Download FREE Sample Here

full file at http://testbankcorner.eu
Chapter 9: Mental Health Assessment Skills
Test Bank
MULTIPLE CHOICE
1. 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.
DIF: Cognitive Level: Comprehension
REF: p. 95
OBJ: 2
TOP: Nursing (Therapeutic) Process
KEY: Nursing Process Step: Assessment
MSC: Client Needs: Health Promotion and Maintenance
2. 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.
DIF: Cognitive Level: Comprehension
REF: p. 93
OBJ: 2
TOP: Nursing (Therapeutic) Process
KEY: Nursing Process Step: Intervention
MSC: Client Needs: Physiological Integrity
3. 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
full file at http://testbankcorner.eu
full file at http://testbankcorner.eu
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.
DIF: Cognitive Level: Comprehension
REF: p. 95
OBJ: 2
TOP: Nursing (Therapeutic) Process
KEY: Nursing Process Step: Assessment
MSC: Client Needs: Health Promotion and Maintenance
4. 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.
DIF: Cognitive Level: Comprehension
REF: p. 94
OBJ: 2
TOP: Nursing (Therapeutic) Process
KEY: Nursing Process Step: Evaluation
MSC: Client Needs: Health Promotion and Maintenance
5. 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.
DIF: Cognitive Level: Comprehension
REF: p. 93
OBJ: 2
TOP: Nursing (Therapeutic) Process
KEY: Nursing Process Step: Planning
MSC: Client Needs: Health Promotion and Maintenance
full file at http://testbankcorner.eu
full file at http://testbankcorner.eu
6. 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(n)
__________ 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.
DIF: Cognitive Level: Knowledge
REF: p. 95
OBJ: 4
TOP: About Assessment
KEY: Nursing Process Step: Assessment
MSC: Client Needs: Psychosocial Integrity
7. 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.
DIF: Cognitive Level: Comprehension
REF: p. 96
OBJ: 4
TOP: Assessment Process
KEY: Nursing Process Step: Assessment
MSC: Client Needs: Psychosocial Integrity
8. During an interview with a 15-year-old female client admitted for depression, the nurse
expresses her disappointment when she to learns that the client recently became pregnant and
then 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
full file at http://testbankcorner.eu
full file at http://testbankcorner.eu
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.
DIF: Cognitive Level: Comprehension
REF: p. 96
OBJ: 5
TOP: Effective Interviews
KEY: Nursing Process Step: Assessment
MSC: Client Needs: Psychosocial Integrity
9. A male client with a history of schizophrenia was admitted to the mental health facility after
he was found on the street in a confused state and was uncooperative when approached by the
police. One of the first assessments that should be performed on this client upon admission is
a _____ assessment.
a. Physical
b. Sociocultural
c. Psychosocial
d. Psychiatric
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.
DIF: Cognitive Level: Application
REF: p. 97
OBJ: 6
TOP: Physical Assessment
KEY: Nursing Process Step: Assessment
MSC: Client Needs: Physiological Integrity
10. 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.
DIF: Cognitive Level: Comprehension
REF: p. 100
TOP: Thinking
KEY: Nursing Process Step: Assessment
MSC: Client Needs: Psychosocial Integrity
full file at http://testbankcorner.eu
OBJ: 9
full file at http://testbankcorner.eu
11. 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 describe 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 describe a stuporous state,
unresponsiveness to verbal or painful stimuli is a comatose state or unconsciousness, and
alternating periods of excitability and drowsiness describe a lethargic state.
DIF: Cognitive Level: Application
REF: p. 100
OBJ: 9
TOP: Sensorium and Cognition
KEY: Nursing Process Step: Assessment
MSC: Client Needs: Psychosocial Integrity
12. 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.
DIF: Cognitive Level: Application
REF: p. 101
OBJ: 9
TOP: Sensorium and Cognition
KEY: Nursing Process Step: Assessment
MSC: Client Needs: Psychosocial Integrity
13. According to the DSM-IV-TR Axis guidelines, clinical disorders are described as:
a. Dependent, antisocial personality disorders, and levels of retardation
b. Educational, housing, legal, and economic problems
c. Heart and digestive disorders
d. Mood disorder, substance abuse, and schizophrenic disorders
ANS: D
full file at http://testbankcorner.eu
full file at http://testbankcorner.eu
The DSM-IV-TR describes five categories of disorders, with clinical disorders in Axis I
described as mood disorder, substance abuse, and schizophrenic disorders. Dependent,
antisocial personality disorders and levels of retardation describes Axis II; educational,
housing, legal, and economic problems describes Axis IV; and heart and digestive disorders
describes Axis III. There is also an Axis V, which comprises global assessment functioning
(GAF), which includes overall levels of psychological, social, and occupational functioning.
DIF: Cognitive Level: Knowledge
REF: p. 93
OBJ: 1
TOP: DSM-IV-TR Diagnosis
KEY: Nursing Process Step: Assessment
MSC: Client Needs: Psychosocial Integrity
14. A score of 1 to 10 on the global assessment functioning (GAF) scale would indicate that a
client was at risk for:
a. Mild difficulty in focusing
b. Mild difficulty in handling social situations
c. Hurting himself or others
d. Serious impairment in social and occupational functioning
ANS: C
The GAF scale ranges from 1 to 100. A score of 1 to 10 indicates a persistent danger that a
client may harm himself or others. Mild difficulty focusing is indicated by a score of 71 to 80,
mild difficulty in social situations is revealed by a score of 61 to 70, and serious impairment
in social and occupational functioning is evident with a score of 41 to 50.
DIF: Cognitive Level: Comprehension
REF: p. 94
OBJ: 1
TOP: DSM-IV-TR Diagnosis
KEY: Nursing Process Step: Assessment
MSC: Client Needs: Psychosocial Integrity
15. 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 them
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.
DIF: Cognitive Level: Comprehension
REF: p. 100
OBJ: 8
TOP: Disorders of ThinkingKEY:
Nursing Process Step: Assessment
MSC: Client Needs: Psychosocial Integrity
16. A client complains to the nurse that he has been fired from his fourth job in 10 months
because his bosses and co-workers “didn’t understand him.” While he once had a few close
friends, he no longer associates with them for the same reason. His level of functioning on
the global assessment of functioning (GAF) scale would be:
a. 71-80; transient symptoms
b. 61-70; some mild symptoms
full file at http://testbankcorner.eu
full file at http://testbankcorner.eu
c. 41-50; serious symptoms
d. 1-10; persistent danger of hurting self or others
ANS: C
The GAF scale score of serious symptoms (41-50) is defined as a serious impairment in social,
occupational, or school functioning; no friends; and an inability to keep a job.
DIF: Cognitive Level: Comprehension
REF: p. 94
OBJ: 8
TOP: Disorders of ThinkingKEY:
Nursing Process Step: Assessment
MSC: Client Needs: Psychosocial Integrity
17. The nurse suspects the client is experiencing a manic episode based on which of the following
observations?
a. Clothing is very colorful and mismatched, and client cannot sit in chair during
interview.
b. Hair is not combed, clothing is dirty, and client has no interest in surroundings.
c. Client repeatedly washes her hands and picks at a button on her shirt.
d. Client expresses fear that someone is waiting outside the room to harm her.
ANS: A
It is not uncommon for manic clients to dress in colorful clothing and have excessive body
movement. Clients who look unkempt and neglected are more commonly diagnosed with
depression. Repeated behaviors and picking at clothing is often seen in clients with
obsessive-compulsive disorders.
DIF: Cognitive Level: Comprehension
REF: p. 98
OBJ: 8
TOP: Mental Status Assessment: General Appearance
KEY: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity
18. A client seen in the emergency department is noted to be stuporous. Which of the following
assessment findings would be of most concern?
a. Elevated blood pressure
b. Elevated cholesterol levels
c. New exercise routine
d. Painting furniture in a windowless room
ANS: D
Assessing occupational/lifestyle factors of chemicals in the workplace such as paint can
impact function. Elevated blood pressure, elevated cholesterol, and exercise would not result
in stupor in the client.
DIF: Cognitive Level: Comprehension
REF: p. 97
OBJ: 9
TOP: Mental Status Assessment: Health History for Mental Health Clients
KEY: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity
MULTIPLE RESPONSE
19. Upon entrance into a mental health care system, clients are thoroughly assessed, and this is
followed by the development of a mental health treatment plan. Which of the following are
purposes of the treatment plan? (Select all that apply.)
full file at http://testbankcorner.eu
full file at http://testbankcorner.eu
a.
b.
c.
d.
e.
Proof of care for insurance reimbursement purposes
A means of monitoring the client’s progress
An instrument for communication and coordination of care
A guide for planning and implementation of care
Evaluating the effectiveness of interventions
ANS: B, C, D, E
Purposes of the treatment plan include serving as a means of monitoring the client’s progress,
acting as an instrument for communication and coordination of care, serving as a guide for
planning and implementation of care, and providing a way to evaluate the effectiveness of
interventions. Documentation for reimbursement purposes is not a primary goal of the
treatment plan.
DIF: Cognitive Level: Comprehension
REF: p. 93
OBJ: 1
TOP: Mental Health Treatment Plan
KEY: Nursing Process Step: Intervention
MSC: Client Needs: Psychosocial Integrity
20. The assessment phase of the nursing process refers to the phase when data collection occurs.
Which methods does the nurse use to collect data? (Select all that apply.)
a. Interpreting client behaviors
b. Interviewing the client and significant others
c. Observing client behavior
d. Performing physical assessment
e. Reviewing diagnostic testing results
ANS: B, C, D, E
Interviewing the client and significant others, observing client behavior, performing a physical
assessment, and reviewing diagnostic testing results are effective ways of collecting data.
Interpreting a client’s behavior should never occur without clarification because interpretation
often is incorrect.
DIF: Cognitive Level: Application
REF: p. 95
OBJ: 3
TOP: Data Collection
KEY: Nursing Process Step: Assessment
MSC: Client Needs: Health Promotion and Maintenance
21. During the sociocultural assessment of a client who is entering a mental health program, the
nurse focuses on which information related to the client? (Select all that apply.)
a. Education
b. Income
c. Ethnicity
d. Age
e. Gender
f. Medications
g. Previous diagnoses
h. Belief system
ANS: A, B, C, D, E, H
Medications and previous diagnoses are not part of the sociocultural assessment.
DIF: Cognitive Level: Comprehension
REF: p. 97
full file at http://testbankcorner.eu
OBJ: 4
full file at http://testbankcorner.eu
TOP: Sociocultural Assessment
KEY: Nursing Process Step: Assessment
MSC: Client Needs: Psychosocial Integrity
22. Short-term memory loss is seen in which of the following disorders? (Select all that apply.)
a. Depression
b. Dissociative disorder
c. Conversion disorder
d. Alzheimer’s disease
e. Anxiety
ANS: A, D, E
Loss of recent memory is seen in persons with Alzheimer’s disease, anxiety, and depression.
Dissociative and conversion disorders cause long-term memory loss.
DIF: Cognitive Level: Comprehension
REF: p. 100
OBJ: 4
TOP: Sociocultural Assessment
KEY: Nursing Process Step: Assessment
MSC: Client Needs: Psychosocial Integrity
COMPLETION
23. __________ is how the client displays his or her emotions through facial, vocal, or gestural
behavior.
ANS:
Affect
A person’s affect usually is termed appropriate, inappropriate, pleasurable, or unpleasurable
by determining whether the affect matches the emotions of the states he or she is feeling.
DIF: Cognitive Level: Knowledge
REF: p. 99
OBJ: 8
TOP: Emotional State
KEY: Nursing Process Step: Assessment
MSC: Client Needs: Psychosocial Integrity
SHORT ANSWER
24. List the five steps of the nursing process in proper chronological order.
ANS:
Assessment, nursing diagnosis, planning, intervention, evaluation
The steps of the nursing process provide a means of addressing problems identified as
affecting the client. Assessment is ongoing, the nursing diagnosis is the identification of client
problems, and client goals are set during the planning phase. Interventions are determined,
then implemented. Lastly, goals are evaluated to determine whether they have been met,
partially met, or not met at all. In the latter two evaluation results if the goals have not been
met or only partially met, the plan of care must be reevaluated and revised.
DIF: Cognitive Level: Knowledge
REF: p. 93
OBJ: 2
TOP: Nursing (Therapeutic) Process
KEY: Nursing Process Step: Intervention
MSC: Client Needs: Health Promotion and Maintenance
full file at http://testbankcorner.eu