question

Involves the collection, organization and analysis of information about the client, as well as a mental status exam. Purpose is to construct a picture of the client's current emotional state, mental capacity and behavioral function.

answer

Psychosocial Assessment

question

What impact might a psychotic state have on a client's psychosocial assessment?

answer

Insufficient attention span Unable to comprehend questions Parts of assessment may be incomplete or vague as a result.

question

Why is the client's health status an important aspect of the psychosocial assessment?

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The client's physical state can impact their emotional state as a result of pain, fatigue, etc. Medication or rest may be necessary to complete the assessment.

question

What type of environment should a psychosocial assessment be completed in?

answer

Comfortable, private and safe for both the nurse and the client. Should be a quiet place with as few distractions as possible. If the nurse's safety even has the possibility of being threatened, the interview should be conducted in a place that ensures help is nearby, or a third party may need to be in the room.

question

What is the number one concern during assessment?

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Safety

question

Why is the use of open-ended questions the optimal way to begin an interview?

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It allows the client to begin as they feel comfortable, and gives the nurse an idea of the client's perception of the situation. Use questions like: "Why are you here today?" "Tell me what has been happening to you." "How can we help you?"

question

When should the nurse use direct, closed-ended questions?

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If the client cannot organize their thoughts or has difficulty answering open-ended questions

question

It is important for the nurse to use _____ tone and language when asking questions in order to get the most honest responses.

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Nonjudgemental

question

What are the ten aspects of the psychosocial assessment?

answer

1. History (age, developmental stage, cultural considerations, spiritual beliefs, previous history) 2. General Appearance and Motor Behavior (hygiene/grooming, dress, posture, eye contact, any unusual movements/mannerisms, quality and clarity of speech) 3. Mood and Affect (expressed emotions/facial expressions) 4. Thought Process and Content (content, process, clarity of ideas, self-harm or suicidal thoughts or urges) 5. Sensorium and Intellectual Processes (Orientation, confusion, memory) 6. Abnormal Sensory Experiences or Misperceptions (concentration, abstract thinking abilities) 7. Judgement and Insight (judgement, decision-making ability, insight) 8. Self-Concept (personal view of self, description of physical self, personal quality and attributes) 9. Roles and Relationships (current roles, satisfaction with roles, success at roles, significant relationships, support systems) 10. Physiologic and Self-Care considerations (eating habits, sleep patterns, health problems, compliance with meds, ability to perform ADLs)

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What the client is thinking; what the client says

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Thought Content

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How the client is thinking; can be inferred from speech and speech patterns

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Thought Process

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Interpretation of environment

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Judgement

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Understanding one's own part in the current situation

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Insight

question

Why is cultural awareness so important in a psychosocial interview?

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The culture can influence what the client considers their role in society to be, and can also effect what they believe is acceptable social or personal behavior.

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What would a good way to determine how a client's culture influences their values and beliefs?

answer

Ask them, "what beliefs and health practices are important to you? How do you view yourself in the context of society and in relationships?" These questions should be modified to the client's level of understanding.

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Repeated purposeless behaviors often indicative of anxiety, such as drumming fingers, twisting locks of hair or tapping one's foot

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Automatisms

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Overall slowed movements

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Psychomotor Retardation

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Maintenance of posture or position over time even when it is awkward or uncomfortable

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Waxy Flexiblity

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What three aspects of speech should the nurse assess?

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Quantity Quality Any abnormalities such as nonstop talking, rhyming or perseveration

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A client who is stuck on a topic and seems unable to move to another idea is said to be exhibiting what?

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Perseveration

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Invented words that have meaning only for the client

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Neologisms

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A client's pervasive and enduring emotional state

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Mood

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A client's outward expression of emotional state

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Affect

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Showing little facial expression; slow-to-respond facial expression

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Blunted Affect

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Displaying a full range of emotional expressions

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Broad Affect

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Showing no facial expressions

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Flat Affect

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Displaying a facial expression that is incongruent with mood or situation; often silly or giddy regardless of circumstances

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Inappropriate Affect

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Displaying one type of expression; usually serious or somber

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Restricted Affect

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A rapidly changing mood; the client exhibits unpredictable and rapid mood swings that can quickly go from depressed and crying to euphoria with no apparent stimuli

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Labile Mood

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What type of questions should be used for clients who have marked difficulties with thought process and content?

answer

Focused questions requiring short answers

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A client eventually answers a question but only after giving excessive unnecessary detail

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Circumstantial Thinking

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You introduce yourself to a new client who arrives for their first interview. They respond with, "Hello, I am a famous actor...you might have heard of me. I've won three Oscars. Would you like an autograph?" What type of thought process might the client be exhibiting?

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Delusion

question

Your client arrives for her first interview. You say, "So, Lucy, tell me a little about you." Her response is made up of rapid, fragmented speech: "My dog is gray and purple is my favorite color of blanket but sleep is not fun, fun things are like running fast, that's how I go to the park, it has swings in the sun, and the sun is pretty like birds and flowers..." What kind of thought content is your client be exhibiting?

answer

Flight of Ideas

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You are meeting with a client, and she begins to tell you about her experience listening to the radio on her drive in this morning. "The disc jockey started talking about relationships, and I just knew she was talking about MY relationship..." What type of thought process is this client exhibiting?

answer

Ideas of Reference

question

You are interviewing a client for the first time. As he begins talking, you become unsure how he is relating his thoughts. He says things like, "I went to the market today and my mother was always very kind to me. A have a blue car, it gets really good gas mileage. Can you believe the price of ground beef these days?" What type of thought content is your client exhibiting?

answer

Loose Associations

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You are meeting with a client who has been suffering depression after the loss of her sister. You ask her how she has been coping since you last met. She replies, "fine, I guess..." So you delve deeper, and ask what she has been doing to cope. Her response is this: "Well retail therapy is always a good thing... hey, have you been to Kohl's lately? They're having this great sale on dresses. I found a beautiful green one that just looked amazing on me. So I had to buy it, and I'm so glad I did." She never truly answers your question. What type of thought process is this client exhibiting?

answer

Tangential thinking

question

A client is responding to your question, but suddenly stops mid-sentence. You wait, and wait, but they never complete their sentence. What type of thought content is the client exhibiting?

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Thought Blocking

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You're conducting an initial assessment on a client. You ask him why he is here today, and he stares back at you. You wait for a response. Finally he says, "You know." You ask, "what do I know?" The client responds, "you know everything. Everyone knows everything. Everyone can hear what I'm thinking." What type of thought process is this?

answer

Thought Broadcasting

question

During an interview, your client becomes agitated. She covers her ears and yells, "stop trying to put ideas in my head!" What type of thought process may she be exhibiting?

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Thought Insertion

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You are interviewing a client, and he seems quiet and withdrawn. You say, "Tell me what you are thinking." He responds with, "I can't. They took my thoughts. Every last one of them." What type of thought process is he exhibiting?

answer

Thought Withdrawal

question

Upon meeting your client for the first time, you notice her speech is slightly unintelligible. You ask why she is here, and her response is this: "The sheep languished blue trains suffer windows books dogs hands run desk making dinner sunglasses." What type of thought content is this?

answer

Word Salad

question

You ask your client to tell you more about why she stated she is angry at her best friend. This is her response: "So, last Tuesday, I was out shopping. I found the perfect pair of shoes. It fit just right, and it was the perfect color and it went perfectly with my favorite blue and pink dress with the little pink sweater. I love that dress, I wear it out all the time. I got home and tried on the dress with the shoes and it matched, and I was so excited! I decided to wear it to the club that weekend. Saturday night rolled around and I got all dressed up. I even went and got my hair done, because the club we were going to was REALLY fancy and I had to look the part. I got some new jewelry, too. It matched my favorite dress too. We got to the club and we were dancing and having such a good time. My favorite song was on, and we were out on the dancefloor, and my best friend had a glass of red wine in her hand. She spilled it all over my new shoes, and I was so upset. Now she won't buy me a new pair, and they are ruined!" This response demonstrates what type of thought content?

answer

Circumstantial Thinking

question

What seven questions should the nurse ask a client who has suicidal ideas?

answer

1. Are you thinking about killing yourself? 2. Do you have a plan? 3. How do you plan to kill yourself? 4. How would you carry out this plan? Do you have access to what you need to carry out your plan? 5. Where would you kill yourself? 6. When do you plan to kill yourself? 7. What time of day do you plan on killing yourself?

question

If a client makes remarks that are angry or hostile in regards to another person, what assessment questions must the nurse ask?

answer

What thoughts have you had about hurting them? What is your plan? What do you want to do to them?

question

The legal term for our responsibility as healthcare providers to alert a potential target of our client's plans to cause them harm; legal requirement to breach confidentiality

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Duty to Warn

question

True or false: A confused person cannot be oriented x 4.

answer

False A confused person cannot make sense of their surroundings or figure things out even though they may be fully oriented.

question

How does a nurse assess memory, both recent and remote?

answer

By asking questions with verifiable answers. Example: What is your social security number? Who is the current president?

question

What are some ways in which a nurse can assess a client's ability to concentrate?

answer

1. Spell "world" backward 2. Serial sevens (100, minus 7, minus 7, minus 7 etc) 3. Say the days of the week backward. 4. Give three instructions at one time, then have the client complete the actions. Example: stand up, place your left hand on your head, and stand on one foot.

question

Ability to make associations or interpretations about a situation or comment

answer

Abstract thinking

question

What is one common way a nurse may assess a client's ability to use abstract thinking?

answer

By using a common saying (i.e. 90% of inspiration is perspiration; a friend to all is a friend to none; all's fair in love and war, etc) After the nurse relays the saying to the client, she asks the client to interpret what the saying means.

question

A client continually gives literal translations, for example: Nurse: "An apple a day keeps the doctor away." Client: "If you have an apple, the doctor will leave you alone.

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Concrete thinking. If the client were capable of abstract thinking, the response would be similar to this: "Eating apples keeps you healthy so you don't need to go to the doctor."

question

How might a nurse assess a client's intellectual abilities?

answer

By having them compare two objects; i.e. "What do a banana and a pear have in common?" or "What is similar about a door and a window?"

question

False sensory perceptions that do not really exist; can involve any of the five senses and bodily sensations

answer

hallucinations

question

What are the first and second most common hallucinations experienced?

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1 - Auditory 2 - Visual

question

The ability to interpret one's environment and situation correctly and to adapt one's behaviors and decisions accordingly; i.e. knowing when it is safe to cross the street

answer

Judgement

question

How might a nurse assess a client's judgement?

answer

By asking hypothetical questions, like "if you found a stamped addressed envelope on the ground, what would you do with it?" or "if you saw a man hitch-hiking with an ax, what would you do?"

question

The ability to understand the true nature of one's situation and accept some responsibility for the situation, i.e. "I got arrested because I stole money that was not mine," rather than "I got arrested because Suzy called the cops on me."

answer

Insight - the second example, where the client blames the arrest on their friend rather than on the fact that they themselves broke the law, is that of "poor insight"

question

The way one views oneself in terms of personal worth and dignity

answer

Self-concept

question

How would the nurse assess the client's self-concept?

answer

Ask the client to describe themselves and what characteristics about themselves they would change.

question

What are some ways in which a nurse might assess a client's relationships, satisfaction with those relationships, or loss of relationship?

answer

Do you feel close to your family? Are you in a romantic relationship? Are there any needs you feel are not being met by the important people in your life? Has anyone been hurting you or abusing you? Have you ever been abused? Tell me what happened with your wife/husband. Do you feel safe at home? Is there anyone in your life who does not make you feel safe?

question

Questions about drug or alcohol use require ______ phrasing, because a truthful response is necessary in determining a plan of care.

answer

Nonjudgemental

question

Data _____ involves thinking about the overall assessment rather than bits of information.

answer

Analysis

question

5 objective personality assessments listed in textbook

answer

1. Minnesota Multiphasic Personality Inventory (MMPI-2) 2. Milton Clinical Multiaxial Inventory 3. Psychological Screening Inventory 4. Beck Depression Inventory 5. Tenessee Self-Concept Scale

question

3 projective personality assessments listed in textbook

answer

1. Rorschach Test 2. Thematic Apperception Test 3. Sentence Completion Test

question

Objective Personality test that involves 567 true/false items; provides score on 20 primary scales

answer

MMPI-2

question

Objective personality test that involves 175 true/false items; provides scores on various personality traits and personality disorders

answer

Milton Clinical Multiaxial Inventory (MCMI)

question

Objective personality test that involves 103 true/false items; used to screen for the need for psychological help

answer

Psychological Screening Inventory (PSI)

question

Objective personality test that involves 21 items rated on a scale of 0 - 3 to indicate the level of depression

answer

Beck Depression Inventory (BDI)

question

Objective personality test that involves 100 true/false items; provides information on 14 scales related to self-concept

answer

Tennessee Self-Concept Scale (TSCS)

question

Projective personality assessment; 10 stimulus cards of inkblots; client describes perceptions of inkblots; narrative interpretation discusses areas such as coping styles, interpersonal attitudes and characteristics of ideation

answer

Rorschach Test

question

Projective personality assessment: 20 stimulus cards with pictures; client tells a story about the picture; narrative interpretation discusses themes about mood state, conflict, and quality of personal relationships

answer

Thematic Apperception Test (TAT)

question

Projective personality assessment; client completes a sentence from beginnings such as "I often wish..." "Most people..." and "When I was young..."

answer

Sentence Completion Test

question

Personality test constructed of true/false or multiple choice questions

answer

Objective Personality Tests

question

Personality tests that are unstructured; usually conducted by interview method

answer

Projective Personality Tests

question

In regards to the mental status exam, the fewer tasks the client completes accurately, the greater the ____ ____.

answer

cognitive deficit

question

What exam is often used to screen for dementia due to its ability to assess cognitive function?

answer

Mental Status Exam

question

Which of the following is an example of an open-ended question? a. Who is the current President of the U.S.? b. What concerns you most about your health? c. What is your address? d. Have you lost any weight recently?

answer

B.

question

Which of the following is an example of a closed-ended question? a. How have you been feeling lately? b. How is your relationship with your wife? c. Have you had any health problems recently? d. Where are you employed?

answer

D.

question

Assessment data about the client's speech patterns are categorized in which of the following areas? a. History b. General Appearance and Motor Behavior c. Sensorium and Intellectual Processes d. Self-Concept

answer

B. Also included in this category is hygiene, grooming, dress, posture, eye contact, and unusual movements or mannerisms.

question

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? a. Thought content b. Thought process c. Memory d. Sensorium

answer

B. Thought process refers to how the client thinks, whereas thought content refers to what the client actually says. Thought content may be used to determine thought process, but it is the content that is ultimately being assessed.

question

The client's belief that a news broadcast has special meaning for him is an example of: a. abstract thinking b. flight of ideas c. ideas of reference d. thought broadcasting

answer

C.

question

The client who believes everyone is out to get him is experiencing a(n): a. delusion b. hallucination c. idea of reference d. loose association

answer

A.

question

To assess the client's ability to concentrate, the nurse would instruct the client to do which of the following? a. Explain what "a rolling stone gathers no moss" means b. Name the last three presidents c. Repeat the days of the week backward d. Tell what a typical day is like

answer

C. Other ways to do this include spelling "world" backward or counting backward from 100 by sevens.

question

This assessment should be completed within three days of admission, and includes a list of thirty items such as the client's appearance, affect, mood, memory, and perceptions, and rates each item on a scale of zero (never) to four (always)

answer

The Nurses' Observation Scale for Inpatient Evaluation (NOSIE)

question

What five aspects of cognition are assessed in a mini-mental status exam?

answer

Orientation Registration Attention & Calculation Recall Language

question

List the 10 major clinical scales measured by the MMPI-2.

answer

1. Hypochondriasis 2. Depression 3. Hysteria 4. Antisocial personality features 5. Comfort with sexual orientation 6. Paranoia 7. Anxiety 8. Schizophrenia 9. Mania 10. Social introversion

question

List what each of the five axis of the DSM identifies

answer

Axis I - Clinical Disorders Axis II - Personality disorders and conditions of mental retardation Axis III - General medical conditions Axis IV - Psychosocial and environmental problems Axis V - Global assessment of functioning

question

DSM-IV - Axis I

answer

Principal disorder that needs immediate attention Example: an exacerbation of schizophrenia or a major depressive episode. Usually what brings the client through the office door.

question

DSM-IV - Axis II

answer

Any personality disorder that may be shaping the current response to the Axis I problem; developmental disorders such as mental retardation which may predispose person to axis I problem. Example: someone with mental retardation may not have the coping skills to deal with a major life event and is more likely to experience a major depressive episode

question

DSM-IV - Axis III

answer

Any medical or neurological problems that may be relevant to current or past psych problems Example: SOB R/T asthma may be confused with a panic attack or may precipitate one

question

DSM-IV - Axis IV

answer

Major psychological stressors the individual has faced recently Examples: divorce, death of a loved one, job loss etc

question

DSM-IV - Axis V

answer

Level of function at time of assessment. Coded on a scale of 0-100 with 100 being perfect functioning (which is basically unattainable). Anything over 61 indicates the client is functioning at least pretty well. Anything over 81 indicates the client is functioning well, and has no more than "everyday" problems or concerns.

question

A numeric scale, 1 through 100, used by mental health clinicians and physicians to rate subjectively the social, occupational and psychological functioning of adults; score is often given as a range

answer

Global Assessment of Functioning (GAF)

question

At what GAF range would a client be considered a danger to self?

answer

41-50 = suicidal ideation 21 - 30 = suicidal preoccupation 11-20 = suicide attempts without clear expectation of death 1-10 = suicide attempt with clear expectation of death

Psych Nursing Chapter 8 – Assessment – Flashcards

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