Assessjment-Ch 8-T1

Question 1

Psychosocial Assessment

Purpose

Answer 1

Picture of patient’s current emotional state, mental capacity, behavioral function.

Basis for developing plan of care.

Clinical baseline to evaluate effectiveness of treatment or measure patient’s progress.

Question 2

Factors Influencing psychosocial Assessment

Answer 2

Patient participation/feedback.

Client’s health status.

Client’s previous experiences/misconceptions about health care.

Client’s ability to understand.
Nurse’s attitude, approach.

Question 3

Interview Questions

Answer 3

Open-ended to initiate assessment.

Focused if patient unable to organize thoughts or has difficulty answering open-ended questions.

Question 4

Assessment Content: History

Answer 4

Age
Developmental stage
Cultural considerations
Spiritual beliefs
Previous history

Question 5

Waxy flexibility

Answer 5

maintenance of a posture/position over time even when it is awkward or uncomfortable.

Question 6

Automatisms

Answer 6

repeated purposeless behaviors often indicative of anxiety (drumming fingers, twisting hair, foot tapping).

Question 7

Psychomotor retardation

Answer 7

overall slowed movements.

Question 8

neologisms

Answer 8

invented words that have meaning only for the client.

Question 9

Labile

Answer 9

Rapidly changing mood, unpredictable.

Question 10

Affect

Answer 10

the outward expression of the emotional state

Question 11

Blunted (facial expression)

Answer 11

showing little or slow-to-respond facial expression

Question 12

Broad (facial expression)

Answer 12

displaying full range of expression.

Question 13

Flat (facial expression)

Answer 13

showing no facial expression

Question 14

Inappropriate (facial expression)

Answer 14

displaying a facial expression that is incongruent with mood or situation (silly, giddy).

Question 15

Restricted (facial expression)

Answer 15

displaying one type of expression (serious, somber).

Question 16

Thought process/content:

Content (what the client ____) and process (how client ___).

Answer 16

says

thinks

Question 17

Circumstantial thinking

Answer 17

answers question only after giving excessive unnecessary detail

Question 18

Delusion

Answer 18

a fixed false belief not based in reality.

Question 19

Flight of ideas

Answer 19

excessive amount & rate of speech composed of fragmented or unrelated ideas.

Question 20

Ideas of reference

Answer 20

inaccurate interpretation that general events are personally directed toward them.

Question 21

Loose associations

Answer 21

disorganized thinking that jumps from one idea to another with little relation between thoughts.

Question 22

Tangential thinking

Answer 22

wandering off topic & never providing the information requested.

Question 23

Thought broadcasting

Answer 23

belief others know what the client is thinking

Question 24

insertion

Answer 24

belief others are putting thoughts into client’s head

Question 25

blocking (in referance to thought process)

Answer 25

stopping abruptly

Question 26

withdrawal (in reference to thought process)

Answer 26

others are taking thought away

Question 27

Word salad

Answer 27

flow of unconnected words that convey no meaning

Question 28

Orientation/confusion

Answer 28

person, place, time, situation.

Question 29

Memory

Answer 29

recent/remote.

Question 30

Concentration

Answer 30

ask client to do tasks – spell word backwards.

Question 31

Abstract thinking abilities

Answer 31

interpret a common proverb – literal interpretations are evidence of concrete thinking.

Question 32

Judgment

Answer 32

interpretation of environment

Question 33

Insight

Answer 33

understanding one’s own part in current situation

Question 34

Self-concept:

Answer 34

Personal view of self. Description of physical self. Personal qualities or attributes.

Question 35

Roles/relationships

Answer 35

Current roles. Satisfaction with roles. Success at roles. Significant relationships. Support systems (see Box 8.3, p.145).

Question 36

Physiologic and self-care considerations

Answer 36

Eating habits. Sleep patterns. Health problems. Compliance with prescribed medications. Ability to perform activities of daily living.

Question 37

Overall assessment data

Answer 37

Not isolated bits of information Patterns or themes in data → nursing diagnoses

Question 38

Psychological tests

Answer 38

IQ & personality tests

Question 39

Psychiatric diagnoses

Answer 39

DSM-5

Question 40

Mental status exam (MSE

Answer 40

focuses on cognitive abilities

Question 41

Intelligence tests:

Answer 41

Cognitive abilities | Intellectual functioning

Question 42

Personality tests: Reflect the client’s personality in areas such as

Answer 42

self-concept, impulse control, reality testing, major defense mechanisms.

Question 43

Diagnostic and Statistical Manual of Mental Disorders (DSM

Answer 43

The DSM classifies psychiatric disorders into categories. | The DSM describes each disorder and provides the diagnostic criteria for each disorder.

Question 44

cognitive abilities

Answer 44

Orientation to person, time, place, date, season, day of the week. Interpretation of proverbs. Math calculations. Memorization, short-term recall. Identification of common objects. Ability to follow multistep commands. Ability to write or copy a simple drawing