Chapter 9 Flashcards
The nurse asks the client a series of questions upon entry into a mental health care system.
This action is an example of which phase of the nursing process?
a. Evaluation
b. Assessment
c. Intervention
d. Planning
ANS: B
Assessment is the phase of the nursing process during which data collection occurs. It is performed not only upon admission into a facility but throughout the care of the client. Evaluation is the phase during which goals are evaluated to determine whether they have been met, partially met, or not met at all; intervention is the phase of the nursing process when planned interventions are actually implemented; planning is the phase of the nursing process when client goals are set and interventions are planned.
A nurse administers antidepressant medication to a client in an assisted-living facility. This is an example of which phase of the nursing process?
a. Intervention
b. Assessment
c. Planning
d. Diagnosis
ANS: A
Intervention is the phase of the nursing process during which planned interventions are actually implemented. Assessment is the phase of the nursing process when data collection occurs. Planning is the phase of the nursing process when client goals are set and interventions are planned. Diagnosis is the phase of the nursing process following assessment when the client’s problem is identified.
Following completion of a male client’s series of group therapy sessions, the nurse periodically talks with the client to determine whether he has any signs of relapse of his previous problems. This action by the nurse is an example of:
a. Planning
b. Assessment
c. Intervention
d. Diagnosing
ANS: B
In this situation, the nurse is assessing for any signs of relapse. Assessment is a continuous process. Planning is the phase of the nursing process when client goals are set and interventions are planned; intervention is the phase of the nursing process when planned interventions are actually implemented; and diagnosis is the phase of the nursing process following assessment when the client’s problem is identified.
During a session with a female client with a diagnosis of social phobia, she talks about how proud she is of herself because she was finally able to shop at the grocery store. The nurse documents the events and knows that this would be considered which phase of the nursing process?
a. Assessment
b. Planning
c. Intervention
d. Evaluation
ANS: D
This client has accomplished a goal; therefore, this would be considered evaluation. Assessment is the phase of the nursing process when data collection occurs; planning is the phase of the nursing process when client goals are set and interventions are planned; and intervention is the phase of the nursing process when planned interventions are actually implemented.
The treatment team meets with a client for the first time and determines, with the client’s input, a nursing diagnosis, goal, and steps to reach this goal. In addition to a nursing diagnosis, the treatment team has completed which phase of the nursing process?
a. Evaluation
b. Intervention
c. Planning
d. Assessment
ANS: C
During the planning phase, goals are established and a plan is developed. Evaluation is the phase in which goals are evaluated to determine whether they have been met, partially met, or not met at all; intervention is the phase of the nursing process when planned interventions are actually implemented; and data collection occurs during the assessment phase.
Without assessment of six specific aspects of an individual’s being, the mental health nurse’s scope of care is narrow and limited in effectiveness. These aspects include social, physical, cultural, intellectual, emotional, and spiritual areas of a person’s life, known as a __________ assessment.
a. Complete
b. Accurate
c. Holistic
d. Psychiatric
ANS: C
Although the other options do address some of these aspects, holistic more accurately describes these six aspects of an individual’s life. The psychiatric assessment tool specifically addresses the problems that are being experienced, coping mechanisms, and resources of the client.
The nurse is reviewing information regarding a female client that was obtained with the psychiatric assessment tool. The client’s ability to provide food and shelter for herself is included in which area of the assessment?
a. Appraisal of health and illness
b. Coping responses, discharge planning needs
c. Knowledge deficits
d. Previous psychiatric treatment
ANS: B
The client’s ability to care for herself outside of the facility would be considered when her discharge planning needs are assessed, to determine whether other resources will be necessary. The other options are included in the psychiatric assessment tool but do not focus on discharge planning. Appraisal of health and illness focuses on the client’s perception of health care and identification of problems and goals; knowledge deficits focus on areas such as medications and coping skills; and previous psychiatric treatment focuses on the client’s psychiatric history, including family history.
During an interview with a 15-year-old female client admitted for depression, the nurse is disappointed to learn that the client recently became pregnant and had an abortion. The nurse is contradicting the effective interview guideline of:
a. Paying close attention to the client’s nonverbal communication
b. Avoiding making assumptions
c. Avoiding one’s personal values that may cloud professional judgment
d. Setting clear client goals
ANS: C
This is an example of the nurse allowing his or her personal values to cloud professional judgment and is an ineffective interview technique that leads to a negative nurse-client relationship. The other options are good interview techniques but do not represent this situation.
A male client with a history of schizophrenia was admitted to the mental health facility after he was found on the street confused and uncooperative when approached by the police. One of the first assessments that should be performed on this client upon admission is a:
a. Physical assessment
b. Sociocultural assessment
c. Psychosocial assessment
d. Psychiatric assessment
ANS: A
Physical problems frequently are overlooked when someone has a diagnosed mental health disorder. These physical problems often can be the cause of symptoms and may be easily treated. For example, low blood sugar, rather than schizophrenia, could be a cause of the symptoms described in this scenario. For this reason, physical examinations are always performed on admission to a mental health facility, followed by the other options listed
During the mental status examination, the nurse observes that the client rapidly changes from one idea to another related thought. Which disordered thinking process is the client displaying?
a. Delusions
b. Perseveration
c. Confabulation
d. Flight of ideas
ANS: D
It is difficult to follow a conversation with an individual who is experiencing flight of ideas because the conversation follows his rapidly changing thought pattern. Delusions result in false beliefs that cannot be corrected by logical explanations or reasoning; perseveration occurs when the client repeats the same word response to different questions; and with confabulation, the client uses untrue statements to fill in gaps of memory loss.
When reviewing the nursing notes from the previous shift, the nurse notices notations indicating that the client was experiencing a somnolent level of consciousness. The client’s behavior would be described as:
a. “Falling asleep easily and only awakening with strong verbal stimuli”
b. “Frequently sleeping and awakening only to strong physical stimuli”
c. “Unresponsive to any verbal or painful stimuli”
d. “Having alternating periods of excitability and drowsiness”
ANS: A
Falling asleep easily and waking only to strong verbal stimuli describes the level of consciousness known as somnolent, which also can be called a state of drowsiness. Frequently sleeping and waking only to strong physical stimuli describes a stuporous state, unresponsiveness to verbal or painful stimuli is a comatose state or unconsciousness, and alternating periods of excitability and drowsiness describes a lethargic state.
During the mental status assessment, the nurse hands the client a piece of paper that reads “Please raise your left hand.” If the client follows the command, the nurse has just assessed which ability of the client?
a. Abstract thinking
b. Reading
c. General knowledge
d. Memory
ANS: B
This is an easy method of assessing the client’s reading ability and is less anxiety provoking than having the client read aloud. Abstract thinking is assessed by methods such as assessing the ability of the client to understand similarities; general knowledge can be assessed by asking questions such as how many months are in a year or discussing current events; and memory can be assessed by testing immediate, recent, and remote memory.
A nurse educates a client on medication side effects and verbal feedback of understanding is given by the client. Which phase of the nursing process is being described?
a. Planning
b. Intervention
c. Assessment
d. Evaluation
ANS: D
This phase determines the effectiveness of the care. Clients are encouraged to become partners in their care.
Components of the sociocultural assessment include a history interview for the purpose of obtaining information about a client’s background and:
a. Observing the client’s appearance, behaviors, and attitudes
. Eliciting answers related to general health, past illnesses, and hospitalizations
c. Encouraging description of lifestyle and activities of daily living
d. Reviewing physical assessment data and various diagnostic examinations
ANS: A
The sociocultural assessment focuses on the cultural, social, and spiritual aspects of an individual. During the history interview, the care provider obtains information about a client’s background and observes the client’s appearance, behaviors, and attitudes.
A client with a history of delusions demonstrates which of the following behaviors?
a. Shifts from laughing to crying with no apparent cause
b. Insists the government is out to harm him
c. Has trouble remembering what he had for breakfast
d. Expresses a constant fear of dying
ANS: B
Delusions are false beliefs that cannot be corrected by reasoning or explanation. A constant fear of dying is an example of an obsession, shifting from laughing to crying for no reason demonstrates the inappropriate response of being labile, while having trouble remembering is indicative of amnesia.
