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chapter 8


What is an assessment the first step of the nursing process and involves the collection, organization, and analysis of information about the clients health. also known as an psychosocial assessment
whats the purpose of a psychsocal assessment to construct a picture of the clientscurrent emotional state, mental capacity, and behavioral function.
what would influence an assessment client participation/ feed back, clients health status, clients previous experience, clients ability to understand, nurse attitude and approach
what type of enviroment should be used for the interview comfortable, private, and sfae for both the client and the nurse
open ended questions what brings you here today?
when do you use a focused or closed ended question if the clien cannot organize his/ her thoughts, or has , difficulty, answering, open ended questions.
automatisms repeated purposeless behaviors often indicative of anxiety, such as drumming fingers, twisting locks of hair, or tapping the foot.
paychomotor retardation overall slowed movements
waxy flexibility maintenance of posture or position over time even when it is awkward or uncomfortable
perseverate seem to be stuck on one topic and unable to move to another idea
neologisms invented words that have meaning only for the client
mood the clients pervasive and enduring emotional state
affect it the outward expression of the clients emotional state
blunted affect showing little or a slow to respond facial expression
broad affect displaying a full range of emotional expressions
flat affect showing no facial expression
inappropriate affect displaying a facial expression that is incongruent w/ mood or situation; often silly or giddy regardless of circumstances
restricted affect displaying one type of expression, usually serious or somber
labile when the client exhibits unpredictable and rapid mood swings form depression and crying to euphoria with no apparent stimuli
thought process how the clien thinks
thought content what the client actually says.
circumstantial thinking a client eventually answers a question but only after giving excessive unnecessary detail
delusion a fixd false belief not based in reality
flight of ideas excessive amt and rate of speech composed of fragmented or unrelated ideas
ideas of reference clients inaccurate interpretations that general events are personally directed to him/ her such as hearing a speech on the news and believing the message had personal meaning
loose associations disorganized thinking that jumps from one idea to another with little or no evident relation b/w the thoughts
tangential thinking wandering off the topic and never providing the info requested
thought blocking stopping abruptly in the middle of a sentence or train of thought; sometimes unable to continue the idea
thought broadcasting a delusional belif that others can hear or know what the client is thinking
thought insertion a delusional belief that others are putting ideas or thoughts into the clients head- that is, the ideas are not those of the client
thought withdrawl a delusional belief that others are taking the clients thoughts away and the client is powerless to stop it
word salad flow of unconnected words that convey no meaning to the listener
how do you asses suicide by asking direct questions
ideation are you thinking about killing yourself
plan do you have a plan to kill yourself
method how do you plan to kill yourself
access how would you carry out this plan
where where would you kill yourself
when when do you plan to kill yourself
timing what day or time if day do you plan ti kill yourself
duty to warn when a client makes specific threats or has a plan ti harm another person, HCP are legally obligated to warn the person who is the target of the threatsor plan
abstract thinking the ability to make associations or interpretations about a situationor comment
concrete thinking client continually gives literal translations.
hallucinations false sensory perceptions or perceptual experiences that do not really exist
most common hallucinations auditory hullicinations
judgements the ability to interprets one's enviroment and situation correctly and to adapt one's behavior and decisions accordingly.
insight the ability to understand the true nature of ones situation and accept some personal responsibility for that situation,
self concept the way one views oneself in terms of personal worth and dignity.
assessment of roles and relationships roles the client occupies, client satisfaction with those roles and whether the client believes he/ she is fulfillingthe roles adequately.
data analysis involves thinking about the overall assessment inorder to make a nursing diagnosis.
intelligence test designed to evaluate the clients cognitive abilities and intellectual functioning
personality test reflects the clients personality in areas such as self concept, impulse control, reality testing, and major defenses.
objective measures of personality MMPI- multiple coice/ true/ false
Projective measures of personality Rorschach Test- 10 stimulus cards of inkblots
Global Assessment of Function(GAF) used to make a judgement about the clients overall level of functioning.
Created by: 661814337