Chapter 9: Mental Health Assessment Skills Nursing School Test Banks

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 clients 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 clients series of group therapy sessions, the nurse periodically talks with the client to determine whether he has any signs of relapse of his previous problems. This action by the nurse is an example of:
a. Planning
b. Assessment
c. Intervention
d. Diagnosing
ANS: B
In this situation, the nurse is assessing for any signs of relapse. Assessment is a continuous process. Planning is the phase of the nursing process when client goals are set and interventions are planned; intervention is the phase of the nursing process when planned interventions are actually implemented; and diagnosis is the phase of the nursing process following assessment when the clients 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 clients 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

6. Without assessment of six specific aspects of an individuals being, the mental health nurses scope of care is narrow and limited in effectiveness. These aspects include social, physical, cultural, intellectual, emotional, and spiritual areas of a persons 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 individuals 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 clients 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 clients 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 clients 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 clients 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 clients nonverbal communication
b. Avoiding making assumptions
c. Avoiding ones personal values that may cloud professional judgment
d. Setting clear client goals
ANS: C
This is an example of the nurse allowing his or her personal values to cloud professional judgment and is an ineffective interview technique that leads to a negative nurseclient 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 OBJ: 9
TOP: Thinking KEY: Nursing Process Step: Assessment
MSC: Client Needs: Psychosocial Integrity

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 clients 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 clients 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
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 Thinking KEY: 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 didnt 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
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 Thinking KEY: 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.)
a. Proof of care for insurance reimbursement purposes
b. A means of monitoring the clients progress
c. An instrument for communication and coordination of care
d. A guide for planning and implementation of care
e. Evaluating the effectiveness of interventions
ANS: B, C, D, E
Purposes of the treatment plan include serving as a means of monitoring the clients 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 clients 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 OBJ: 4
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. Alzheimers disease
e. Anxiety
ANS: A, D, E
Loss of recent memory is seen in persons with Alzheimers 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 persons 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

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