Health & Physical Assessment In Nursing 3rd Edition by Donita T D’Amico – Test Bank

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Sample Questions Posted Below

 

D’Amico/Barbarito Health & Physical Assessment in Nursing, 3/e

Chapter 5

Question 1

Type: MCSA

The nurse is caring for a client in the emergency department (ED) who complains of chest pain and reports that people were following her. She states, “I can’t see them but they are talking about grabbing me.” While the woman is explaining the event, she alternates between wringing her hands and manipulating the items in her purse over and over. Which is the priority when continuing the assessment for this client?

1. Spiritual affiliations.

2. Dietary preferences and habits.

3. Review of systems.

4. Focused psychosocial interview.

Correct Answer: 4

Rationale 1: A spiritual assessment is important, but the psychosocial interview would be a priority given the behaviors exhibited.

Rationale 2: Dietary preferences are important, but the psychosocial interview would be a priority given the behaviors exhibited.

Rationale 3: The physical examination is conducted after the interviewing is complete.

Rationale 4: The woman is exhibiting bizarre behavior and her story indicates some paranoia; therefore, a focused psychosocial interview is warranted.

Global Rationale: The woman is exhibiting bizarre behavior and her story indicates some paranoia; therefore, a focused psychosocial interview is warranted. A spiritual assessment and dietary preferences are important, but the psychosocial interview would be a priority given the behaviors exhibited. The physical examination is conducted after the interviewing is complete.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5.4: Describe application of the nursing process in the assessment of psychosocial health.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment.

Page Number: pp. 90–97

Question 2

Type: MCSA

The nurse is interviewing a client prior to a physical examination. The client reports aches, pains, and abdominal discomfort. Which factor does the nurse suspect is impacting the client’s physical health?

1. Income.

2. Stress.

3. Ethnicity.

4. Occupation.

Correct Answer: 2

Rationale 1: Income may influence physical and emotional health in some way, but stress is most likely having the greatest impact with the symptoms being reported.

Rationale 2: Stress is most likely having the greatest impact with the symptoms being reported. Emotional stress affects the immune system and typically causes individuals to be less attentive to their personal health. Individuals under stress may also use mood-altering substances to “feel better.”

Rationale 3: Ethnicity may influence physical and emotional health in some way, but stress is most likely having the greatest impact with the symptoms being reported.

Rationale 4: Occupation may influence physical and emotional health in some way, but stress is most likely having the greatest impact with the symptoms being reported.

Global Rationale: All of the above factors may influence physical and emotional health in some way, but stress is most likely having the greatest impact with the symptoms being reported. Emotional stress affects the immune system and typically causes individuals to be less attentive to their personal health. Individuals under stress may also use mood-altering substances to “feel better.”

Cognitive Level: Remembering

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5.3: Examine factors that affect psychosocial health in patients across the life span.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment.

Page Number: pp. 89–90

Question 3

Type: MCSA

The nurse is interviewing an overweight adolescent who looks downward and speaks softly when answering questions. The nurse identifies a problem with client’s self-concept. Which finding supports the nurse’s conclusion?

1. Increased desire to form lasting relationships.

2. Decreased ability to form attachments with other people.

3. Inability to maintain stable employment.

4. Feelings of worthlessness, anxiety, and/or depression.

Correct Answer: 4

Rationale 1: The increased desire to form lasting relationships may be seen in individuals with healthy or unhealthy self-concepts.

Rationale 2: Decreased ability to form attachments to other people results from many factors not limited to poor self-concept.

Rationale 3: Decreased ability to maintain stable employment results from many factors not limited to poor self-concept.

Rationale 4: Problems with self-concept may manifest in feelings of worthlessness, anxiety, and/or depression, among other issues.

Global Rationale: Problems with self-concept may manifest in feelings of worthlessness, anxiety, and/or depression, among other issues. Decreased ability to maintain stable employment and to form attachments to other people results from many factors not limited to poor self-concept. The increased desire to form lasting relationships may be seen in individuals with healthy or unhealthy self-concepts.

Cognitive Level: Remembering

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care.

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches.

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5.2: Apply knowledge of psychosocial functioning to assessment of overall health and wellness.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment.

Page Number: pp. 92–93

Question 4

Type: MCSA

A school-age client is admitted to the hospital following an appointment in the pediatric oncology clinic. The client’s mother is distraught over her child’s recent leukemic relapse and states, “What did I do wrong? Why does he deserve this? Why can’t it be me?” What do these statements indicate?

1. Ineffective coping.

2. Emotional emptiness.

3. Spiritual distress.

4. Psychologic anxiety.

Correct Answer: 3

Rationale 1: Those types of statements are common responses to a serious diagnosis and do not indicate ineffective coping.

Rationale 2: Emotional emptiness is not an acceptable term to describe behaviors indicating distress.

Rationale 3: Questions such as “What did I do wrong?” and “Why does he deserve this?” indicate spiritual distress.

Rationale 4: Further evidence would be required before determining psychologic anxiety.

Global Rationale: Questions such as “What did I do wrong?” and “Why does he deserve this?” indicate spiritual distress. Further evidence would be required before determining psychologic anxiety. Emotional emptiness is not an acceptable term to describe behaviors indicating distress. Those types of statements are common responses to a serious diagnosis and do not indicate ineffective coping.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development.

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 5.3: Examine factors that affect psychosocial health in patients across the life span.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment.

Page Number: pp. 95–96

Question 5

Type: MCSA

The nurse is reviewing the plan of care for a client who was admitted for suicidal tendencies. The nurse documents that the client is no longer experiencing thoughts of hurting self. Which step of the nursing process is the nurse using?

1. Implementation.

2. Evaluation.

3. Planning.

4. Assessment.

Correct Answer: 2

Rationale 1: Implementation is the process of performing certain interventions designed to move the client toward achievement of the goal.

Rationale 2: Evaluation is the process whereby the progress toward achieving the goals is reviewed and documented.

Rationale 3: During the planning phase of the nursing process, nursing diagnoses are formulated after data have been assessed, and then goal setting takes place.

Rationale 4: Assessment is the process by which data are collected.

Global Rationale: Evaluation is the process whereby the progress toward achieving the goals is reviewed and documented. Implementation is the process of performing certain interventions designed to move the client toward achievement of the goal. During the planning phase of the nursing process, nursing diagnoses are formulated after data have been assessed, and then goal setting takes place. Assessment is the process by which data are collected.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development.

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 5.4: Describe application of the nursing process in the assessment of psychosocial health.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment.

Page Number: pp. 97–98

Question 6

Type: MCSA

The nurse educator is reviewing the component of a psychosocial assessment with a group of students. Which definition of psychosocial health is appropriate for the educator to include in the review session?

1. Being emotionally balanced and socially astute.

2. Being mentally stable, physically fit, and psychologically well.

3. Being spiritually and psychologically mature.

4. Being mentally, emotionally, socially, and spiritually well.

Correct Answer: 4

Rationale 1: Emotionally balanced is another way of referring to emotionally well, though the term is not often used. Being socially astute is a characteristic that one may develop but is not necessary for social wellness.

Rationale 2: Mental stability is a component of psychosocial health and includes psychologic health. Being physically fit may influence psychosocial health, but individuals may be not physically fit but still in good psychosocial health.

Rationale 3: Many would argue that children are not spiritually and psychologically mature, yet may exhibit psychosocial health, so being spiritually and psychologically mature are not criteria for psychosocial health.

Rationale 4: Psychosocial health is defined as being mentally, emotionally, socially, and spiritually well.

Global Rationale: Psychosocial health is defined as being mentally, emotionally, socially, and spiritually well. Emotionally balanced is another way of referring to emotionally well, though the term is not often used. Being socially astute is a characteristic that one may develop but is not necessary for social wellness. Mental stability is a component of psychosocial health and includes psychologic health. Being physically fit may influence psychosocial health, but individuals may be not physically fit but still in good psychosocial health. Many would argue that children are not spiritually and psychologically mature, yet may exhibit psychosocial health, so being spiritually and psychologically mature are not criteria for psychosocial health. The same is true with being emotionally balanced and socially astute.

Cognitive Level: Remembering

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5.4: Describe application of the nursing process in the assessment of psychosocial health.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment.

Page Number: p. 85

Question 7

Type: MCSA

The nurse is conducting a class on health promotion and uses the following definition: “The ability to perform daily tasks vigorously and alertly, with energy left over for enjoying leisure-time activities and meeting emergency demands.” Which area is the nurse stressing?

1. Physical fitness.

2. Emotional health.

3. Physical health.

4. Psychologic well-being.

Correct Answer: 1

Rationale 1: Physical fitness is the ability to perform daily tasks vigorously and alertly, with energy left over for enjoying leisure-time activities and meeting emergency demands.

Rationale 2: Physical fitness is an important component of physical and emotional health.

Rationale 3: Physical fitness is an important component of physical and emotional health.

Rationale 4: Physical fitness influences mental alertness and emotional stability, as well as a general feeling of well-being, which some may call psychologic fitness.

Global Rationale: Physical fitness is the ability to perform daily tasks vigorously and alertly, with energy left over for enjoying leisure-time activities and meeting emergency demands. Physical fitness is an important component of physical and emotional health. Physical fitness influences mental alertness and emotional stability, as well as a general feeling of well-being, which some may call psychologic fitness.

Cognitive Level: Remembering

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Knowledge and Science: Defining how the evidence on which practice is based is developed and by whom.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5.1: Categorize the major components of psychosocial health.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment.

Page Number: p. 86

Question 8

Type: MCSA

The nurse is caring for a client admitted for severe weight loss and depression. The client recently experienced the loss of three close family members and has withdrawn from all social activities. In developing the plan of care, the nurse would correctly choose which nursing diagnosis?

1. Powerlessness.

2. Anxiety.

3. Complicated grieving.

4. Spiritual distress.

Correct Answer: 3

Rationale 1: Powerlessness refers to feelings of a loss of control with the situation.

Rationale 2: Anxiety infers feelings of apprehension.

Rationale 3: Clients experiencing tremendous loss often develop depression as part of their reaction to grief. However, this depression should also be seen with other stages of the grieving process such as denial, anger, bargaining, and acceptance. Clients remaining in one stage of the grieving process may not be progressing toward acceptance.

Rationale 4: Spiritual distress infers the client would be at odds with her feelings.

Global Rationale: Clients experiencing tremendous loss often develop depression as part of their reaction to grief. However, this depression should also be seen with other stages of the grieving process such as denial, anger, bargaining, and acceptance. Clients remaining in one stage of the grieving process may not be progressing toward acceptance. There are not enough data to support the remaining nursing diagnoses. Powerlessness refers to feelings of a loss of control with the situation. Anxiety infers feelings of apprehension. Spiritual distress infers the client would be at odds with her feelings.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development.

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 5.4: Describe application of the nursing process in the assessment of psychosocial health.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment.

Page Number: pp. 98–99

Question 9

Type: MCSA

The nurse is reviewing the plan of care for a client and notes that the following goal has not been met: “Client will verbalize three positive things about himself.” Which action by the nurse is the most appropriate?

1. Tell the client three things that he does well.

2. Ask other clients to tell the client what he does well.

3. Determine barriers to achieving the goal.

4. Do nothing as long as the client appears better.

Correct Answer: 3

Rationale 1: Telling the client things that he does well will not aid in the achievement of the goal.

Rationale 2: Involving other clients in the plan of care may be a violation of the client’s privacy and is not appropriate.

Rationale 3: The nursing process must be approached in a cyclic and systematic fashion in order to best meet the identified needs of clients. When goals are not met within established time frames, the nurse must examine potential reasons for this and develop new interventions and time frames for goal achievement.

Rationale 4: Ignoring the absence of progression toward the established goal will not aid the client in improving.

Global Rationale: The nursing process must be approached in a cyclic and systematic fashion in order to best meet the identified needs of clients. When goals are not met within established time frames, the nurse must examine potential reasons for this and develop new interventions and time frames for goal achievement. The goal statements are based upon the client’s achievements. Telling the client things that he does well will not aid in the achievement of the goal. Involving other clients in the plan of care may be a violation of the client’s privacy and is not appropriate. Ignoring the absence of progression toward the established goal will not aid the client in improving.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development.

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 5.4: Describe application of the nursing process in the assessment of psychosocial health.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment.

Page Number: pp. 98–99

Question 10

Type: MCMA

The client admitted to the hospital for an arm fracture requiring surgery appears disheveled and has a body odor. The nurse expresses surprise at the client’s appearance and reports that this is not the normal appearance of the client, who is usually clean and meticulously groomed. Based on this information, which assessments are priority to plan this client’s care?

Standard Text: Select all that apply.

1. Food preferences.

2. Psychosocial assessment.

3. Memory assessment and orientation.

4. Spiritual assessment.

5. Body systems examination.

Correct Answer: 2, 3, 5

Rationale 1: Collection of dietary preferences is completed on clients when they are admitted to a facility, however, this information will not provide an explanation for the changes being noted in the client’s behaviors.

Rationale 2: The client’s appearance indicates there has been some change in mental outlook or condition. These changes may be the result of psychosocial issues and they must be investigated.

Rationale 3: The client’s appearance indicates there has been some change in mental outlook or condition. The client’s memory and level of orientation will provide information relating to potential causes. This assessment will also provide an indication as to the seriousness of the problems being noted.

Rationale 4: While this is an important aspect of the overall client’s assessment, this is not a priority in the current situation. 

Rationale 5: The assessment of the client’s body systems will yield clues as to the cause of the changes being noted in behavior.

Global Rationale: The client’s appearance indicates there has been some change in mental outlook or condition. These changes may be the result of psychosocial issues and they must be investigated. The client’s memory and level of orientation will provide information relating to potential causes. This assessment will also provide an indication as to the seriousness of the problems being noted. The assessment of the client’s body systems will yield clues as to the cause of the changes being noted in behavior. Collection of dietary preferences is completed on clients when they are admitted to a facility, however, this information will not provide an explanation for the changes being noted in the client’s behaviors. A spiritual assessment is not a priority given the current assessment findings.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5.4: Describe application of the nursing process in the assessment of psychosocial health.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment.

Page Number: 97

Question 11

Type: MCSA

The nurse is reviewing the care plan for a client with schizophrenia. Upon assessment the client admits to hearing voices that say, “Kill yourself.” The nurse documents the client is at risk for injury and includes the following statement in the plan of care, “Client will not harm self during hospitalization.” Which step of the nursing process is the nurse using?

1. Goal setting.

2. Implementation.

3. Diagnosis.

4. Evaluation.

Correct Answer: 1

Rationale 1: Goal setting occurs after a diagnosis has been formulated. The statement written is a goal for the client during hospitalization.

Rationale 2: Implementation is the process of performing certain interventions designed to move the client toward achievement of the goal.

Rationale 3: The diagnosis is formulated after data have been collected.

Rationale 4: Evaluation is the process whereby the progress toward achieving the goals is reviewed and documented. The nurse’s recorded observations indicate the goals of the nursing care plan have been achieved.

Global Rationale: Goal setting occurs after a diagnosis has been formulated. The statement written is a goal for the client during hospitalization. Implementation is the process of performing certain interventions designed to move the client toward achievement of the goal. The diagnosis is formulated after data have been collected, and goal setting occurs after a diagnosis has been formulated. Evaluation is the process whereby the progress toward achieving the goals is reviewed and documented. The nurse’s recorded observations indicate the goals of the nursing care plan have been achieved.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development.

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 5.4: Describe application of the nursing process in the assessment of psychosocial health.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment.

Page Number: 95

Question 12

Type: MCMA

The nurse admits a client to a psychiatric facility and plans to conduct a psychosocial assessment. Which assessment tools are appropriate for the nurse to use to collect this data?

Standard Text: Select all that apply.

1. Healthy Day Measures.

2. Multidimensional Health Profile.

3. Emotional Readiness Assessment Profile.

4. Holmes Social Readjustment Scale.

5. Duke Social Support and Stress Scale.

Correct Answer: 1, 2, 4, 5

Rationale 1: The Healthy Day Measures is used by the Centers for Disease Control and Prevention. The scale is used to measure the quality of life.

Rationale 2: The Multidimensional Health Profile is a tool used to assess psychosocial problems. The tool specifically targets stress, coping, social supports, and mental health.

Rationale 3: The Emotional Readiness Scale is not a true test, and therefore not a valid test to assess psychosocial variables in a client.

Rationale 4: The Holmes Social Readjustment Scale is used to measure the stressors in a client’s life.

Rationale 5: The Duke Social Support and Stress scale is an instrument to measure family and nonfamily support and stress.

Global Rationale: The Healthy Day Measures is used by the Centers for Disease Control and Prevention. The scale is used to measure the quality of life. The Multidimensional Health Profile is a tool used to assess psychosocial problems. The tool specifically targets stress, coping, social supports, and mental health. The Holmes Social Readjustment Scale is used to measure the stressors in a client’s life. The Duke Social Support and Stress scale is an instrument to measure family and nonfamily support and stress. The Emotional Readiness Scale is not a true test, and therefore not a valid test to assess psychosocial variables in a client.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5.4: Describe application of the nursing process in the assessment of psychosocial health.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment.

Page Number: pp. 90–97

Question 13

Type: MCSA

While being interviewed, a client admits to the nurse that she has been hearing voices and sounds for the past three days. Which response by the nurse is the most appropriate?

1. “How long have you been hearing these voices?”

2. “Tell me about what the voices tell you to do.”

3. “These must be other things you are hearing.”

4. “Do the voices bother you during the night only?”

Correct Answer: 2

Rationale 1: Knowing the length of time a person has had auditory hallucinations is helpful but is not the most important next question. Also, the client already said that she had been hearing the voices for 3 days.

Rationale 2: The most appropriate next question after the client tells the nurse she hears voices is asking the client if the voices tell her what she must do. Command hallucinations are dangerous and may lead to self-destructive behavior or harm to other people or property.

Rationale 3: Telling the client that there cannot be voices may indicate your lack of belief regarding in what is being said. This may cause refusal to answer additional questions.

Rationale 4: Asking whether or not the voices are bothersome to the client only at night does not yield helpful information, as hallucinations are not a normal phenomenon and treatment goals would include eliminating the hallucinations. Additionally, the goal of the interview is to obtain the information most important to the treatment plan and is not to dwell on the hallucinations, thereby reinforcing them to the patient.

Global Rationale: The most appropriate next question after the client tells the nurse she hears voices is asking the client if the voices tell her what she must do. Command hallucinations are dangerous and may lead to self-destructive behavior or harm to other people or property. Knowing the length of time a person has had auditory hallucinations is helpful but is not the most important next question. Also, the client already said that she had been hearing the voices for 3 days. Telling the client that there cannot be voices may indicate your lack of belief regarding in what is being said. This may cause refusal to answer additional questions. Asking whether or not the voices are bothersome to the client only at night does not yield helpful information, as hallucinations are not a normal phenomenon and treatment goals would include eliminating the hallucinations. Additionally, the goal of the interview is to obtain the information most important to the treatment plan and is not to dwell on the hallucinations, thereby reinforcing them to the patient.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5.4: Describe application of the nursing process in the assessment of psychosocial health.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment.

Page Number: pp. 94–95

Question 14

Type: MCSA

The nurse is caring for a confused client. The nurse informs the client of the date, day of the week, time, and location each time the room is entered. Which step of the nursing process is the nurse using to orient this client?

1. Implementation.

2. Evaluation.

3. Planning.

4. Assessment.

Correct Answer: 1

Rationale 1: Implementation is the process of performing certain interventions designed to move the client toward achievement of the goal. A confused client needs reorientation as part of the nursing care provided.

Rationale 2: Evaluation is the process whereby the progress toward achieving the goals is reviewed and documented.

Rationale 3: During the planning phase of the nursing process, nursing diagnoses are formulated after data have been assessed, and then goal setting takes place.

Rationale 4: Assessment is the phase of obtaining subjective and objective data about the client.

Global Rationale: Implementation is the process of performing certain interventions designed to move the client toward achievement of the goal. A confused client needs reorientation as part of the nursing care provided. Evaluation is the process whereby the progress toward achieving the goals is reviewed and documented. During the planning phase of the nursing process, nursing diagnoses are formulated after data have been assessed, and then goal setting takes place. Assessment is the phase of obtaining subjective and objective data about the client.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5.4: Describe application of the nursing process in the assessment of psychosocial health.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment.

Page Number: pp. 94–95

Question 15

Type: MCSA

The nurse is completing the psychosocial history on a newly admitted adult client. The client reports trouble concentrating, rapid heartbeats, irritability, and inability to make decisions. Based on these assessment findings, which does the nurse suspect?

1. A stress reaction.

2. Role confusion.

3. An impending heart attack.

4. Dysfunctional anxiety.

Correct Answer: 1

Rationale 1: A high level of stress may result in symptoms such as irritability, indecisiveness, confusion, pounding heart or pulse, and trouble concentrating, among other symptoms.

Rationale 2: There are no data to support the concern of role confusion.

Rationale 3: Symptoms of an impending heart attack may include irritability, confusion, and a pounding heart rate, but there are other more classic symptoms that typically also appear.

Rationale 4: Symptoms of anxiety include some of the above symptoms, but there is not enough evidence to call it dysfunctional.

Global Rationale: A high level of stress may result in symptoms such as irritability, indecisiveness, confusion, pounding heart or pulse, and trouble concentrating, among other symptoms. There are no data to support the concern of role confusion. Symptoms of an impending heart attack may include irritability, confusion, and a pounding heart rate, but there are other more classic symptoms that typically also appear. Symptoms of anxiety include some of the above symptoms, but there is not enough evidence to call it dysfunctional.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care.

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches.

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development.

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 5.2: Apply knowledge of psychosocial functioning to assessment of overall health and wellness.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment.

Page Number: pp. 93–94

Question 16

Type: MCSA

An older adult client who is hard-of-hearing is observed not participating in conversation and sits quietly in the corner of the room. This client’s physical ailment is impacting which psychosocial dimension?

1. Mental.

2. Emotional.

3. Social.

4. Spiritual.

Correct Answer: 3

Rationale 1: Mental functioning refers to the ability to cognitively process and interact with the environment.

Rationale 2: The emotional dimension is subjective and includes one’s feelings.

Rationale 3: Psychosocial health includes mental, emotional, social, and spiritual dimensions. When one part is missing or dysfunctional, all other parts of the individual are affected. Social functioning refers to the ability to form relationships with others.

Rationale 4: Spirituality refers to the beliefs and values that give meaning to life.

Global Rationale: Psychosocial health includes mental, emotional, social, and spiritual dimensions. When one part is missing or dysfunctional, all other parts of the individual are affected. Social functioning refers to the ability to form relationships with others. Mental functioning refers to the ability to cognitively process and interact with the environment. The emotional dimension is subjective and includes one’s feelings. Spirituality refers to the beliefs and values that give meaning to life.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Knowledge and Science: Defining how the evidence on which practice is based is developed and by whom.

 Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 5.1: Categorize the major components of psychosocial health.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment.

Page Number: pp. 91–92

Question 17

Type: MCSA

The adult caregiver of an older adult client states, “When my mother takes ill, you can predict I’ll be sick in about 6 weeks.” What does this statement from the adult caregiver indicate?

1. The client has a communicable disease.

2. The caregiver has uncared for health problems.

3. The caregiver is more ill than the client.

4. The caregiver is experiencing emotional stress.

Correct Answer: 4

Rationale 1: There is no indication the caregiver has an underlying health problem such as a communicable disease.

Rationale 2: There is no indication the caregiver has an underlying health problem such as uncared for health problems.

Rationale 3: There is no indication the caregiver is more ill than the client.

Rationale 4: Emotional health affects health in several ways. Stress affects the immune system, leading to increased susceptibility to infections. During periods of stress or change, the individual is less likely to adhere to positive health behaviors.

Global Rationale: Emotional health affects health in several ways. Stress affects the immune system, leading to increased susceptibility to infections. During periods of stress or change, the individual is less likely to adhere to positive health behaviors. There is no indication the caregiver has an underlying health problem such as a communicable disease, uncared for health problems, or is more ill than the client.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development.

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 5.3: Examine factors that affect psychosocial health in patients across the life span.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment.

Page Number: pp. 93–94

Question 18

Type: MCSA

A client tells the nurse, “I want to make sure my children have every possible opportunity to complete their education.” The nurse realizes this client’s philosophy on education will influence which aspect of the children’s health?

1. Attempt to meet immediate needs.

2. Help to elevate self-esteem.

3. Ongoing family disturbances.

4. Can lead to mental illness.

Correct Answer: 2

Rationale 1: Focus on immediate needs is seen more in those individuals from lower socioeconomic groups. This is not associated with an increased emphasis and achievement of educational goals.

Rationale 2: The higher the income, the more likely that individuals and families will achieve higher levels of education. The advantage contributes to the feelings of high self-worth and high self-esteem.

Rationale 3: Individuals from lower socioeconomic groups face a focus on immediate needs. This focus promotes a sense of low self-esteem. Continued feelings of this nature may result in family disturbances.

Rationale 4: Mental illness may be seen and remain untreated in lower socioeconomic groups as a result of ongoing focus on the meeting of immediate needs. This focus is often linked directly to a lack of education as seen in this population.

Global Rationale: The higher the income, the more likely that individuals and families will achieve higher levels of education. The advantage contributes to the feelings of high self-worth and high self-esteem. In lower socioeconomic groups, energies are spent in attempts to achieve more immediate needs. This focus promotes a concern on those present issues, resulting in less health promotion and future focused goals. Family disturbances and mental illness are seen in lower socioeconomic groups.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development.

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 5.3: Examine factors that affect psychosocial health in patients across the life span.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment.

Page Number: pp. 92–93

Question 19

Type: MCSA

The nurse conducts a physical assessment for a client. Which client statement during the assessment indicates the client is at risk for developing a major illness?

1. “Look at that person’s pants! Don’t they realize how ugly they are?”

2. “That sounds like a good idea! I think I will try that at home.”

3. “I just love spending time outside. It energizes me!”

4. “I set aside a period of time each day for myself.”

Correct Answer: 1

Rationale 1: There are different characteristics and behaviors a person demonstrates that can be categorized along the continuum of being psychosocially healthy vs. being psychosocially unhealthy. Those who are unhealthy psychosocially are at risk for the onset of an illness. Those who are psychosocially unhealthy will demonstrate pessimism, will openly laugh at others, are a “challenge” to be around, have little fun, and are self-absorbed.

Rationale 2: Individuals who are psychosocially healthy will demonstrate a zest for life and are adaptable to change.

Rationale 3: Individuals who are psychosocially healthy will demonstrate respect for nature.

Rationale 4: Individuals who are psychosocially healthy will demonstrate a zest for life, manage time well, and demonstrate coping skills.

Global Rationale: There are different characteristics and behaviors a person demonstrates that can be categorized along the continuum of being psychosocially healthy vs. being psychosocially unhealthy. Those who are unhealthy psychosocially are at risk for the onset of an illness. Individuals who are psychosocially healthy will demonstrate a zest for life, manage time well, are adaptable to change, demonstrate coping skills, and respect nature. Those who are psychosocially unhealthy will demonstrate pessimism, will openly laugh at others, are a “challenge” to be around, have little fun, and are self-absorbed.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care.

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches.

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development.

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 5.2: Apply knowledge of psychosocial functioning to assessment of overall health and wellness.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment.

Page Number: pp. 98–99

Question 20

Type: MCSA

A client with hypertension stops into the clinic for a weekly blood pressure and blood glucose measurement along with a full set of vital signs. The client is in a hurry because he started a new job and has to get back to work. Which finding would indicate that the client is having a healthy response to the new job?

1. Blood pressure of 160/90 mmHg.

2. Respirations 16 and regular.

3. Blood glucose 210 mg/dL.

4. Heart rate 150 and regular.

Correct Answer: 2

Rationale 1: Physical signs of stress include elevated blood pressure, pulse, and respirations, dilated pupils, increased blood volume, and elevated blood glucose level. A blood pressure of 160/90 mmHg is considered elevated and would indicate stress.

Rationale 2: Physical signs of stress include elevated blood pressure, pulse, and respirations, dilated pupils, increased blood volume, and elevated blood glucose level. Respirations of 16 are within normal limits for an adult. This finding indicates a healthy response.

Rationale 3: Physical signs of stress include elevated blood pressure, pulse, and respirations, dilated pupils, increased blood volume, and elevated blood glucose level. Blood glucose of 210 mg/dL is elevated and would indicate stress.

Rationale 4: Physical signs of stress include elevated blood pressure, pulse, and respirations, dilated pupils, increased blood volume, and elevated blood glucose level. While the rhythm is regular, the rate of 150 is abnormal and would indicate stress.

Global Rationale: Physical signs of stress include elevated blood pressure, pulse, and respirations, dilated pupils, increased blood volume, and elevated blood glucose level. Respirations of 16 are within normal limits for an adult. This finding indicates a healthy response. A blood pressure of 160/90 mmHg, a blood glucose of 210 mg/dL, and a heart rate of 150 are all elevated and would indicate stress.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care.

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches.

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5.2: Apply knowledge of psychosocial functioning to assessment of overall health and wellness.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment.

Page Number: pp. 96–97Question 21

Type: MCSA

The nurse is assessing a client’s spiritual and belief patterns and asks the client about participation in organized religion. The nurse is on which step of the HOPE assessment with this client?

1. H

2. O

3. P

4. E

Correct Answer: 2

Rationale 1: H is for spiritual resources.

Rationale 2: O is for participation in organized religion.

Rationale 3: P is for personal spiritual practices.

Rationale 4: E is for effects of healthcare and end-of-life issues.

Global Rationale: The pneumonic HOPE is described as: H for spiritual resources, O for participation in organized religion, P for personal spiritual practices, and E for effects of healthcare and end-of-life issues.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub: 

QSEN Competencies: I.B.1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development

 Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5.5: Formulate patient-specific strategies for assessment of psychosocial health in patients across the life span.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment 

Page Number: p. 90

Question 22

Type: MCSA

A client is admitted to the psychiatric unit with complaints consistent with an anxiety disorder. During the assessment the nurse learns a client has a history of asthma and arthritis. Based on this information, which action is the priority for the nurse? 

1. Beginning the respiratory assessment

2. Beginning the musculoskeletal status assessment

3. Beginning the medication assessment 

4. Beginning the psychosocial assessment

Correct Answer: 4

Rationale 1: There is no indication the client is currently experiencing respiratory compromise, so the assessment of this system is not an immediate concern.

Rationale 2: Although the patient has a history of arthritis there is no indication that the client is experiencing immediate concerns related to the musculoskeletal system.

Rationale 3: A review of the client’s current medications will be included in the admission assessment but are not an immediate need.

Rationale 4: The client in the question is being admitted for concerns related to an anxiety disorder. The admitting issues take priority in the collection of data. Some physical problems have associated or underlying psychosocial problems. Examples of these physical problems include arthritis and asthma. The nurse should spend time on the psychosocial assessment with this client.

Global Rationale: The client in the question is being admitted for concerns related to an anxiety disorder. The admitting issues take priority in the collection of data. Some physical problems have associated or underlying psychosocial problems. Examples of these physical problems include arthritis and asthma. The nurse should spend time on the psychosocial assessment with this client. There is no indication the client is currently experiencing respiratory compromise so the assessment of this system is not an immediate concern. Although the patient has a history of arthritis there is no indication that the client is experiencing immediate concerns related to the musculoskeletal system. A review of the client’s current medications will be included in the admission assessment but are not immediate.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub: 

QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: I.1.Integrate theories and concepts from liberal education into nursing practice

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development

 Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5.3: Examine factors that affect psychosocial health in patients across the life span.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment 

Page Number: pp. 97-98

Question 23

Type: MCSA

The nurse is concerned that a client is having a problem with self-concept. Which statement by the client supports the nurse’s concern?  

1. “I never have any fun.”

2. “I am the oldest in the family.”

3. “I think I’m pretty much outgoing.”

4. “At times I like to be alone.”

Correct Answer: 1

Rationale 1: There are a variety of questions that can be asked to assess a client’s self concept. The client’s response provides information to the nurse about problems or concerns with this characteristic. Clients who are unable to explain a social life or who do not have any fun may be depressed or out of touch with reality.

Rationale 2: Birth order in the family is not implicated in the client.

Rationale 3: An outgoing client is not at high risk for problems with self-concept.

Rationale 4: Occasional desire to be alone does not indicate a problem with self-concept.

Global Rationale: There are a variety of questions that can be asked to assess a client’s self-concept. The client’s response provides information to the nurse about problems or concerns with this characteristic. Clients who are unable to explain a social life or who do not have any fun may be depressed or out of touch with reality. Birth order in the family is not implicated in the client. An outgoing client is not at high risk for problems with self-concept. Occasional desire to be alone does not indicate a problem with self-concept.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub: 

QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: I.1.Integrate theories and concepts from liberal education into nursing practice

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development

 Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5.4: Describe application of the nursing process in the assessment of psychosocial health.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment 

Page Number: pp. 92-93

Question 24

Type: MCSA

The nurse believes a client is having difficulty coping with current illness and hospitalization. Which assessment question would best help the nurse identify the client’s coping ability?

1. Who is your closest friend?

2. What social groups do you belong to?

3. What is your birth order in your family?

4. Who do you call when you need help?

Correct Answer: 4

Rationale 1: Questions about friends assess the client’s Roles & Relationships.

Rationale 2: Questions about social groups assess the client’s Roles & Relationships.

Rationale 3: Questions about birth order focus on the client’s Family History.

Rationale 4: Questions that are helpful to gather additional information about a client’s stress and coping mechanisms include: What do you do for relaxation? For recreation? What is your greatest source of comfort when you are feeling upset? Who do you call for help? What is your current level of stress?

Global Rationale: Questions that are helpful to gather additional information about a client’s stress and coping mechanisms include: What do you do for relaxation? For recreation? What is your greatest source of comfort when you are feeling upset? Who do you call for help? What is your current level of stress? Questions about friends and social groups assess the client’s Roles & Relationships, whereas questions about birth order focus on the client’s Family History.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub: 

QSEN Competencies: I.B.1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development

 Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 5.5: Formulate patient-specific strategies for assessment of psychosocial health in patients across the life span.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment 

Page Number: pp. 93-94

 

Question 25

Type: MCSA

During an assessment the assessment of a client admitted with new onset schizophrenia, the nurse observes the client repeating the last word of each question asked. Because of this, the client unable to completely answer any of the assessment questions. Which speech pattern in this client exhibiting? 

1. Circumlocution

2. Flight of ideas

3. Neologisms

4. Echolalia

Correct Answer: 4

Rationale 1: Circumlocution means the client is demonstrating numerous digressions.

Rationale 2: The speech pattern where thoughts and ideas jump is termed flight of ideas.

Rationale 3: Neologisms are the coining of new words that have significance to the client.

Rationale 4: Echolalia is the constant repetition of words or phrases that the client hears others say.

Global Rationale: Echolalia is the constant repetition of words or phrases that the client hears others say. Circumlocution means the client is demonstrating numerous digressions. Flight of ideas is a speech pattern where thoughts and ideas jump. . Neologisms are the coining of new words that have significance to the client. 

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub: 

QSEN Competencies: I.B.1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development

 Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 5.2: Apply knowledge of psychosocial functioning to assessment of overall health and wellness.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment 

Page Number: p. 96

Question 26

Type: MCSA

A client, whose mother has a history of schizophrenia, voices concerns about becoming pregnant and is fearful of having a child with the same disorder. Which response by the nurse is the most appropriate? 

1. “Schizophrenia is a genetic disorder so you are right to be very concerned.”

2. “Your family history does increase the risk factors but there are other variables to be considered.”

3. “Schizophrenia should not be a significant concern for you.”

4. “You should consider being tested before becoming pregnant.”

Correct Answer: 2

Rationale 1: Telling the patient to be very concerned does not present the maximum amount of information.

Rationale 2: Schizophrenia does have genetic links. Individuals having a family history have a greater incidence of also displaying the disorder. There are, however, other variables such as environment that should be considered.

Rationale 3: Advising the client that it should not be a significant concern both downplays the actual risk and minimizes the client’s concerns.

Rationale 4: There are no tests that can be run for this disease.

Global Rationale: Schizophrenia does have genetic links. Individuals having a family history have a greater incidence of also displaying the disorder. There are, however, other variables such as environment that should be considered. Telling the patient to be very concerned does not present the maximum amount of information. Advising the client that it should not be a significant concern both downplays the actual risk and minimizes the client’s concerns. There are no tests that can be run for this disease.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub: 

QSEN Competencies: I.B.1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development

 Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5.2: Apply knowledge of psychosocial functioning to assessment of overall health and wellness.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment 

Page Number: p. 92

Question 27

Type: MCSA

A client is seen at the ambulatory care clinic for a routine physical examination. During the examination, the client discusses having gained more than 25 pounds in the past year despite not changing the level of activity or dietary intake. What response by the nurse is the most appropriate? 

1. “You must be eating more than you realize.”

2. “Do you think increasing exercise might help you with your excessive weight gain?”

3. “Tell me about any changes in your stress levels.”

4. “This weight gain is likely the result of aging.”

Correct Answer: 3

Rationale 1: Telling the client that he is indeed eating more than realized is confrontational.

Rationale 2: Encouraging the client to increase exercise may be beneficial but the nurse must first assess for potential causes.

Rationale 3: Periods of stress may result in obesity. In addition, some individuals will use comfort foods during periods of stress.

Rationale 4: Many people do gain weight as they age but there is no indication that this is correct for this individual.

Global Rationale: Periods of stress may result in obesity. In addition, some individuals will use comfort foods during periods of stress. Telling the client that he is indeed eating more than realized is confrontational. Encouraging the client to increase exercise may be beneficial but the nurse must first assess for potential causes. Many people do gain weight as they age but there is no indication that this is correct for this individual.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: 

QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: I.1.Integrate theories and concepts from liberal education into nursing practice

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development

 Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5.3: Examine factors that affect psychosocial health in patients across the life span.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment 

Page Number: pp. 93-94

Question 28

Type: MCSA

A client is admitted to the psychiatric care unit. While the nurse is explaining the use of the call light, the client smiles and says, “Apples, corn, dogs, my foot.” The nurse correctly documents the client is demonstrating which speech pattern?

1. Neologisms

2. Clanging

3. Word salad

4. Echolalia

Correct Answer: 3

Rationale 1: Neologisms refer to the coining of new words.

Rationale 2: Clanging refers to engaging in a conversation in which the words rhyme.

Rationale 3: The grouping of words together in a manner that does not make sense is known as word salad.

Rationale 4: Echolalia is the constant repetition of words by the client that have been said by others.

Global Rationale: The grouping of words together in a manner that does not make sense is known as word salad. Neologisms refer to the coining of new words. Clanging refers to engaging in a conversation in which the words rhyme. Echolalia is the constant repetition of words by the client that have been said by others.

Cognitive Level: Understanding

Client Need: Psychosocial Integrity

Client Need Sub: 

QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes

AACN Essentials Competencies: I.1.Integrate theories and concepts from liberal education into nursing practice

NLN Competencies: Knowledge and Science: Defining how the evidence on which practice is based is developed and by whom

 Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5.2: Apply knowledge of psychosocial functioning to assessment of overall health and wellness.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment 

Page Number: p. 96

Question 29

Type: MCMA

The nurse is attempting to assess an agitated client. The client believes the nurse is trying to hurt him and is not cooperating with the nurse. What actions by the nurse are appropriate?

Standard Text: Select all that apply.

1. Advise the client that the healthcare provider will be contacted unless the client complies.

2. Restrain the client using leather restraints.

3. Speak to the client in a calm voice.

4. Explain actions to the client as they are done.

5. Medicate the client.

Correct Answer: 3,4

Rationale 1: Advise the client that the healthcare provider will be contacted unless the client complies. Telling the client that the healthcare provider will be called in this manner may be viewed as threatening. This action may further upset the client.

Rationale 2: Restrain the client using leather restraints. The use of restraints in the psychiatric setting is limited. Restraints should be a last resort and only indicated when the client may harm himself or another individual. There is no indication either of these criteria has been met.

Rationale 3: Speak to the client in a calm voice. Speaking in a calm voice may help to diffuse the situation and relax the client.

Rationale 4: Explain actions to the client as they are done. Explaining activities to the client may help to reduce the fears being experienced by the client.

Rationale 5: Medicate the client. The administration of medications simply to quiet the client is considered a form of chemical restraint. In addition, it is beyond the scope of practice to medicate the client without specific orders from the healthcare provider.

Global Rationale: Telling the client that the healthcare provider will be called in this manner may be viewed as threatening. This action may further upset the client. The use of restraints in the psychiatric setting is limited. Restraints should be a last resort and indicated only when the client may harm himself or another individual. There is no indication either of these criteria has been met. Speaking in a calm voice may help to diffuse the situation and relax the client. Explaining activities to the client may help to reduce the fears being experienced by the client. The administration of medications simply to quiet the client is considered a form of chemical restraint. In addition, it is beyond the scope of practice to medicate the client without specific orders from the healthcare provider.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub: 

QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: I.1.Integrate theories and concepts from liberal education into nursing practice

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development

 Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5.4: Describe application of the nursing process in the assessment of psychosocial health.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment 

Page Number: pp. 97-98

Question 30

Type: MCSA

A client presents to the ambulatory care clinic with complaints of back pain, nausea, and fatigue. When the nurse questions the client about recent stressors the client becomes irritated and states, “I am sick. Why are you asking me about all of this stress stuff?” Which response by the nurse is the most appropriate?

1. “Stress can impact our body by producing a variety of symptoms.”

2. “Your nausea and fatigue are most often related to an overabundance of stress in life.”

3. “Asking about stress is required for every client.”

4. “We all have stress and I need to see how much you have.”

Correct Answer: 1

Rationale 1: Stress is associated with a variety of physical ailments, including back pain, nausea, and fatigue. The nurse has a responsibility to provide education to the client concerning the reasons behind the questions being asked.

Rationale 2: The final diagnosis as to the cause of the ailments being reported has not been completed. It is premature for the nurse to equate an overabundance of stress to the physical concerns reported.

Rationale 3: Stress assessment may be a requirement for many data collections but this does not provide an adequate response to the client.

Rationale 4: Telling the client that all people have stress downplays the client’s individual needs and is inappropriate.

Global Rationale: Stress is associated with a variety of physical ailments, including back pain, nausea, and fatigue. The nurse has a responsibility to provide education to the client concerning the reasons behind the questions being asked. The final diagnosis as to the cause of the ailments being reported has not been completed. It is premature for the nurse to equate an overabundance of stress to the physical concerns reported. Stress assessment may be a requirement for many data collections but this does not provide an adequate response to the client. Telling the client that all people have stress downplays the client’s individual needs and is inappropriate.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub: 

QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: I.1.Integrate theories and concepts from liberal education into nursing practice

NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person’s development

 Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5.3: Examine factors that affect psychosocial health in patients across the life span.

MNL Learning Outcome: 1.6.1. Categorize the behaviors and level of consciousness that are assessed in a mental health assessment 

Page Number: pp. 93-94

 

D’Amico/Barbarito Health & Physical Assessment in Nursing, 3/e
Copyright 2016 by Pearson Education, Inc.