Test Bank For Foundations of Mental Health Care 3rd Edition Morrison Valfre

Test Bank for Foundations of Mental Health Care, 3rd
Edition: Morrison-Valfre
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Test Bank for Foundations of Mental Health Care, 3rd Edition: Morrison-Valfre
Morrison-Valfre: Foundations of Mental Health Care, 4th Edition
Test Bank
Chapter 9: Mental Health Assessment Skills
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: Page 86 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 client’s problem is identified.

TOP: Nursing (Therapeutic) Process KEY: Nursing Process Step: Intervention
MSC: Client Needs: Physiological Integrity
3. Following completion of a male client’s 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:
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Test Bank 9-2
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 client’s problem is identified.

TOP: Nursing (Therapeutic) Process KEY: Nursing Process Step: Assessment
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.

TOP: Nursing (Therapeutic) Process KEY: Nursing Process Step: Evaluation
5. The treatment team meets with a client for the first time and determines, with the
client’s 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
Test Bank 9-3
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.

TOP: Nursing (Therapeutic) Process KEY: Nursing Process Step: Planning
6. During an admission assessment, a male client states that he has been having auditory
hallucinations and difficulty concentrating at work. This type of data is referred to as:
a. Objective
b. Subjective
c. Measured
d. Shared
ANS: B
Subjective data refer to what the client feels or perceives. Objective data are collected
by another person and can be measured and shared.

TOP: Data Collection KEY: Nursing Process Step: Assessment
7. The nurse observes the client as he paces the floor and talks to himself. The nurse
documents, “Client confused and agitated.” This is an example of:
a. Objective data
b. A judgment
c. Subjective data
d. An observation
ANS: B
Without further assessing the client, this is an interpretive statement or judgment. The
client may be concerned about something and may be simply thinking out loud.
Nurses should avoid interpretive statements because they may not be accurate.
Objective data consist of observations made, and subjective data include client
perceptions.

TOP: Data Collection KEY: Nursing Process Step: Intervention
8. Without assessment of six specific aspects of an individual’s being, the mental health
nurse’s scope of care is narrow and limited in effectiveness. These aspects include
social, physical, cultural, intellectual, emotional, and spiritual areas of a person’s life,
known as a __________ assessment.
a. Complete
b. Accurate
Test Bank 9-4
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 individual’s 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: Page 87 OBJ: 2

TOP: About Assessment KEY: Nursing Process Step: Assessment
MSC: Client Needs: Psychosocial Integrity
9. The nurse is reviewing information regarding a female client that was obtained with
the psychiatric assessment tool. The client’s 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 client’s 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 client’s
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 client’s psychiatric history, including family history.

TOP: Assessment Process KEY: Nursing Process Step: Assessment
10. During an interview with a 15-year-old female client admitted for depression, the
nurse is disappointed to learn that the client recently became pregnant and had an
abortion. The nurse is contradicting the effective interview guideline of:
a. Paying close attention to the client’s nonverbal communication
b. Avoiding making assumptions
c. Avoiding one’s 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
nurse-client relationship. The other options are good interview techniques but do not
represent this situation.
Test Bank 9-5
TOP: Effective Interviews KEY: Nursing Process Step: Assessment

11. A male client with a history of schizophrenia was admitted to the mental health facility
after he was found on the street confused and uncooperative when approached by the
police. One of the first assessments that should be performed on this client upon
admission is a:
a. Physical assessment
b. Sociocultural assessment
c. Psychosocial assessment
d. Psychiatric assessment
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: Page 90 OBJ: 6

TOP: Physical Assessment KEY: Nursing Process Step: Assessment
MSC: Client Needs: Physiological Integrity
12. The nurse is completing the general description portion of the mental status
examination tool. One of the primary focuses of this portion of the tool is the client’s:
a. Level of consciousness
b. Motor activity, gestures, and posture
c. Level of concentration and judgment
d. Perceptions
ANS: B
The mental status tool is used to assess the client’s mental health dysfunction and
causes of the problems. The general description portion of the tool not only assesses
the client’s motor activity, gestures, and posture but evaluates the general appearance,
speech, and interaction during the interview. Level of consciousness and level of
concentration and judgment are found in the sensorium and cognition portions of the
tool, and perceptions are found in the experiences portion.

TOP: Mental Status Assessment KEY: Nursing Process Step: Assessment
13. The nurse documents in a male client’s records that he displayed a “flat affect.” The
client’s behavior most likely would consist of:
a. Rapid, dramatic changes in emotion
b. Sadness and hopelessness
c. Lack of agreement of affect and mood
d. Unresponsive emotions
Test Bank 9-6
ANS: D
An unresponsive display of emotions is the description of a flat affect. With this affect,
it is difficult to tell whether the client’s mood is happy, sad, or indifferent. Rapid,
dramatic changes in emotion describes a labile affect, sadness and hopelessness
describe a depressed affect, and having an affect and mood that do not agree is the
description for an inconsistent affect.

TOP: Emotional State KEY: Nursing Process Step: Assessment
14. 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.

TOP: Thinking KEY: Nursing Process Step: Assessment
15. 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
client’s 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 describes 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 describes a stuporous
state, unresponsiveness to verbal or painful stimuli is a comatose state or
unconsciousness, and alternating periods of excitability and drowsiness describes a
lethargic state.
Test Bank 9-7
TOP: Sensorium and Cognition KEY: Nursing Process Step: Assessment

16. When assessing the recent memory of a client, the nurse may ask questions regarding
events that occurred within the past __________.
a. 2 weeks
b. 3 weeks
c. 4 weeks
d. 5 weeks
ANS: A
When the memory of a client is assessed, recent memory is defined as events that have
occurred within the past 2 weeks. The other options do not fall into the memory
categories of recall (immediate events) and remote (past events such as information
from the client’s background).

17. 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 client’s 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.

18. 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
Test Bank 9-8
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.

TOP: DSM-IV-TR Diagnosis KEY: Nursing Process Step: Assessment
19. 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.

TOP: DSM-IV-TR Diagnosis KEY: Nursing Process Step: Assessment
MULTIPLE RESPONSE
1. 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 client’s 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 client’s
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.
Test Bank 9-9
DIF: Cognitive Level: Comprehension REF: Page 85 | Page 86

OBJ: 1 TOP: Mental Health Treatment Plan
KEY: Nursing Process Step: Intervention MSC: Client Needs: Psychosocial Integrity
2. 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 client’s behavior should never occur without
clarification because interpretation often is incorrect.
DIF: Cognitive Level: Application REF: Page 87 | Page 88

OBJ: 3 TOP: Data Collection
KEY: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and
Maintenance
3. 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.

TOP: Sociocultural Assessment KEY: Nursing Process Step: Assessment
COMPLETION
1. __________ is how the client displays his or her emotions through facial, vocal, or
gestural behavior.
ANS:
Test Bank for Foundations of Mental Health Care, 3rd Edition: Morrison-Valfre
Test Bank 9-10
Affect
A person’s 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.

TOP: Emotional State KEY: Nursing Process Step: Assessment
OTHER
1. List the five steps of the nursing process in proper 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, the
plan of care must be reevaluated and revised.

TOP: Nursing (Therapeutic) Process KEY: Nursing Process Step: Intervention
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Morrison-Valfre: Foundations of Mental Health Care, 4th Edition

Chapter 9: Mental Health Assessment Skills

DIF: Cognitive Level: Comprehension REF: Page 86 OBJ: 2

2. A nurse administers antidepressant medication to a client in an assisted-living facility.

DIF: Cognitive Level: Comprehension REF: Page 87 OBJ: 2

Visit TestBankBell.com to get complete for all chapters

DIF: Cognitive Level: Comprehension REF: Page 86 OBJ: 2

DIF: Cognitive Level: Comprehension REF: Page 87 OBJ: 2

DIF: Cognitive Level: Comprehension REF: Page 87 OBJ: 2

DIF: Cognitive Level: Comprehension REF: Page 87 OBJ: 3

DIF: Cognitive Level: Comprehension REF: Page 87 OBJ: 3

DIF: Cognitive Level: Knowledge REF: Page 87 OBJ: 2

DIF: Cognitive Level: Comprehension REF: Page 88 OBJ: 4

DIF: Cognitive Level: Comprehension REF: Page 90 OBJ: 5

TOP: Effective Interviews KEY: Nursing Process Step: Assessment

DIF: Cognitive Level: Application REF: Page 90 OBJ: 6

DIF: Cognitive Level: Knowledge REF: Page 91 OBJ: 7

DIF: Cognitive Level: Knowledge REF: Page 92 OBJ: 9

DIF: Cognitive Level: Comprehension REF: Page 93 OBJ: 9

DIF: Cognitive Level: Application REF: Page 94 OBJ: 9

TOP: Sensorium and Cognition KEY: Nursing Process Step: Assessment

DIF: Cognitive Level: Knowledge REF: Page 94 OBJ: 9

DIF: Cognitive Level: Application REF: Page 94 OBJ: 9

DIF: Cognitive Level: Knowledge REF: Page 86 OBJ: 1

DIF: Cognitive Level: Comprehension REF: Page 86 OBJ: 1

DIF: Cognitive Level: Comprehension REF: Page 85 | Page 86

DIF: Cognitive Level: Application REF: Page 87 | Page 88

3. During the sociocultural assessment of a client who is entering a mental health

DIF: Cognitive Level: Comprehension REF: Page 90 OBJ: 4

Test Bank 9-10

DIF: Cognitive Level: Knowledge REF: Page 92 OBJ: 8

1. List the five steps of the nursing process in proper order.

DIF: Cognitive Level: Knowledge REF: Page 86 OBJ: 2

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