1. Chapter 8 When assessing a patient's mental health status, which of the following
describe the purpose of the psychosocial assessment? Select all that apply.
A) To assess the client's current emotional state
B) To assess the client's mental capacity
C) To assess the client's behavioral function
D) To assess the client's plan of care
E) To assess the client's physical health status
Ans: A, B, C
Feedback:
The purpose of the psychosocial assessment is to construct a picture of the client's
current emotional state, mental capacity, and behavioral function. This assessment
serves as the basis for developing a plan of care to meet the client's needs. The client's
physical health status would need to be completed as another assessment or an extended
assessment.
2. Which of the following factors influencing assessment is under the nurse's control?
A) Client participation and feedback
B) Client's health status
C) Nurse's attitude and approach
D) Client's ability to understand
Ans: C
Feedback:
The factors that influence assessment include client participation and feedback, client's
health status, client's ability to understand, client's previous experiences, and
misconceptions about health care. The only one of these that is under the control of the
nurse is the nurse's attitude and approach.
3. Which of the following are components of the assessment of thought process and
content? Select all that apply.
A) What the client is thinking
B) Abstract thinking abilities
C) How the client is thinking
D) Clarity of ideas
E) Self-harm or suicide urges
Ans: A, C, D, E
Feedback:
The components of the assessment of thought process and content include content (what
the client is thinking), process (how the client is thinking), clarity of ideas, self-harm, or
suicide urges. Abstract thinking abilities are an element of the abnormal sensory
experiences or misperception assessment.
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4. A client is being evaluated for dementia. The nurse knows that a client who is able to
complete very few tasks is most likely to have
A) a greater cognitive deficit.
B) A less precise mental status exam.
C) more potential for agitation.
D) no bearing on mental status.
Ans: A
Feedback:
The fewer tasks the client competes accurately, the greater the cognitive deficit. The
other choices are not true.
5. 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
A) admitting diagnosis.
B) communication skills.
C) perception of the problem.
D) personal needs.
Ans: C
Feedback:
The question will elicit information about the client's view or perspective of the
problem.
6. A delusion represents a problem in which of the following areas?
A) Memory
B) Motivation
C) Orientation
D) Thinking
Ans: D
Feedback:
A delusion is a fixed false idea or thought. Memory relates to the client's knowledge of
past events. Motivation relates to the client's interest in doing things. Orientation relates
to the client's perception of reality.
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7. The nurse asks a patient to list the days of the week in reverse order. The nurse is
assessing which of the following?
A) Concentration
B) Memory
C) Orientation
D) Abstract thinking
Ans: A
Feedback:
The nurse assesses the client's ability to concentrate by asking the client to perform
certain tasks such as repeating the days of the week backward. The nurse directly
assesses memory, both recent and remote, by asking questions with verifiable answers.
Orientation refers to the client's recognition of person, place, and time. Abstract thinking
is to making associations or interpretations about a situation or comment.
8. 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,
ìA stitch in time saves nine.î
A) The client's orientation
B) The client's memory
C) The client's ability to concentrate
D) The client's ability to use abstract thinking
Ans: D
Feedback:
When the nurse states, ìA stitch in time saves nine,î and asks the client to restate it in his
or her own words, the nurse is assessing the client's ability to use abstract thinking. The
client's orientation is recognizing person, place, and time. The client's memory, both
recent and remote, can be assessed by asking the client questions that have verifiable
answers. The client's ability to concentrate can be assessed by asking the client to
perform certain tasks including spelling the word ìworldî backward.
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9. The nurse is assessing suicide potential in a patient who has expressed hopelessness. In
what order does the nurse question the patient about suicidal thoughts?
A. ìHow would you carry out this plan?î
B. ìDo you have a plan to kill yourself?î
C. ìAre you thinking of killing yourself?î
D. ìHow do you plan to kill yourself?î
Ans: C, B, D, A
Feedback:
Suicide assessment should be performed through direct questioning. First, the nurse
would need to know if the patient has ideations: ìAre you thinking about killing
yourself?î; then if the patient has a plan, ìDo you have a plan to kill yourself?î If the
patient has a plan, then the nurse would ask about method: ìHow do you plan to kill
yourself?î If the patient has ideations, a plan, a method, then does the patient have
access to that method the nurse asks, ìHow would you carry out this plan? Do you have
access to the means to carry out the plan?î
10. The nurse best assesses a patient's memory by asking which of the following questions?
A) ìDo you have any problems with memory?î
B) ìWhat did you have for lunch yesterday?î
C) ìDo you know where you are?î
D) ìWho is the current president?î
Ans: D
Feedback:
The nurse directly assesses memory, both recent and remote, by asking questions with
verifiable answers such as ìWhat is the name of the current president?î The nurse may
not be able to verify the accuracy of the client's responses to questions such as ìDo you
have any memory problems?î or ìWhat did you do yesterday?î Orientation refers to the
client's recognition of person, place, and time.
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11. 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
patient's affect?
A) Blunt affect
B) Restricted affect
C) Broad affect
D) Flat affect
Ans: D
Feedback:
Common terms used in assessing affect include blunted affect: showing little or a slowto-respond facial expression; broad affect: displaying a full range of emotional
expressions; flat affect: showing no facial expression; inappropriate affect: displaying a
facial expression that is incongruent with mood or situation, often silly or giddy
regardless of circumstances; restricted affect: displaying one type of expression, usually
serious or somber.
12. The 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?
A) Delusional thinking
B) Ideas of reference
C) Word salad
D) Hallucination
Ans: A
Feedback:
A delusion is a fixed false belief not based in reality. Ideas of reference are client's
inaccurate interpretation that general events are personally directed to him or her, such
as hearing a speech on the news and believing the message had personal meaning. Word
salad is flow of unconnected words that convey no meaning to the listener.
Hallucinations are false sensory perceptions or perceptual experiences that do not really
exist.
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13. A patient is known to express tangential thinking. The nurse would assess for which of
the following when interacting with the patient?
A) Stopping abruptly in the middle of expressing himself
B) Jumping from one idea to another
C) Wandering off the topic and never answering the question
D) Excessive and fast talking about an array of ideas
Ans: C
Feedback:
Tangential thinking is wandering off the topic and never providing the information
requested. Thought blocking is stopping abruptly in the middle of a sentence or train of
thoughts, sometimes unable to continue the idea. Loose associations are disorganized
thinking that jumps from one idea to another with little or no evident relation between
the thoughts. Flight of ideas is excessive amount and rate of speech composed of
fragmented or unrelated ideas.
14. A nurse can best assess a patient's ability to use abstract thinking by asking the patient
which of the following questions?
A) ìWhat would you do if you found a wallet containing $100 on the sidewalk?î
B) ìWhat do I mean when I say, 'Don't sweat the small stuff?'î
C) ìWhat are you going to do next time you hear voices?î
D) ìCan you begin with the number 100 and subtract 7, and then subtract 7 again?î
Ans: B
Feedback:
The nurse assesses the client's ability to use abstract thinking, which is to make
associations or interpretations about a situation or comment. The nurse usually can do so
by asking the client to interpret a common proverb. If the client can explain the proverb
correctly, his or her abstract thinking abilities are intact. Judgment refers to the ability to
interpret one's environment and situation correctly and to adapt one's behavior and
decisions accordingly. Insight is the ability to understand the true nature of one's
situation and accept some personal responsibility for that situation. The nurse assesses
the client's ability to concentrate by asking the client to perform certain tasks such as
ìserial sevens.î
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15. 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, ìI pulled over, of course.î Which of the following was the nurse trying to assess?
A) The client's judgment
B) The client's insight
C) The client's concentration
D) The client's self-concept
Ans: A
Feedback:
Judgment refers to the ability to interpret one's environment and situation correctly and
to adapt one's behavior and decisions accordingly. Insight is the ability to understand the
true nature of one's situation and accept some personal responsibility. Self-concept is the
way one views oneself in terms of personal worth and dignity. The nurse assesses the
client's ability to concentrate by asking the client to perform certain cognitive tasks. To
assess a client's self-concept, the nurse can ask the client to describe himself or herself
and what characteristics he or she likes and what he or she would change.
16. The client spoke of a current event in the national news and described it as it relates to
the client. Then the client spoke of a historical event 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?
A) ìWhere were you when this happened?î
B) ìWhy do you think that?î
C) ìAre you sure?î
D) ìThat is unbelievable!î
Ans: A
Feedback:
Ideas of reference are the client's inaccurate interpretation that general evens are
personally directed to him or her, such as hearing a speech on the news and believing
the message had personal meaning. ìWhere were you when this happened,î would relate
to the place and might give the nurse more information to validate the client's previous
comments. ìWhy do you think that,î may be interpreted as the nurse challenging the
client. ìAre you sure,î is a closed-ended question and does not encourage the client to
elaborate. ìThat is unbelievable,î is a statement rather than a question and could be
interpreted as the nurse's opinion of the information provided by the client.
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17. Which of the following questions is best to ask when assessing the client's judgment?
A) ìCan you describe your usual daily activities for me?î
B) ìIf you found yourself downtown without money or a car, how would you get
home?î
C) ìOn a scale of 1 to 10, how stressed would you rate yourself?î
D) ìWhat problem would you like to work on while you're hospitalized?î
Ans: B
Feedback:
Judgment refers to the ability to interpret one's environment and situation correctly and
to adapt one's own behavior and decisions accordingly. This question will elicit
information about the client's problem-solving and decision-making abilities. The other
choices do not assess the concept of judgment.
18. The nurse asks the client, ìWhat is similar about a cow and a horse?î and ìWhat do a bus
and an airplane have in common?î These questions would best assess which of the
following areas?
A) Intellectual function
B) Insight
C) Judgment
D) Memory
Ans: A
Feedback:
These questions would elicit information about the client's intellectual function. Insight
is the ability to understand the true nature of one's situation and accept some personal
responsibility for that situation. Judgment refers to the ability to interpret one's
environment and situation correctly and to adapt one's behavior and decisions
accordingly. Questions about memory would require that the client identify knowledge
of past events.
19. Which of the following would best assess a client's judgment?
A) Counting by serial sevens
B) Discussing hypothetical situations
C) Interpreting proverbs
D) Spelling words backward
Ans: B
Feedback:
The client's judgment can be elicited by asking the client to discuss hypothetical
situations, which would indicate one's ability to interpret one's environment and
situation correctly and to adapt one's behavior and decisions accordingly. Counting by
serial sevens and spelling words backward would assess the client's ability to
concentrate. Interpreting proverbs would assess the client's abstract thinking.
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20. The nurse plans to assess a patient's self-concept in the admission assessment knowing
that self-concept influences which of the following? Select all that apply.
A) Body image
B) Cognitive processing
C) Frequently experienced emotions
D) Coping strategies
E) Responsiveness to medications
Ans: A, C, D
Feedback:
Self-concept is the way one views oneself in terms of personal worth and dignity. The
client's description of self in terms of physical characteristics gives the nurse
information about the client's body image. Also included in an assessment of selfconcept are the emotions that the client frequently experiences and whether or not the
client is comfortable with those emotions. The nurse also must assess the client's coping
strategies. Cognitive processing and response to medications are biologically based.
21. Which of the following are the types of roles that are usually included when assessing
roles and relationships? Select all that apply.
A) Family
B) Hobbies
C) Occupation
D) Activities
E) Race
F)
Ethnicity
Ans: A, B, C, D
Feedback:
The number and type of roles may vary, but they usually include family, occupation,
and hobbies or activities.
22. Knowing that relationships with others are significant to mental health, the nurse
effectively assesses a patient's family relationships through which of the following?
A) ìDo you feel your family helps you?î
B) ìHow many people are in your family?î
C) ìWhom are you closest to in your family?î
D) ìDescribe your relationships with your family.î
Ans: D
Feedback:
The nurse must assess the relationships in the client's life, the client's satisfaction with
those relationships, or any loss of relationships. Open-ended questions and statements
elicit more descriptive responses from the patient than direct questions.
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23. A nurse assesses that a depressed patient is lethargic during the day and does not
actively participate in unit activities. The notes from the night shift document that the
patient did not sleep well. The most probable interpretation of these data is
A) the patient's medications are ineffective.
B) the patient is being kept awake at night due to noise on the unit.
C) the patient's depressed mood is impairing restful sleep patterns.
D) the patient is resisting treatment recommendations to participate in unit activities
Ans: C
Feedback:
Emotional problems often affect some areas of physiologic function. Emotional
problems can greatly affect eating and sleeping patterns. Therefore, the nurse must
assess the client's usual patterns of eating and sleeping and then determine how those
patterns have changed.
24. 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?
A) Firmly inform the patient of the dangers of mixing medications with alcohol.
B) Recommend a higher level of care, so the patient can be more closely supervised.
C) Emphasize the importance of truthful information using a nonjudgmental
approach
D) Recognize the patient's right to self-determination and avoid addressing the
subject.
Ans: C
Feedback:
Noncompliance with prescribed medications is an important area. If the client has
stopped taking medication or is taking medication other than as prescribed, the nurse
must help the client feel comfortable enough to reveal this information. The nurse also
explores the client's use of alcohol and over-the-counter or illicit drugs. Such questions
require nonjudgmental phrasing; the nurse must reassure the client that truthful
information is crucial in determining the client's plan of care.
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25. The nurse has completed the psychosocial assessment. Which of the following is the
best approach toward analysis of the data to identify nursing diagnoses and develop an
appropriate plan of care?
A) Focus on each piece of information obtained from the patient.
B) Look for patterns reflected in the overall assessment.
C) Consider only the abnormal findings in the assessment.
D) Present all data obtained in the treatment team meeting.
Ans: B
Feedback:
After completing the psychosocial assessment, the nurse analyzes all the data that he or
she has collected. Data analysis involves thinking about the overall assessment rather
than focusing on isolated bits of information. The nurse looks for patterns or themes in
the data that lead to conclusions about the client's strengths and needs and to a particular
nursing diagnosis. No one statement or behavior is adequate to reach such a conclusion.
26. The nurse reviews results of the Minnesota Multiphasic Personality Inventory (MMPI)
recorded in a patient record. While considering the usefulness of these data, the nurse is
mindful that the MMPI has which limitation?
A) The patient must be able to read to complete the MMPI.
B) The results of the MMPI could be culturally biased.
C) The MMPI assesses a narrow scope of functioning.
D) The MMPI does not have established validity.
Ans: B
Feedback:
Both intelligence tests and personality tests are frequently criticized as being culturally
biased. It is important to consider the client's culture and environment when evaluating
the importance of scores or projections from any of these tests. Objective personality
tests compare the client's answers with standard answers or criteria and obtain a score or
scores. The MMPI provides scores on 10 clinical scales such as hypochondriasis,
depression, hysteria, and paranoia; four special scales such as anxiety and alcoholism;
three validity scales to evaluate the truth and accuracy of responses.
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27. The client tells the nurse, ìThat new TV anchor is telling the world about me.î This is an
example of
A) ideas of reference.
B) persecutory delusions.
C) thought broadcasting.
D) thought insertion.
Ans: A
Feedback:
The client's inaccurate interpretation that general events are personally directed to him
or her is an example of ideas of reference. Persecutory delusions involve the client's
belief that ìothersî are planning to harm the client. Thought broadcasting is a delusional
belief that others can hear or know what the client is thinking. Thought insertion is a
delusional belief that others are putting ideas or thoughts into the client's head.
28. During the admission assessment, the nurse asks the client, ìHow are you feeling?î The
client responds, ìI was able to purchase gas for 7 cents a gallon less than yesterday,
which saved me a total of 84 cents. My car has a 12-gallon gas tank. Usually I am able
to put in 11.7 gallons. I am very happy to have saved so much money.î The nurse
recognizes this response as which of the following?
A) Circumstantial thinking
B) Echolalia
C) Flight of ideas
D) Neologisms
Ans: A
Feedback:
With circumstantial thinking, the client eventually answers a question but only after
giving excessive unnecessary detail. Echolalia is repetition or imitation of what
someone else says. Flight of ideas is excessive amount and rate of speech composed of
fragmented or unrelated ideas. Neologisms are invented words that have meaning only
for the client.
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29. A client is admitted to the psychiatric unit and states, ìI am president of the largest
corporation in the world. Everyone comes to me for advice.î The client is exhibiting
which of the following?
A) Flight of ideas
B) Thought broadcasting
C) Delusion
D) Loose associations
Ans: C
Feedback:
The client has a delusion (a fixed false belief not based in reality) about his superiority
over others. Flight of ideas is excessive amount and rate of speech composed of
fragmented or unrelated ideas. Thought broadcasting is a delusional belief that others
can hear or know what the client is thinking. Loose associations are disorganized
thinking that jumps from one idea to another with little or no evident relation between
the thoughts.
30. In the space of 5 minutes, the client has been laughing and euphoric, then angry, and
then crying for no reason that is apparent to the nurse. This behavior would be best
described as
A) flight of ideas.
B) lack of insight.
C) labile mood.
D) tangential thinking.
Ans: C
Feedback:
Moods that shift rapidly, displaying a range of emotions, are termed labile. Flight of
ideas is manifested by excessive amount and rate of speech composed of fragmented or
unrelated ideas. Lack of insight would be manifested by the lack of the ability to
understand the true nature of one's situation and accept some personal responsibility for
that situation. Tangential thinking would be manifested by wandering off the topic and
never providing the information requested.
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31. Throughout the assessment, the client displays disorganized thinking, jumping from one
idea to another with no clear relationship between the thoughts. The nurse would assess
the client as having which of the following?
A) Tangential thinking
B) Ideas of reference
C) Loose associations
D) Word salad
Ans: C
Feedback:
The client displayed ideas that were loosely associated to one another. Tangential
thinking is manifested by wandering off the topic and never providing the information
requested. Ideas of reference are the client's inaccurate interpretation that general events
are personally directed to him or her. Word salad is a flow of unconnected words that
convey no meaning to the listener.
32. Sexuality and self-harm behaviors are often difficult areas for nurses to assess. An
effective way for nurses to deal with this discomfort includes
A) recognizing that these areas may also be uncomfortable for the patient to discuss.
B) share feelings of discomfort with the patient.
C) defer assessing these areas to a more experienced nurse.
D) develop a standard question to ask of all patients during this area of assessment
Ans: A
Feedback:
Two areas that may be uncomfortable or difficult for the nurse to assess are sexuality
and self-harm behaviors. The beginning nurse may feel uncomfortable, as if prying into
personal matters, when asking questions about a client's intimate relationships and
behavior and any self-harm behaviors or thoughts of suicide. Asking such questions,
however, is essential to obtaining a thorough and complete assessment. The nurse needs
to remember that it may be uncomfortable for the client to discuss these topics as well.
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33. Which of the following is the most compelling reason for the nurse to discuss matters of
sexuality and suicide?
A) It is required by the law by the federal government and in most states in the union.
B) It is the nurse's professional responsibility to keep safety needs first and foremost.
C) This is commonly required documentation for every encounter with every client.
D) It allows the nurse to gain valuable experience in these kind of difficult
discussions.
Ans: B
Feedback:
It is the nurse's professional responsibility to keep the client's safety needs first and
foremost, and this includes overcoming any personal discomfort in talking about
suicide. This is not required by any laws nor is it commonly required documentation for
every encounter with every client. The nurse needs to gain experience in these kind of
difficult discussions, but that is not a compelling reason for the nurse to discuss it if not
warranted.
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