Question 1

The nurse is reviewing the care plan for a client who is being treated for schizophrenia.The client had been hearing voices for quite some time,but now doesn't state or deny that voices are heard.The nurse notes that the established goals have been met-the client is interacting appropriately with staff and family,is well-groomed,and has expressed excitement about the discharge.The nurse is using which step of the nursing process?

Accepted Answer

A)  Goal setting
B)  Implementation
C)  Diagnosis
D)  Evaluation D

Question 2

The nurse is concerned that a client is having a problem with self-concept.Which of the following statements would cause the nurse to have this concern?

Accepted Answer

A)  "I never have any fun."
B)  "I am the oldest in the family."
C)  "I think I'm pretty much outgoing."
D)  "At times I like to be alone." A

Question 3

A client is admitted to the orthopedic unit after breaking an arm after a fall.The client appears disheveled and has a body odor.The family arrives and expresses surprise at the client's appearance.They report that this is not the normal appearance of the client and that they are usually clean and meticulously groomed.Which of the following assessments does the nurse need to complete in order to formulate relevant nursing diagnoses and a plan of care for this patient?

Accepted Answer

A)  Food preferences
B)  Psychosocial assessment
C)  Memory assessment and orientation
D)  Family medical history
E)  Body systems examination B,C,D,E

Question 4

A client is admitted to the psychiatric care unit.During the admission process,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 of the following speech patterns?

Accepted Answer

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

Question 5

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 indicated?

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 6

The nurse is caring for a client admitted for severe weight loss and depression.The client has 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 of the following nursing diagnoses?

Accepted Answer

A)  Powerlessness
B)  Anxiety
C)  Dysfunctional grieving
D)  Spiritual distress

Question 7

The nurse is interviewing a client prior to a physical examination.The client tells the nurse that she has been experiencing a lot of aches,pains,and abdominal discomfort.The nurse may suspect which of the following factors that impact physical health?

Accepted Answer

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

Question 8

The nurse is admitting a client to a psychiatric facility and is planning to conduct a psychosocial assessment.The nurse would correctly choose which of the following tools to obtain 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

Question 9

A client voices concerns about becoming pregnant.The client reports her mother had a history of schizophrenia.The client is fearful of having a child with the same disorder.What is the best initial response by the nurse?

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 10

During an assessment the nurse observes the client jumping from one idea to another,unable to completely answer any of the assessment questions.The nurse recognizes this speech pattern as being:

Accepted Answer

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

Question 11

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." The nurse is stressing which of the following areas?

Accepted Answer

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

Question 12

A client has presented 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 of the following responses by the nurse is most appropriate?

Accepted Answer

A)  "Stress can impact our body by producing a variety of symptoms."
B)  "Your nausea and fatigue are most often related to an overabundance of stress in life."
C)  "Asking about stress is required for every client."
D)  "We all have stress and I need to see how much you have."

Question 13

The nurse has gathered assessment data on a client admitted for suicidal tendencies.The nurse develops appropriate nursing diagnoses and formulates goals to achieve client outcomes.The nurse is utilizing which step of the nursing process?

Accepted Answer

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

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 of the following would be the nurse's best response in this situation?

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

Because of statements made by the client during a physical assessment,the nurse believes the client is at risk for developing a major illness.Which of the following statements would cause the nurse to fear for this client?

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 16

The nurse is caring for a woman in the emergency room who is complaining of chest pain.She states that she was walking from her apartment to the grocery store when the pain became very severe.She reported that people were following her.She said she couldn't really see them but she could hear them 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.The nurse would obtain what further assessment data in this situation?

Accepted Answer

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

Question 17

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.The nurse suspects which of the following?

Accepted Answer

A)  Stress reaction
B)  Role confusion
C)  Impending heart attack
D)  Dysfunctional anxiety

Question 18

A 7-year-old client was just admitted to the hospital following an appointment in the pediatric oncology clinic.His mother,who is distraught over his recent leukemic relapse,accompanies the child.She is crying and asking,"What did I do wrong? ...Why does he deserve this? ...Why can't it be me?" The nurse understands that these statements indicate which of the following?

Accepted Answer

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

Question 19

A client with hypertension stops into the clinic for his weekly blood pressure measurement.He tells the nurse that he is in a hurry because he started a new job and has to get back to work.Evidence that this client is responding to the new job in a stressful way would be:

Accepted Answer

A)  Elevated blood pressure.
B)  Respirations 16 and regular.
C)  Temperature within normal limits.
D)  Heart rate 86 and regular.

Question 20

The nurse is interviewing an overweight teenager who looks downward and speaks softly when answering questions.The nurse identifies a problem with client's self-concept.Which of the following findings would support the nurse's conclusions?

Accepted Answer

A)  Increased desire to form lasting relationships
B)  Decreased ability to form attachments with other people
C)  Inability to maintain stable employment
D)  Feelings of worthlessness,anxiety,and/or depression

Exam 5: Psychosocial Assessment