Question 1

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?

Accepted Answer

A)   Healthy Day Measures.
B)   Multidimensional Health Profile.
C)   Emotional Readiness Assessment Profile.
D)   Holmes Social Readjustment Scale.
E)   Duke Social Support and Stress Scale. A,B,D,E

Question 2

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?

Accepted Answer

A)   Food preferences.
B)   Psychosocial assessment.
C)   Memory assessment and orientation.
D)   Spiritual assessment.
E)   Body systems examination. B,C,E

Question 3

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?

Accepted Answer

A)   Circumlocution
B)   Flight of ideas
C)   Neologisms
D)   Echolalia D

Question 4

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?

Accepted Answer

A)   "Look at that person's pants! Don't they realize how ugly they are?"
B)   "That sounds like a good idea! I think I will try that at home."
C)   "I just love spending time outside. It energizes me!"
D)   "I set aside a period of time each day for myself."

Question 5

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 The client recently experienced the loss of three close family members and has withdrawn from all social activities.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?

Accepted Answer

A)   Powerlessness.
B)   Anxiety.
C)   Complicated grieving.
D)   Spiritual distress.

Question 6

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?

Accepted Answer

A)   "Schizophrenia is a genetic disorder so you are right to be very concerned."
B)   "Your family history does increase the risk factors but there are other variables to be considered."
C)   "Schizophrenia should not be a significant concern for you."
D)   "You should consider being tested before becoming pregnant."

Question 7

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?

Accepted Answer

A)   Being emotionally balanced and socially astute.
B)   Being mentally stable, physically fit, and psychologically well.
C)   Being spiritually and psychologically mature.
D)   Being mentally, emotionally, socially, and spiritually well.

Question 8

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?

Accepted Answer

A)   Income.
B)   Stress.
C)   Ethnicity.
D)   Occupation.

Question 9

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?

Accepted Answer

A)   A stress reaction.
B)   Role confusion.
C)   An impending heart attack.
D)   Dysfunctional anxiety.

Question 10

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?

Accepted Answer

A)   Beginning the respiratory assessment
B)   Beginning the musculoskeletal status assessment
C)   Beginning the medication assessment
D)   Beginning the psychosocial assessment

Question 11

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?

Accepted Answer

A)   Mental.
B)   Emotional.
C)   Social.
D)   Spiritual.

Question 12

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?

Accepted Answer

A)   Neologisms
B)   Clanging
C)   Word salad
D)   Echolalia

Question 13

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?

Accepted Answer

A)   "You must be eating more than you realize."
B)   "Do you think increasing exercise might help you with your excessive weight gain?"
C)   "Tell me about any changes in your stress levels."
D)   "This weight gain is likely the result of aging."

Question 14

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?

Accepted Answer

A)   "How long have you been hearing these voices?"
B)   "Tell me about what the voices tell you to do."
C)   "These must be other things you are hearing."
D)   "Do the voices bother you during the night only?"

Question 15

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?

Accepted Answer

A)   Spiritual affiliations.
B)   Dietary preferences and habits.
C)   Review of systems.
D)   Focused psychosocial interview.

Question 16

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?

Accepted Answer

A)   The client has a communicable disease.
B)   The caregiver has uncared for health problems.
C)   The caregiver is more ill than the client.
D)   The caregiver is experiencing emotional stress.

Question 17

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?

Accepted Answer

A)   Physical fitness.
B)   Emotional health.
C)   Physical health.
D)   Psychologic well-being.

Question 18

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?

Accepted Answer

A)   Ineffective coping.
B)   Emotional emptiness.
C)   Spiritual distress.
D)   Psychologic anxiety.

Question 19

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?

Accepted Answer

A)   Implementation.
B)   Evaluation.
C)   Planning.
D)   Assessment.

Question 20

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?

Accepted Answer

A)   Tell the client three things that he does well.
B)   Ask other clients to tell the client what he does well.
C)   Determine barriers to achieving the goal.
D)   Do nothing as long as the client appears better.

Exam 5: Psychosocial Assessment