Chapter 8: Assessment
A nurse is assessing a newly diagnosed client with depression. Which question will the nurse prioritize?
A. "Are you thinking about killing yourself?"
B. "Do I need to call someone for you to talk to about this?"
C. "Have you told anyone else about this?"
D. "Do you want to share your feelings in group?"
Answer: A
Rationale: The nurse must determine whether the depressed or hopeless client has suicidal ideation or a lethal plan. The nurse does so by asking the client directly. This is a priority question because of the direct link with safety. Calling someone else does not address this situation. Asking if the client has told anyone else does not matter in this situation. This is not likely something that would be shared in group until coping mechanism are in place.
The nurse is working on the behavioral health unit caring for several clients. Which client situation indicates that the client is being falsely imprisoned?
A. A client is confused, combative, and insists they will not be stopped from leaving. The nurse restrains the client and then seeks the order.
B. When the client exhibits attention seeking behaviors, the nurse informs the client they will have to stay in their room or be restrained.
C. A client with psychosis attempts to leave the unit, and the nurse escorts the client back to the unit.
D. An involuntarily admitted client is brought back to the unit by security when locking themselves in the bathroom.
Answer: B
Rationale: False imprisonment involves holding a competent person against their will. Actual force is not a requirement of false imprisonment. The individual needs only to be placed in fear of imprisonment by someone who has the ability to carry out the threat. The client who is combative and confused is not competent, and the nurse is acting beneficently. The clients who have been admitted as involuntary clients and should not be allowed to leave without permission of the treatment team.
A client stops abruptly in the middle of a sentence while speaking to the nurse. How does the nurse analyze and document this behavior?
A. Circumstantial thinking
B. Loose associations
C. Thought blocking
D. Blunted affect
Answer: C
Rationale: Thought blocking is stopping abruptly in the middle of a sentence or train of thought; sometimes unable to continue the idea. Loose associations are disorganized thinking that jumps from one idea to another with little or no evident relation between the thoughts. Circumstantial thinking is when a client eventually answers a question but only after giving excessive unnecessary detail. Blunted affect is showing little or a slow-to-respond facial expression.
A nurse is reviewing an electronic medical record to determine if a client’s rights have been violated by another member of the health care team. Which finding will the nurse identify that would indicate a violation of the client rights?
A. There is no documentation of benefits of treatment or treatment options.
B. The client’s belongings are searched at admission.
C. Physical restraints were used to prevent harm to self and others.
D. The client was placed on one-to-one continuous observation for threats of self-harm.
Answer: A
Rationale: A client has the right to be informed of the benefits of treatment and treatment options. Inspecting client’s belongings is performed as a safety measure so that anything that can be used as a harmful object can be removed. Clients have the right to a safe environment. Clients have the right to be protected against the possible impulse to harm oneself that occurs as a result of a mental disorder and to be monitored 1:1.
The nurse is conducting a psychosocial assessment for a client that reports, “My spouse gets so angry and hits and kicks me and then will treat me well for a while.” Which is the most therapeutic response by the nurse?
A. “I was in an abusive relationship for several years and finally got my strength up to get out of it.”
B. “I am sorry that you are experiencing this, and I would like to sit and talk with you for a while.”
C. “I am not sure why you would stay with someone that hurts you. You need to get out.”
D. “I have to check on another client now but we can talk about this situation later.”
Answer: B
Rationale: By sitting down and talking with the client in an unhurried manner, the client will not feel rushed or pressured to complete the assessment and provide in depth information versus superficial. The client has divulged very sensitive and potentially embarrassing information to the nurse. Although the nurse should be aware of their own feelings in regard to the abuse, it is not appropriate to make the client’s issue the nurse’s. The nurse is presenting a judgmental attitude by saying the client should not stay with someone that would cause pain or harm. The nurse must be aware of their feelings and responses and approach the assessment matter-of-factly.
A nurse is assigned to administer oral medications to a client. Which actions will the nurse take if a client refuses to take prescribed oral medications?
A. Inform the client that the nurse will get reprimanded for not administering the medication.
B. Inform the client that refusal is not permitted and it is required that the client take the medication.
C. Document the client's refusal on the medication administration record without comment.
D. Ask the client's reason for refusing and report it to the health care provider.
Answer: D
Rationale: The client has the right to refuse medication unless a court order to medicate has been obtained. The client's reason for refusing should be ascertained, and the refusal should be reported to the health care provider. Sometimes refusals are based on unpleasant side effects or lack of education about the medication. Threats and manipulation are inappropriate such as referring to the nurse’s reprimand, or that refusal is not permitted.
The nurse is conducting an admission interview for a client. Which questions or statements asked by the nurse may create a barrier for obtaining further information from the client? Select all that apply.
A. “How are you feeling today?”
B. “Did you have any difficulty obtaining your medications?”
C. “How is your relationship with your partner?”
D. “Talk with me about why you are here today”
E. “Where are you currently working?”
Answer: A, B, C, E
Rationale: Close-ended questions may be answered with a yes or no response or a short response that does not encourage further discussion. Asking the client how they feel may be responded to by one word responses as would asking about difficulty obtaining medications. Without the development of a therapeutic nurse–client relationship, the client may opt to only answer “fine” or “good” related to a question about a relationship. Asking the client to talk about why they are here is an open-ended question/statement.
A nurse in the emergency department is planning for a client with mental illness to be placed in an inpatient hospitalization. Which is a criterion assessed by the nurse is condition of this type of admission?
A. Nonadherence with medication administration at home
B. Presents a clear danger to self or others
C. Develops new symptoms of the illness
D. Has no support systems in the community
Answer: B
Rationale: Hospitalization is justified when the client is a danger to self or others. Medication nonadherence, new symptoms, or no community support would require in hospital treatment.
The nurse is performing an assessment of a client’s mental health status. Which assessment data is important for the nurse to obtain to determine the client’s psychosocial function? Select all that apply.
A. Current emotional state
B. Mental capacity
C. Behavioral function
D. Current plan of care
E. Physical health status
Answer: A, B, C
Rationale: The purpose of the psychosocial assessment is to construct a picture of the client’s current emotional state, mental capacity, and behavioral function. This assessment serves as the basis for developing a plan of care to meet the client’s needs. However, it is not conducting for the purpose of assessing the client’s care plan. The client’s physical health status would need to be addressed in a physical assessment.
The nurse is working in a state psychiatric facility and encounters situations which require the evaluation of ethical dilemmas. Which dilemmas involve the ethical principle of fidelity? Select all that apply.
A. The nurse is unable to agree with the policies or common practices of an agency.
B. The nurse is faced with a decision to violate a policy that is harmful to the client.
C. The nurse is certain that clients of different racial and ethnic backgrounds are treated the same as other clients.
D. The nurse identifies a combative client must be secluded against their will to prevent harm to others.
E. The client refuses to take medication and the nurse respects the client's right to refuse medication.
Answer: A, B
Rationale: When the nurse is unable to agree with the policies or common practices of an agency, the nurse is facing a dilemma about fidelity, which refers to the obligation to honor commitments and contracts. When the nurse is faced with a decision to violate a policy that is harmful to the client, the nurse is facing a dilemma about fidelity—that is, should the nurse be faithful to the employing agency or the individual client being cared for. When the nurse is certain that clients of different racial and ethnic backgrounds are being treated the same as other clients, the nurse is acting in accord with the ethical principle of justice. When the nurse understands that a combative client must be secluded against their will to prevent harm to others, the nurse is following the ethical principle of utilitarianism. When a client refuses to take medications and the nurse respects the client's right to refuse medication, the nurse is enacting the ethical principle of autonomy.