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chapter 8
Assessment
| Question | Answer |
|---|---|
| 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. |
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