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NRSG 126: Mental Health > Chapter 8: Assessment > Flashcards

Chapter 8: Assessment Flashcards

1
Q

What does assessment involve?

A

Collection, organization, and analysis of information about client’s health

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2
Q

What is assessment often referred to?

A

Psychosocial Assessment, which includes mental status examination

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3
Q

Purpose of psychosocial assessment?

A

Construct a picture of clients current emotional state, mental capacity, and behavioral function

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4
Q

Client’s Health Status: The informaiton that the nuse obtains may reflect what?

A

Client’s pain or anxiety rather than assessment of the clients situation. REcognize these situation and deal with them before continuing assessment

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5
Q

Client’s Previous Experiences / Misconceptions about Health Care: What may cause the client to have difficulty answering questions directly?

A

If client is reluctant to seek treatment or has previous unsatisfactory experiences with the health care system . May minimize or maximize symptoms or problems

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6
Q

Nurses Attitude and Approach: If client feels questions to be short or rush, what may happen?

A

May provide only superficial information or omit discussing problems in some areas together

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7
Q

Environment: Where should a psychosocial assessment be conducted?

A

An environment that is comfortable, privaee, and safe for both client and nurse

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8
Q

Environment: Where should you never perform an assessment?

A

An isolated location , particularly if the client is unknown

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9
Q

How to Phrase Questions: How should an assessment be started?

A

With open-ended questions

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10
Q

How to Phrase Questions: Examples of open-ended questions to begin assessment?

A

What brings you here today?

Tell me what has been happening to you

How can we help you?

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11
Q

How to Phrase Questions: How do questions need to be?

A

Clear, simple, and focused on one specific behavior or symptom

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12
Q

How to Phrase Questions: What are some examples of focused or closed-ended questions?

A

How many hours did you sleep last night?

Have you been thinking about suicide?

How well have you been sleeping?

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13
Q

How to Phrase Questions: what tone should nurse use?

A

Nonjudgmental tone and language, particularly when asking about sensitive information

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14
Q

How to Phrase Questions: How would you phrase a question toward a client in regards to their parenting role?

A

“What types of discipline do you use” rather than “how often do you physically punish your child”

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15
Q

How to Phrase Questions: When beginning an assessment, nurse must address

A

the client’s feelings and perceptions to establish a trustiing working relationship before proceeding with the assessment

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16
Q

Content of the Assessment: What is the framework that we should use?

A

History

General Appearance/Motor Behavior

Mood and Affect

Thought Process and Content

Sensorium and Intellectual Processes

Judgement and Insight

Self-Concecpt

Roles and Relationships

Physiologic and Self-Care Concerns

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17
Q

Content of the Assessment: What components fall under history?

A

Age, developmental stage, cultural considerations, spirtiual beliefs, previous history

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18
Q

Content of the Assessment: What components fall under general assessment and m otor behavior?

A

Hygiene and grooming, appropriate dress, posture, eye contact, unusual movement, speech

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19
Q

Content of the Assessment: What compoennts fall under mood and affect?

A

Expressed emotions, facial expressions

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20
Q

Content of the Assessment: What components fall under thought process and content?

A

Content (what clients thinking), process (how client is thinking), clarity of ideas, self-harm or suicide urges

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21
Q

Content of the Assessment: What falls under sensorium and intellectual processes?

A

Orientation, confusion, memory

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22
Q

Content of the Assessment: What falls under abnormal sensory experiences or misperceptions

A

concentration and abstract thinking abilitites

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23
Q

Content of the Assessment: What falls under judgement and insight?

A

Judgement (interpretation of environment, decision-making ability, insight (understanding one’s own part in current sitation)

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24
Q

Content of the Assessment: What falls under self-concept ?

A

Personal view of self, description of physical self, personal qualities or attributes

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25
Q

Content of the Assessment: What falls under roles and relationships?

A

Current roles, satisfaction with roles , success at roles, significant relationships, support systems

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26
Q

Content of the Assessment: What falls under physiologic and self-care considerations?

A

Eating habits, sleep patterns, health problems

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27
Q

History: Background assesments include

A

clients history, age, and developmental stage, cultural and spiritual beliefs, and beliefs about health and illness

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28
Q

History: What insight may a family provide about a patients past?

A

Has client experienced similar diffilties in the past? Has client been admitted into hospital?

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29
Q

History: What does western culture except of poeple when they reach adulthood?

A

They will become financially independent, leave home, and make their own life decisions

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30
Q

History: What doesEastern culture expect of people when they reach adulthood?

A

In some households, three generations may live in a household and elders of family make decisions for all.

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31
Q

History: To avoid making inaccurate assumptions about one cultures, what should a nurse ask?

A

Nurse must ask clients about the beliefs or health practices that are important to them or how they view themselves in context of socieety

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32
Q

General Appearance and Motor Behavior: What does the nurse assess here?

A

The client’s overall appearance including dress, hygiene and grooming. Are they appropriately dress for their age and weather? Is client unkempt or disheveled?

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33
Q

General Appearance and Motor Behavior: What are some specific terms used in making assessments of general appearance and motor behavior?

A

Automatisms, Psychomotor Retardation, Waxy Flexibility

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34
Q

General Appearance and Motor Behavior: What are Automatisms?

A

Repeated, purposeless behaviors often indicative of anxiety, such as drumming fingers, twisting locks of hair or tapping food

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35
Q

General Appearance and Motor Behavior: What is Psychomotor Retardation?

A

Overall slowed movements

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36
Q

General Appearance and Motor Behavior: What is waxy flexibility?

A

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

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37
Q

General Appearance and Motor Behavior: Another thing they look for are neologisms. What is this?

A

Invented words that have meaning only for the client.

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38
Q

Mood and Affect: Mood refers to what?

A

Clients pervasive and enduring emotional state. Client may make statements about feelings like “Im depressed”

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39
Q

Mood and Affect: What does Affect mean?

A

Outward expression of the client’s emotional state. Client may infere clients mood from postures , gestures, or ton e

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40
Q

Mood and Affect: Common terms used in assessing affect include?

A 
Blunted Affect
Broad Affect
Flat Affect
Inappropriate Affect
Restricted Affect
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41
Q

Mood and Affect: What is Blunted Affect?

A

Showing little or a slow-to-repsond facial expression

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42
Q

Mood and Affect: What is Broad Affect?

A

Displaying a full range of emotional expressions

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43
Q

Mood and Affect: What is Flat Affect?

A

Showing no facial expression

44
Q

Mood and Affect: What is Inappropriate Affect?

A

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

45
Q

Mood and Affect: What is restricted affect?

A

Displaying one tpye of expression ,usually serious or somber

46
Q

Mood and Affect: What is labile called?

A

When the client exhibits unpredictable and rapid mood swings from depressed and crying to euphoria with no apparent stimuli

47
Q

Thought Process and Content: What is Thought Process?

A

Refers to how the client thinks. Can infer clients thought process from speech and speech patterns

48
Q

Thought Process and Content: What is Thought Content?

A

Is what the client actually says.

49
Q

Thought Process and Content: What are some common terms related here?

A 
Circumstantial Thinking
Delusion
Flight of Ideas
Ideas of Reference
Loose Associations
Tangential Thinking
Thought Blockng
Thought Broadcasting
Thought Insertion
Thought Withdrawal
Word Salad
50
Q

Thought Process and Content: What is Circumstantial Thinking?

A

Client evantually answers a question but only after giving excessive unneccesary detail

51
Q

Thought Process and Content: What is Delusion?

A

Fixed false belief not based in reality

52
Q

Thought Process and Content: What is Flight of Ideas?

A

Excessive amount and rate of speech composed of fragmented or unrealted ideas

53
Q

Thought Process and Content: What is ideas of reference?

A

Clients inaccurate interpretation that general events are personally directed to him or her, such as hearing a speech on the news

54
Q

Thought Process and Content: What are loose associations?

A

Disorganized thinking that jumps from one idea to another with little or no evident relation

55
Q

Thought Process and Content: What is tangential thinking?

A

wandeirng off topic and never providing the information requested

56
Q

Thought Process and Content: What is thought blocking?

A

stopping abruptly in the middle of a sentence or train of thought

57
Q

Thought Process and Content: what is thought broadcasting?

A

delusional belief that others can hear or know what client is thinking

58
Q

Thought Process and Content: What is thought insertion?

A

delusional belief that others are putting ideas or thoughts into clients head

59
Q

Thought Process and Content: What is thought iwthdrawal?

A

delusioal belief that others are taking the clients thoughts away

60
Q

Thought Process and Content: What is word salad?

A

Flow of unconnected words that convey no meaning to the listener

61
Q

Assessment of Suicide or Harm Toward Others: How does the nurse ask the patient if he has plans of suicide?

A

Must ask them directly.

62
Q

Assessment of Suicide or Harm Toward Others: Ideation Suicide example

A

are you thinking about killing yourself

63
Q

Assessment of Suicide or Harm Toward Others: plan suicide example

A

do you have a plan to kill yourself

64
Q

Assessment of Suicide or Harm Toward Others: method suicide example

A

how do you plan to kill yourself

65
Q

Assessment of Suicide or Harm Toward Others: access suicide exampleh

A

how would you carry out this plan. Do you have access to the measn to carry out this plan

66
Q

Assessment of Suicide or Harm Toward Others: where suicide example

A

where would you kill uyourself

67
Q

Assessment of Suicide or Harm Toward Others: when suicide example

A

when do you plan to kill yourslef

68
Q

Assessment of Suicide or Harm Toward Others: timing suicide example

A

what day or time of day o you plan to kill yourself

69
Q

Assessment of Suicide or Harm Toward Others: What should nurse do when client makes specific threats?

A

Legally obligated to warn the person who is the target of the threats or plan

70
Q

Orientation: What is this?

A

Refers to the client’s recognition of place, person, time

71
Q

Orientation: What is the order of which a person becomes disoriented?

A

First loses track of time
Then Place
Then PErson

72
Q

Orientation: How does orientation return to a person?

A

First person, then place, and finally tim e

73
Q

Orientation: Different between disorientation and confusion?

A

Confused person cannot make sense of his or her surroundings or figure things out

74
Q

Memory: How can a nurse verify memory?

A

By not asking if theyhave memory issues, but ask them to specifially recall something

75
Q

Memory: Some questions to assess memory?

A

What is the name of the current president?

Who was the president before that?

76
Q

Ability to Concentrate: How does the nurse assess this ability?

A

Ask client to spell world backword.

Serial Sevens

Repeat days of the weak backward

77
Q

Abstract Thinking and Intellectual Abilities: Nurses asseses ability for abstract thinking. What is this?

A

Making associations or interpretations about a siutation or comment. Can do this by asking client to interpret “a stitch in time says nine”

78
Q

Abstract Thinking and Intellectual Abilities: What is concrete thinking?

A

When a client continually gives literal translations

79
Q

Abstract Thinking and Intellectual Abilities: Example of Abstract vs Concrete thinking?

A

People who live in glass houses shouldn’t throw stones

Abstract: Don’t critize others for things you may be guilty of doing
Literal: If you throw a stone at a glass house, the glass will break

80
Q

Sensory-Perceptual Alterations: What are Hallucinations?

A

False sensory perceptions or perceptual experiences that do not really exist. Involve the five senses.

81
Q

Sensory-Perceptual Alterations: Most common Hallucination?

A

Auditory hallucination

82
Q

Judgement and Insight: What is judgement?

A

Refers to the ability to interpret one’s environment and siutation correctly and to adapt one’s behavior and decisoins accordingly

83
Q

Judgement and Insight: What is insight?

A

Ability to understand the true nature of one’s siutation and accept some personal responsibility for that siutation

84
Q

Judgement and Insight: Nurse can frequently infer from insight form client’s ability to

A

realistically describe the strengths and weaknesses of his or her behavior

85
Q

Judgement and Insight: Example of poor insight?

A

Client who places all blame on others for his own behavior saying “It’s my wifes fault hat I drink and get into fightS:

86
Q

Judgement and Insight: Another example of pooor insight?

A

Expects all problems to be solves with little or no personal effort

87
Q

Self-Concept: What is this?

A

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

88
Q

Self-Concept: How do you assess this?

A

Nurse can ask client to describe him or herself , what characteristic they like, or what theyd change

89
Q

Roles and Relationships: Types of role may vary but they usually include

A

family, occupation, and hobbies or activites

90
Q

Roles and Relationships: Family roles include

A

son/daughter, sibiling, parents, children

91
Q

Roles and Relationships: questions to ask client?

A

Do you feel close to your family?

Do you hve/want relationship with SO

Can you meet your sexual needs satisfactiorily?

92
Q

Roles and Relationships: Due to social media, it is important to do what?

A

Distinguihs between face-to-face contact with others versus online contact. May not actually be friends with those people

93
Q

Data Analysis: This involves thinking about

A

the overall assessment rather than focusing on isolated bits of information . Looks for patterns or themes

94
Q

Data Analysis: TRaditionally , data anlysis leads to the formulation

A

of nursing diagnoses as a basis for hte client’s plan of care

95
Q

Psychological Tests: Two basic types of tests are

A

inteligence tests and personality tests

96
Q

Psychological Tests: Intelligence tests are designed to evaluate

A

the clients cognitive abilitites and intellectual functioning

97
Q

Psychological Tests: Personality tests reflect

A

the clietns personality in areas such as self-concept, impulse control, reality testing, and major defenses

98
Q

Psychological Tests: Personality tests may be objective meaning

A

constructed of true-or-false or multiple coice questions

99
Q

Psychological Tests: Other personality tests are called projective tests. What are these?

A

unstructured and are suually conducted by the interview method

100
Q

Psychological Tests: Stimuli for projective tests are

A

pictures or rorschachs inkblots but may respond with answers that vary widely

101
Q

Psychological Tests: Both intelligence tests and personality tests are frequently critized as being

A

culturally biased. Important to consider client’s culture and environment

102
Q

Psychiatric Diagnoses: What is the DSM-5?

A

Medical didagnsoes of psychiatric illness are found here. Universally used in diagnoses of illness

103
Q

Mental Status Examination: What does an exam for ones cognitive ability include?

A

Orientation to person, time, place, date, season and day of week

Ability to interpret proverbs

Ability to perform math calculations

Ability to write

104
Q

Components of a through pschosocial assessment include

A

clients history, general appearance and motor behavior , mood and affect, thought process and content, sensorium and intellectual process, judgement and insight, self-concept , roles and relationships, and physiologic and self-care considerations

105
Q

What important factors in client can influence the psychosocial assessment?

A

Ability to participate and give feedback

Physical health status

emotional well-being adn perception of situation

ability to comunicate

NRSG 126: Mental Health (24 decks)

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