Deck 5: Psychosocial Assessment

Question 1

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. Which step of the nursing process is the nurse using to orient this client?

A) Implementation.
B) Evaluation.
C) Planning.
D) Assessment.

Answer 1

Implementation.

Question 2

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

A) Mental.
B) Emotional.
C) Social.
D) Spiritual.

Answer 2

Social.

Question 3

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 the children's health?

A) Attempt to meet immediate needs.
B) Help to elevate self-esteem.
C) Ongoing family disturbances.
D) Can lead to mental illness.

Answer 3

Help to elevate self-esteem.

Question 4

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." Which action by the nurse is the most appropriate?

A) Tell the client three things that he does well.
B) Ask other clients to tell the client what he does well.
C) Determine barriers to achieving the goal.
D) Do nothing as long as the client appears better.

Question 5

A school-age client is admitted to the hospital following an appointment in the pediatric oncology clinic. The client's mother is distraught over her child's recent leukemic relapse and states, "What did I do wrong? Why does he deserve this? Why can't it be me?" What do these statements indicate?

A) Ineffective coping.
B) Emotional emptiness.
C) Spiritual distress.
D) Psychologic anxiety.

Question 6

While being interviewed, a client admits to the nurse that she has been hearing voices and sounds for the past three days. Which response by the nurse is the most appropriate?

A) "How long have you been hearing these voices?"
B) "Tell me about what the voices tell you to do."
C) "These must be other things you are hearing."
D) "Do the voices bother you during the night only?"

Question 7

The nurse conducts a physical assessment for a client. Which client statement during the assessment indicates the client is at risk for developing a major illness?

A) "Look at that person's pants! Don't they realize how ugly they are?"
B) "That sounds like a good idea! I think I will try that at home."
C) "I just love spending time outside. It energizes me!"
D) "I set aside a period of time each day for myself."

Question 8

The nurse educator is reviewing the component of a psychosocial assessment with a group of students. Which definition of psychosocial health is appropriate for the educator to include in the review session?

A) Being emotionally balanced and socially astute.
B) Being mentally stable, physically fit, and psychologically well.
C) Being spiritually and psychologically mature.
D) Being mentally, emotionally, socially, and spiritually well.

Question 9

The nurse is interviewing an overweight adolescent who looks downward and speaks softly when answering questions. The nurse identifies a problem with client's self-concept. Which finding supports the nurse's conclusion?

A) Increased desire to form lasting relationships.
B) Decreased ability to form attachments with other people.
C) Inability to maintain stable employment.
D) Feelings of worthlessness, anxiety, and/or depression.

Question 10

The nurse is interviewing a client prior to a physical examination. The client reports aches, pains, and abdominal discomfort. Which factor does the nurse suspect is impacting the client's physical health?

A) Income.
B) Stress.
C) Ethnicity.
D) Occupation.

Question 11

The adult caregiver of an older adult client states, "When my mother takes ill, you can predict I'll be sick in about 6 weeks." What does this statement from the adult caregiver indicate?

A) The client has a communicable disease.
B) The caregiver has uncared for health problems.
C) The caregiver is more ill than the client.
D) The caregiver is experiencing emotional stress.

Question 12

The nurse is caring for a client admitted for severe weight loss and depression. The client 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 nursing diagnosis?

A) Powerlessness.
B) Anxiety.
C) Complicated grieving.
D) Spiritual distress.

Question 13

The nurse is reviewing the care plan for a client with schizophrenia. Upon assessment the client admits to hearing voices that say, "Kill yourself." The nurse documents the client is at risk for injury and includes the following statement in the plan of care, "Client will not harm self during hospitalization." Which step of the nursing process is the nurse using?

A) Goal setting.
B) Implementation.
C) Diagnosis.
D) Evaluation.

Question 14

The nurse is reviewing the plan of care for a client who was admitted for suicidal tendencies. The nurse documents that the client is no longer experiencing thoughts of hurting self. Which step of the nursing process is the nurse using?

A) Implementation.
B) Evaluation.
C) Planning.
D) Assessment.

Question 15

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." Which area is the nurse stressing?

A) Physical fitness.
B) Emotional health.
C) Physical health.
D) Psychologic well-being.

Question 16

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. Based on these assessment findings, which does the nurse suspect?

A) A stress reaction.
B) Role confusion.
C) An impending heart attack.
D) Dysfunctional anxiety.

Question 17

The nurse admits a client to a psychiatric facility and plans to conduct a psychosocial assessment. Which assessment tools are appropriate for the nurse to use to collect this data?

A) Healthy Day Measures.
B) Multidimensional Health Profile.
C) Emotional Readiness Assessment Profile.
D) Holmes Social Readjustment Scale.
E) Duke Social Support and Stress Scale.

Question 18

The nurse is caring for a client in the emergency department (ED) who complains of chest pain and reports that people were following her. She states, "I can't see them but they are 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. Which is the priority when continuing the assessment for this client?

A) Spiritual affiliations.
B) Dietary preferences and habits.
C) Review of systems.
D) Focused psychosocial interview.

Question 19

A client with hypertension stops into the clinic for a weekly blood pressure and blood glucose measurement along with a full set of vital signs. The client is in a hurry because he started a new job and has to get back to work. Which finding would indicate that the client is having a healthy response to the new job?

A) Blood pressure of 160/90 mmHg.
B) Respirations 16 and regular.
C) Blood glucose 210 mg/dL.
D) Heart rate 150 and regular.

Question 20

The client admitted to the hospital for an arm fracture requiring surgery appears disheveled and has a body odor. The nurse expresses surprise at the client's appearance and reports that this is not the normal appearance of the client, who is usually clean and meticulously groomed. Based on this information, which assessments are priority to plan this client's care?

A) Food preferences.
B) Psychosocial assessment.
C) Memory assessment and orientation.
D) Spiritual assessment.
E) Body systems examination.

Question 21

A client is admitted to the psychiatric unit with complaints consistent with an anxiety disorder. During the assessment the nurse learns a client has a history of asthma and arthritis. Based on this information, which action is the priority for the nurse?

A) Beginning the respiratory assessment
B) Beginning the musculoskeletal status assessment
C) Beginning the medication assessment
D) Beginning the psychosocial assessment

Question 22

The nurse is concerned that a client is having a problem with self-concept. Which statement by the client supports the nurse's concern?

A) "I never have any fun."
B) "I am the oldest in the family."
C) "I think I'm pretty much outgoing."
D) "At times I like to be alone."

Question 23

The nurse believes a client is having difficulty coping with current illness and hospitalization. Which assessment question would best help the nurse identify the client's coping ability?

A) Who is your closest friend?
B) What social groups do you belong to?
C) What is your birth order in your family?
D) Who do you call when you need help?

Question 24

A client, whose mother has a history of schizophrenia, voices concerns about becoming pregnant and is fearful of having a child with the same disorder. Which response by the nurse is the most appropriate?

A) "Schizophrenia is a genetic disorder so you are right to be very concerned."
B) "Your family history does increase the risk factors but there are other variables to be considered."
C) "Schizophrenia should not be a significant concern for you."
D) "You should consider being tested before becoming pregnant."

Question 25

The nurse is attempting to assess an agitated client. The client believes the nurse is trying to hurt him and is not cooperating with the nurse. What actions by the nurse are appropriate?

A) Advise the client that the healthcare provider will be contacted unless the client complies.
B) Restrain the client using leather restraints.
C) Speak to the client in a calm voice.
D) Explain actions to the client as they are done.
E) Medicate the client.

Question 26

A client is seen at the ambulatory care clinic for a routine physical examination. During the examination, the client discusses having gained more than 25 pounds in the past year despite not changing the level of activity or dietary intake. What response by the nurse is the most appropriate?

A) "You must be eating more than you realize."
B) "Do you think increasing exercise might help you with your excessive weight gain?"
C) "Tell me about any changes in your stress levels."
D) "This weight gain is likely the result of aging."

Question 27

During an assessment the assessment of a client admitted with new onset schizophrenia, the nurse observes the client repeating the last word of each question asked. Because of this, the client unable to completely answer any of the assessment questions. Which speech pattern in this client exhibiting?

A) Circumlocution
B) Flight of ideas
C) Neologisms
D) Echolalia

Question 28

A client presents to the ambulatory care clinic with complaints of back pain, nausea, and fatigue. When the nurse questions the client about recent stressors the client becomes irritated and states, "I am sick. Why are you asking me about all of this stress stuff?" Which response by the nurse is the most appropriate?

A) "Stress can impact our body by producing a variety of symptoms."
B) "Your nausea and fatigue are most often related to an overabundance of stress in life."
C) "Asking about stress is required for every client."
D) "We all have stress and I need to see how much you have."

Question 29

A client is admitted to the psychiatric care unit. While the nurse is explaining the use of the call light, the client smiles and says, "Apples, corn, dogs, my foot." The nurse correctly documents the client is demonstrating which speech pattern?

A) Neologisms
B) Clanging
C) Word salad
D) Echolalia