Assessment

Question 1

What are the Nursing Process and Clinical Judgment Action Model?

Answer 1

1. Recognize Cues
2. Analyze cues
3. Prioritize hypothesis
4. Generate solutions
5. Take action
6. Evaluate outcomes

Question 2

What are the American Psychiatric Nurse Association Standards?

Answer 2

Similar to the nursing process.
1. Assessment
2. Diagnosis
3. Outcome Identification
4. Planning
5. Implementation
6. Evaluation

Question 3

What are the purposes of Psychosocial Assessment?

Answer 3

1. Gather information related to the presenting symptoms
2. Picture of the patient’s emotional state, mental capacity, and behavioral function
3. Clinical BASELINE to evaluate the effectiveness of treatment and interventions or measure patient’s progress

Question 4

Psychosocial assessment is just as important as what?

Answer 4

How the Psychosocial assessment is conducted is just as crucial in completing as the physical assessment!

Question 5

For doing the psychosocial assessment, what kind of interview technique would you use? What are they?

Answer 5

“FUNNEL” Interview Technique (Layering)!
1) Open-ended questions!
And then..
2) Clarifying Questions (Who, What, Where, When, Why, How?)
And then…
3) Closed ended questions

Question 6

What are examples of Open and Closed ended questions?

Answer 6

1) Open-ended: “Tell me about why you came to the hospital?” “What are you most worried about?”

2) Closed-ended: “Does it hurt?” “Are you sad?”

Question 7

Even though close-ended questions are not beneficial in gaining more of the client’s thoughts in their own words, closes-ended questions are important in what?

Answer 7

Important in assessing a client’s risk of SUICIDE or Self-harming behaviors!!!!!!
Often clients want someone who cares to ask about their thoughts, including direct questions about their thoughts regarding suicide or self-harm

Question 8

What are the 7 Factors influencing the Assessment??

Answer 8

1) Patients ability to participate in the assessment
2) Patients health status.
3) Their previous experience/misconceptions about healthcare
4) Patients ability to understand and communicate
5) Nurse’s attitude approach! Ex: Approach the patient non reactive and nonjudgmental
6) Not rushing, focusing on the pt without distractions
7) Displaying a genuine interest in what the patient has to say!

Question 9

What are included in Affect?

Answer 9

Affect is observable emotions/expressions and is defined by the interviewer.
1. Blunted- Showing littler to No expression & no voice change
2. Broad- Displaying FULL RANGE OF emotions

Question 10

When you’re doing the interview for ur assessments, how should the interview be done?

Answer 10

1. Environment:
   1) Comfortable, private, and safe
   2) Quiet with few distractions. Make sure that they’re not anxious, paranoid, & feel safe!
2. Input from family, friends (PERMISSION IS NEEDED FROM THE PATIENT)!!!!
   1) Information about their perceptions. It’s good to talk to the family separately to get their perception of what they see is going on.
3. Questions:
   1) Open-ended to initiate assessment
   2) Focused if patient is unable to organize thoughts or has difficulty answering open-ended questions!!!

Question 11

What patient history should you assess?

Answer 11

1. Age
2. Developmental stage
3. Cultural considerations
4. Spiritual beliefs
5. Tobacco and Alcohol/drug use

Question 12

What would you assess for in a Focused Physical Assessment???

Answer 12

1. Hygiene/ Grooming
2. Appropriate dress
3. Posture
4. Eye contact
5. Usual movements/mannerism
   - Automatism, psychomotor retardations, waxy flexibility
6. Speech: Quality, Quantative, Rate, and Volume
   - Neologism: words that have meaning to you but not to others
7. Dental health
8. Visions/eye health
9. Sexual/reproductive health – look for sexually transmitted disease

Question 13

During interview, how should you should ASSESS their MOOD??**

Answer 13

1. The patient’s emotions
2. “How have you been feeling these days?”
3. List the mood in the patient’s OWN words!!!
4. Rate the mood on a scale of 1-10!
5. Look for NON-VERBAL CUES, like if they’re depressed, anxious, or happy

Question 14

What are the affect and the 6 types of it??

Answer 14

Observable emotions/ facial expressions defined by the interviewer!
1. BLUNTED – Showing little to no emotions & no voice changes
2. BROAD – Displaying FULL RANGE of motions
3. Flat – showing no facial expressions.
4. Inappropriate – Laughing at something that somebody would be crying over about
5. Restricted – patient is Guarded
6. Labile – up & down, flunctuating

Question 15

How is the patient’s thought process assessed?

Answer 15

Through the patient’s speech and speech patterns.

Question 16

What are the 5 Thought Processes???

Answer 16

1. Circumstantial thinking – They eventually answer the questions, but they give lots of details before
2. Flight of ideas – Excessive amnt of info or rate of speech with fragmented unrelated ideas
3. Loose association – disorganized thinking & it jumps from one idea to another but it’s completed
4. Tangential thinking – wandering off the topics you’ve been asked and NEVER answering the question
5. WORD SALAD – Completely connected; basically random words put in together!

Question 17

What should the nurse assist in regards of the patient’s thought content??

Answer 17

1. MUST assess and document suicide and harm towards others!! (remember the Duty to Warn)
2. Assess and document the presence of Delusional thinking

Question 18

What are the Suicide Assessment Questions??

Answer 18

1. Ideation
2. Plan
3. Method
4. Access
5. Where, When, How, & Timing???

Question 19

What is Delusions????? What is Bizarre Delusions??

Answer 19

Delusions: Fixed, false beliefs with no basis in reality. The false belief is firmly maintained despite evidence of the contrary!!!!!!!!
Bizarre Delusion: Clearly implausible and incomprehensible false belief that does not derive from ordinary experiences

Question 20

What are the Delusions Thought Content???

Answer 20

1. Thought Blocking – When they’re talking to someone and stop mid sentence
2. Thought Broadcasting – Delusion beliefs that others are broadcasting their thoughts & would know what they’re thinking about
3. Thought Insertion – Beliefs that others are putting thoughts into their heads
4. Thought withdrawal – Beliefs that others are taking their thoughts away & they can’t stop it!!

Question 21

What are Persecutory? Grandiose? Somatic? Delusion of Reference? and Idea of reference????

Answer 21

1. Persecutory – a belief that others are trying to harm them
2. Grandiose – a belief that they know it all
3. Somatic – a belief that their organs are infected
4. Delusion of Reference – a belief that the events within the environment are referring to them. EX: “The man on the radio is talking about me!”
5. Idea of Reference – Is less rigid than delusion of reference. EX: “In the store, there are 2 girls behind me and I know that they’re talking about me” even though they’re not.

Question 22

What is the difference between hallucination and Illusion?????**

Answer 22

Hallucination: there’s nothing there, while
Illusion: there’s actually something there but they perceive it as smth else!!!!

Question 23

How do you test pt orientation, memory, concentration, and ABSTRACT thinking abilities???

Answer 23

1.

Question 24

When ur assessing someone with their eating habit, what do you ask them???????**

Answer 24

“What do you eat in a typical day?” **
Not

Question 25

What is a BROAD mood?????**

Answer 25

Displaying full range of emotion;
IT IS TYPICAL mood expected of the average person. They appear happy when they feel happy and sad when they’re sad!

Question 26

What is Loose association?

Answer 26

Disorganized thinking & it jumps from one idea to another But it’s completed.

EX: “ I like to dance. All the people have hands. I like to play because the river is flowing down the mountain. The weather is sunny”

Question 27

What is tangential thinking?

Answer 27

Wandering off the topics that have been asked and NEVER Answering the question!!!

Question 28

What is word salad?

Answer 28

bunch of random words together.

Question 29

What is circumstantial thinking?

Answer 29

They will eventually answer the question, but they give lots of details before.

Question 30

What is flight of ideas?

Answer 30

Excessive amnt of info and rate of speech with fragmented unrelated ideas.