ch 8

Question 1

which is an example of an open ended question?

Answer 1

What concerns you most about your health?

Question 2

which is an example of a close ended question?

Answer 2

where are you employed

Question 3

assessment data about the clients speech patterns are categorized in which of the following areas?

Answer 3

-general appearance and motor behavior

Question 4

when the nurse is assessing whether the client’s ideas are logical and make sense, the nurse is examining which of the following areas?

Answer 4

-though process

Question 5

the client’s belief that a news broadcast has special meaning for him or her is an example of

Answer 5

-ideas of reference

Question 6

the client who believes everyone is out to get him or her is experiencing a

Answer 6

-delusion

Question 7

to assess the client’s ability to concentrate, the nurse would instruct the client to do which?

Answer 7

-repeat the days of the week backwards

Question 8

the client tells the nurse “I never do anything right. I make a mess of everything. Ask anyone, and they will tell you the same thing”
the nurse recognizes these statements as examples of

Answer 8

-negative thinking

Question 9

assessment of sensorium and intellectual processes includes which? select all that apply

Answer 9

-concentration

-memory

-orientation

Question 10

assessment of suicidal risk includes which? select all that apply

Answer 10

-intent to die

-method

-plan

-reason

Question 11

when assessing a patients mental health status, which of the following describe the purpose of psychosocial assessment? select all

Answer 11

-to assess current emotional state

-mental capacity

-behavioral function

Question 12

which of the following factors influencing assessment is under the nurses control

Answer 12

attitude and approach

Question 13

which of the following are components of the assessment of thought process and content? select all

Answer 13

-what the client is thinking

-how the client is thinking

-clarity of ideas

-self harm or suicide urges

Question 14

a licentious is being evaluated for dementia. the nurse knows that the celtic who is able to complete very few tasks is most likely to have

Answer 14

a greater cognitive deficit

Question 15

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

Answer 15

perception of the problem

Question 16

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

Answer 16

thinking

Question 17

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

Answer 17

concentration

Question 18

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

Answer 18

the client’s ability to use abstract thinking

Question 19

the nurse is assessing suicide potential in a patient who has expressed hopelessness. in what order does the nurse question about suicidal thoughts?

Answer 19

-are you thinking about killing yourself?

-do you have a plan

-how do you plan to

-how would you carry out the plan

Question 20

the nurse best assesses a patients memory by asking which of the following questions?

Answer 20

who is the current president

Question 21

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 patients affect

Answer 21

flat affect

Question 22

a 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?

Answer 22

delusional thinking

Question 23

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

Answer 23

wandering off the topic and never answering the question

Question 24

the nurse can best assess a patients ability to use abstract thinking by asking the patient which of the following questions

Answer 24

what do i mean when i say, don’t sweat the small stuff

Question 25

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

Answer 25

judgment

Question 26

the client spoke of a current event in the national news 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

Answer 26

where were you when this happened?

Question 27

which of the following questions is best to ask when assessing the client’s judgment?

Answer 27

if you found yourself downtown without money or a car, how would you get home

Question 28

the nurse asks the client, what is similar about a cow and a horse? and what do a bus and a plane have in common? these questions would best assess which of the following areas?

Answer 28

intellectual function

Question 29

which of the following would best assess a client’s judgment?

Answer 29

discussing hypothetical situations

Question 30

the nurse plans to assess a patients self concept in admission assessment knowing that self concept influences which of the following? select all that apply

Answer 30

-body image -frequently experienced emotions -coping strategies

Question 31

which of the following are the types of roles that are usually included when assessing roles and relationships? select all

Answer 31

-family -hobbies -occupation -activities

Question 32

knowing that relationships with others are significant to mental health, the nurse effectively assesses a patients family relationships through which of the following?

Answer 32

describe your relationships with your family

Question 33

a nurse assesses that a depressed patient is lethargic during the day and does not actively participate in activities. the notes from the last shift say they did not sleep well. the most probable interpretation of these data is

Answer 33

the patients depressed mood is impairing restful sleep patterns

Question 34

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?

Answer 34

emphasize the importance of truthful information using a nonjudgmental approach

Question 35

the nurse has completed the psychosocial assessment. which of the following is the best approach toward analysis of the data to identify nursing diagnosis and develop an appropriate plan of care?

Answer 35

look for patterns reflected in the overall assessment

Question 36

the nurse reviews the results of the MMPI recorded in patient record. while considering the usefulness of these data, the nurse is mindful that the MMPI has which limitation?

Answer 36

the result of the MMPI could be culturally biased

Question 37

the client tells the nurse that the new tv anchor is telling the world about me. this is an example of

Answer 37

ideas of reference

Question 38

during the admission assessment, the client says they were able to save money on my gas that was 11.7 gallons. this is what type of response

Answer 38

circumstantial thinking

Question 39

a client is admitted to the psychiatric unit and states, i am president of the largest corporation in the world. the client is exhibiting which of the following

Answer 39

delusion

Question 40

in the space of 5 minutes, the client has been laughing then crying for no reason. this behavior is best described as

Answer 40

labile mood

Question 41

throughout the assessment, the client displays disorganized thinking. this is called what

Answer 41

loose associations

Question 42

an effective way for nurses to deal with self harm and sexuality is

Answer 42

recognizing that these topics may also be difficult for the patient to discuss

Question 43

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

Answer 43

it is the nurse’s professional responsibility to keep safety needs first and foremost