Upgrade to remove ads
chapter 8: assessment
Terms in this set (48)
what is the first step of the nursing process?
assessment; involves collection, orginization, and analysis
what is the assessment called in psychiatric nursing?
psychosocial assessment which includes a mental status health exam.
-constructs a picture of the clients current emotional state, mental capacity and behavioral fucntion
what factors may influence the assessment?
client participation/feedback, clients health, clients previous experiences, clients ability to understand and nurses attitude and approach.
what does the background assessment include?
clients hx, age, and developmental level, cultural and spiritual belief and belief about health and illness
-evalulate the clients age and devlopmental level for congruence with expected norms
the nurse also assess the overall appearance including what?
dressing, hygeine and grooming,posture, facial expression and any unusual tremor
what terms are commonly used when assessing appearance and motor behavior?
what is an automatism?
repeated purposeless behavior= anxiety, such as drumming fingers etc
what is psychomotor retardation?
overall slow movement
what is waxy flexibility?
maintenance of posture or position over time, even when it is akward or uncomfortable
what is neologism?
invented words that only have meaning toward the client
what is a blunted affect?
showing little or no a slow to respind facial expression
what is a broad affect?
displaying a full range of emotional expressions
what is a flat affect?
showing no facial expression
what is an inappropriate affect?
displaying a facial expression that is incongruent with mood or situation
what is a restricted afect?
1 type of expression, usually serious or somber
what is labile?
a rapidly changing mood
what is thought process?
refers to how the client thinks can can infer a clients thought process from speech and speech patterns
what is thought content?
what the client actually says
-assess wether or not the verbalizations make sense
and must determine if the client is preoccupied.
what is circumstantial thinking?
pt eventually answers a question
what is a delusion?
a fixed false belief, not based on reality
what is a flight of ideas?
excessive amt and rate of speech composed of fragmented or unrealted ideas.
what is ideas of reference?
clients inaccurate interpretation that general ecents are personally directed to him or her.
what is loose associations
disorganized thinking that jumps from one idea to another
what is tangenital thinking?
wandering off topic
what is thought blocking?
stoping abruptly in the middle of a sentence or train of thought
what is thought broadcasting?
a delusional belif that others can hear or know what client thinks
what is thought insertion?
a delusional belief that others are putting ideas or thoughts into the clients head
what is thought withdrawl?
others are taking the clients thoughts away and client is powerless
what is word salad?
flow of unconnected words
how does the nurse assess memory?
with verifiable answers from both recent and remote
how does the nurse assess the ability to concentrate?
asking the client to perform a certain task
before a nurse assess level of intellectual functioning, what must the nurse do?
consider the clients level of formal education
how does the nurse assess intellectual functioning?>
with abstract thinkning
what is abstract thinking?
make associations or interpretations about a situation or comment
what two ways can the nurse assess abstract thinking?
asking a proverb or asking to identify similarities between pairs of objects
if the client provides a literal explanation of the proverb and cannot interpret its meaning?
abstract abilities are lacking which is evidence of concrete thinkning
what is the first and second most common hallucination
-hearing then seeing
how would the nurse assess judgement?
with a hypothetical question
what is insight?
ability to understand the true nature of ones situation and accept some personal responsibility for that situation
-nurse can infer this by asking them to describe strngths and weaknesses
what is self concept?
the way one vies oneself in terms of worth and dignity
-the nurse does this by asking them to describe him or herself and what characterisitcs he or she likes and would change.
-nurse should also assess emotions frequently exper. and assess clients coping strategy
what is the mcmaster family assessment device used for?
when family relationships seem to be a significant source of stress
what else is important to do when doing a psychosocial assessment?
a physiologic assessment dt emotional problems can greatly affect eating and sleeping
-assess usual eating and sleeping patterns
clients with bipolar might what?
not eat or sleep for days
clients with major depression might whtat?
not get out of bed
once the nurse completes the psychosocial assessment, what is the next step?
analyze the data to look for patterns or themes in the data that lead to conclusions about the clients strenghts and needs to a particular nursing dx.
what is another source of data that the nurse can use to plan care?
a psychological test
what are the two types of psychological test?
intelligence: eval the clients cognitive ability
personality test: reflect the clients personality in areas such as self concept, impulse, control, reality testing and major defenses
projective test: interview and unconstructed
what are two areas that the nurse ma feel uncomfotbe or difficult to assess?
sexulaity and self harm behaviors
THIS SET IS OFTEN IN FOLDERS WITH...
Foundations of Psych Nursing questions,…
Care of Children ATI Review
2017 N290 Psychiatric Nursing Assessment
Psychiatric/Mental Health Nursing - Psychobiologic…
YOU MIGHT ALSO LIKE...
Chapter 8: Assessment
psychosocial assessment mental health
Psych Nursing Chapter 8 - Assessment
OTHER SETS BY THIS CREATOR
APEX: Pharmacology 1- Pharmacodynamics
APEX: PHARM 1- Pharmacokinetics
Barash: Chapter 43 Cont...
Barash Ch. 43- Pediatrics
OTHER QUIZLET SETS
Criminal Law - Defenses
Pharmacology Chapter 4
Ch 3: Assessment and Diagnosis
Caring for pt w/ neuro disorder