being interviewed,a client admits to the nurse that she has been hearing voices and sounds for the past three days.Which of the following would be the nurse's best response in this situation?

Accepted Answer

Asking the client to describe what the voices are saying is an open-ended approach that encourages further discussion about the client's experiences, which is crucial for understanding the nature of the auditory hallucinations and assessing the need for intervention.

Quiz 5: Psychosocial Assessment