Question 1

During an interview with a 15-year-old female client admitted for depression,the nurse is disappointed to learn that the client recently became pregnant and had an abortion.The nurse is contradicting the effective interview guideline of:

Accepted Answer

This is an example of the nurse allowing his or her personal values to cloud professional judgment and is an ineffective interview technique that leads to a negative nurse-client relationship.The other options are good interview techniques but do not represent this situation.

Question 2

The treatment team meets with a client for the first time and determines,with the client's input,a nursing diagnosis,goal,and steps to reach this goal.In addition to a nursing diagnosis,the treatment team has completed which phase of the nursing process?

Accepted Answer

During the planning phase,goals are established and a plan is developed.Evaluation is the phase in which goals are evaluated to determine whether they have been met,partially met,or not met at all;intervention is the phase of the nursing process when planned interventions are actually implemented;and data collection occurs during the assessment phase.

Question 3

Without assessment of six specific aspects of an individual's being,the mental health nurse's scope of care is narrow and limited in effectiveness.These aspects include social,physical,cultural,intellectual,emotional,and spiritual areas of a person's life,known as a __________ assessment.

Accepted Answer

Although the other options do address some of these aspects,holistic more accurately describes these six aspects of an individual's life.The psychiatric assessment tool specifically addresses the problems that are being experienced,coping mechanisms,and resources of the client.

Question 4

Upon entrance into a mental health care system,clients are thoroughly assessed,and this is followed by the development of a mental health treatment plan.Which of the following are purposes of the treatment plan? (Select all that apply. )

Accepted Answer

Purposes of the treatment plan include serving as a means of monitoring the client's progress,acting as an instrument for communication and coordination of care,serving as a guide for planning and implementation of care,and providing a way to evaluate the effectiveness of interventions.Documentation for reimbursement purposes is not a primary goal of the treatment plan.

Question 5

When reviewing the nursing notes from the previous shift,the nurse notices notations indicating that the client was experiencing a somnolent level of consciousness.The client's behavior would be described as:

Accepted Answer

Falling asleep easily and waking only to strong verbal stimuli describes the level of consciousness known as somnolent,which also can be called a state of drowsiness.Frequently sleeping and waking only to strong physical stimuli describes a stuporous state,unresponsiveness to verbal or painful stimuli is a comatose state or unconsciousness,and alternating periods of excitability and drowsiness describes a lethargic state.

Question 6

A male client with a history of schizophrenia was admitted to the mental health facility after he was found on the street confused and uncooperative when approached by the police.One of the first assessments that should be performed on this client upon admission is a:

Accepted Answer

Physical problems frequently are overlooked when someone has a diagnosed mental health disorder.These physical problems often can be the cause of symptoms and may be easily treated.For example,low blood sugar,rather than schizophrenia,could be a cause of the symptoms described in this scenario.For this reason,physical examinations are always performed on admission to a mental health facility,followed by the other options listed.

Question 7

Components of the sociocultural assessment include a history interview for the purpose of obtaining information about a client's background and:

Accepted Answer

The sociocultural assessment focuses on the cultural,social,and spiritual aspects of an individual.During the history interview,the care provider obtains information about a client's background and observes the client's appearance,behaviors,and attitudes.

Question 8

A client seen in the emergency department is noted to be stuporous.Which of the following assessment findings would be of most concern?

Accepted Answer

Assessing lifestyle,occupational/lifestyle factors of chemicals such as paint in the workplace can impact function.Elevated blood pressure,elevated cholesterol,and exercise would not result in stupor in the client.

Question 9

During the mental status assessment,the nurse hands the client a piece of paper that reads "Please raise your left hand." If the client follows the command,the nurse has just assessed which ability of the client?

Accepted Answer

This is an easy method of assessing the client's reading ability and is less anxiety provoking than having the client read aloud.Abstract thinking is assessed by methods such as assessing the ability of the client to understand similarities;general knowledge can be assessed by asking questions such as how many months are in a year or discussing current events;and memory can be assessed by testing immediate,recent,and remote memory.

Question 10

The assessment phase of the nursing process refers to the phase when data collection occurs.Which methods does the nurse use to collect data? (Select all that apply. )

Accepted Answer

Interviewing the client and significant others,observing client behavior,performing a physical assessment,and reviewing diagnostic testing results are effective ways of collecting data.Interpreting a client's behavior should never occur without clarification because interpretation often is incorrect.

Question 11

A nurse educates a client on medication side effects and verbal feedback of understanding is given by the client.Which phase of the nursing process is being described?

Accepted Answer

This phase determines the effectiveness of the care.Clients are encouraged to become partners in their care.

Question 12

The nurse asks the client a series of questions upon entry into a mental health care system.This action is an example of which phase of the nursing process?

Accepted Answer

Assessment is the phase of the nursing process during which data collection occurs.It is performed not only upon admission into a facility but throughout the care of the client.Evaluation is the phase during which goals are evaluated to determine whether they have been met,partially met,or not met at all;intervention is the phase of the nursing process when planned interventions are actually implemented;planning is the phase of the nursing process when client goals are set and interventions are planned.

Question 13

During a session with a female client with a diagnosis of social phobia,she talks about how proud she is of herself because she was finally able to shop at the grocery store.The nurse documents the events and knows that this would be considered which phase of the nursing process?

Accepted Answer

This client has accomplished a goal;therefore,this would be considered evaluation.Assessment is the phase of the nursing process when data collection occurs;planning is the phase of the nursing process when client goals are set and interventions are planned;and intervention is the phase of the nursing process when planned interventions are actually implemented.

Question 14

A client complains to the nurse that he has been fired from his fourth job in 10 months because his bosses and co-workers "didn't understand him." While he once had a few close friends,he no longer associates with them for the same reason.His level of functioning on the Global Assessment of Functioning Scale would be:

Accepted Answer

The Global Assessment of Functioning Scale score of serious symptoms (41-50)is defined as a serious impairment in social,occupational,or school functioning;no friends;and an inability to keep a job.

Question 15

A client with a history of delusions demonstrates which of the following behaviors?

Accepted Answer

Delusions are false beliefs that cannot be corrected by reasoning or explanation.A constant fear of dying is an example of an obsession,shifting from laughing to crying for no reason demonstrates the inappropriate response of being labile,while having trouble remembering is indicative of amnesia.

Question 16

During the mental status examination,the nurse observes that the client rapidly changes from one idea to another related thought.Which disordered thinking process is the client displaying?

Accepted Answer

It is difficult to follow a conversation with an individual who is experiencing flight of ideas because the conversation follows his rapidly changing thought pattern.Delusions result in false beliefs that cannot be corrected by logical explanations or reasoning;perseveration occurs when the client repeats the same word response to different questions;and with confabulation,the client uses untrue statements to fill in gaps of memory loss.

Question 17

Following completion of a male client's series of group therapy sessions,the nurse periodically talks with the client to determine whether he has any signs of relapse of his previous problems.This action by the nurse is an example of:

Accepted Answer

In this situation,the nurse is assessing for any signs of relapse.Assessment is a continuous process.Planning is the phase of the nursing process when client goals are set and interventions are planned;intervention is the phase of the nursing process when planned interventions are actually implemented;and diagnosis is the phase of the nursing process following assessment when the client's problem is identified.

Question 18

The nurse suspects the client is experiencing a manic episode based on which of the following observations?

Accepted Answer

It is not uncommon for manic clients to dress in colorful clothing and have excessive body movement.Clients who look unkempt and neglected are more common in depression.Repeated behaviors and picking at clothing are often seen in obsessive-compulsive disorders.

Question 19

The nurse is reviewing information regarding a female client that was obtained with the psychiatric assessment tool.The client's ability to provide food and shelter for herself is included in which area of the assessment?

Accepted Answer

The client's ability to care for herself outside of the facility would be considered when her discharge planning needs are assessed,to determine whether other resources will be necessary.The other options are included in the psychiatric assessment tool but do not focus on discharge planning.Appraisal of health and illness focuses on the client's perception of health care and identification of problems and goals;knowledge deficits focus on areas such as medications and coping skills;and previous psychiatric treatment focuses on the client's psychiatric history,including family history.

Question 20

A nurse administers antidepressant medication to a client in an assisted-living facility.This is an example of which phase of the nursing process?

Accepted Answer

Intervention is the phase of the nursing process during which planned interventions are actually implemented.Assessment is the phase of the nursing process when data collection occurs.Planning is the phase of the nursing process when client goals are set and interventions are planned.Diagnosis is the phase of the nursing process following assessment when the client's problem is identified.

Quiz 9: Mental Health Assessment Skills