Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito)

Chapter 11 Psychosocial Health, Substance Abuse, and Intimate Partner Violence

1. The educator is reviewing the symptoms associated with emotional stress with the staff nurses. Which symptoms should the educator include? Select all that apply.

1. Chest pain.

2. Vomiting.

3. Difficulty breathing.

4. Back pain.

5. Diaphoresis.

Page Ref: 150

Cognitive Level: Applying

Client Need & Sub: Psychosocial Integrity; Stress Management

Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis

Learning Outcome: 11.1: Understand the major components of psychosocial health and apply to overall health and wellness.

MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.

1. A client being seen in the clinic for abdominal discomfort and a decreased energy level tells the nurse they just lost their job. Which factor should the nurse suspect could be attributed to the client's abdominal discomfort?

1. Income.

2. Stress.

3. Ethnicity.

4. Occupation.

Page Ref: 154

Cognitive Level: Applying

Client Need & Sub: Psychosocial Integrity; Stress Management

Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11.1: Understand the major components of psychosocial health and apply to overall health and wellness.

MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.

1. The nurse interviewing an adolescent suspects problem with self-concept. Which should the nurse recognize is a main contributing factor to a limited self-concept?

1. Inability to form lasting relationships.

2. Decreased ability to form attachments with other people.

3. Inability to maintain stable employment.

4. Feelings of worthlessness, anxiety, and/or depression.

Page Ref: 152

Cognitive Level: Applying

Client Need & Sub: Psychosocial Integrity; Mental Health Concepts

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis

Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan.

MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.

1. A client's mother is distraught over her child's recent leukemic relapse and states, "What did I do wrong? Why does he deserve this? Why can't it be me?" Which should the nurse recognize the statements are associated with?

1. Ineffective coping.

2. Emotional emptiness.

3. Spiritual distress.

4. Psychologic anxiety.

Page Ref: 155

Cognitive Level: Analyzing

Client Need & Sub: Psychosocial Integrity; Coping Mechanisms

Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; and facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan.

MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.

1. A client tells the nurse that they have been experiencing emotional distress over the past few weeks. Which physical assessment finding should the nurse anticipate?

1. Hyperactive bowel sounds.

2. Elevated blood pressure.

3. Pinpoint pupils.

4. Elevated temperature.

Page Ref: 150

Cognitive Level: Analyzing

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.2. Describe EBP to include the components of research evidence, clinical expertise, and patient/family values. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis

Learning Outcome: 11.1: Understand the major components of psychosocial health and apply to overall health and wellness.

MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.

1. The nurse educator is reviewing the components of a psychosocial assessment with a group of students. Which definition of psychosocial health is appropriate for the educator to include in the review session?

1. Being emotionally balanced and socially astute.

2. Being mentally stable, physically fit, and psychologically well.

3. Being spiritually and psychologically mature.

4. Being mentally, emotionally, socially, and spiritually well.

Page Ref: 149

Cognitive Level: Remembering

Client Need & Sub: Psychosocial Integrity; Coping Mechanisms

Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person's development. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11.1: Understand the major components of psychosocial health and apply to overall health and wellness.

MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.

1. The nurse is preparing to give an injection to a young child. Which technique should the nurse use?

1. Place the child in the parent's lap.

2. Request the parent to leave the room.

3. Allow the parent to remain with the child.

4. Have the parent restrain the child.

Page Ref: 150

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: I.2. Synthesize theories and concepts from liberal education to build an understanding of the human experience. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan.

MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.

1. The nurse is assessing a client that lives in a rural area for stressors. Which should the nurse assess the client for?

1. Unhealthy living conditions.

2. High crime rates.

3. Limited resources.

4. Access to healthy food.

Page Ref: 151

Cognitive Level: Understanding

Client Need & Sub: Psychosocial Integrity; Stress Management

Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: VII.2. Conduct a health history, including environmental exposure and a family history that recognizes genetic risks, to identify current and future health problems. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis

Learning Outcome: 11.1: Understand the major components of psychosocial health and apply to overall health and wellness.

MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.

1. The educator is discussing the impact of self-concept on health with the nursing staff. Which factor should the educator include in the discussion?

1. Self-concept develops in early childhood.

2. Self-concept develops over time.

3. Self-concept is a component of self-esteem.

4. Self-concept is a component of body image.

Page Ref: 152

Cognitive Level: Applying

Client Need & Sub: Psychosocial Integrity; Coping Mechanisms

Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: I.2. Synthesize theories and concepts from liberal education to build an understanding of the human experience. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Diagnosis: Nursing Diagnosis

Learning Outcome: 11.1: Understand the major components of psychosocial health and apply to overall health and wellness.

MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.

1. The nurse is caring for a client with anorexia. Which subjective findings should the nurse anticipate? Select all that apply.

1. Constipation.

2. Abdominal pain.

3. Obsession with physical appearance.

4. Periods of excessive food consumption followed by purging.

5. Perception of being overweight.

Page Ref: 152

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis

Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan.

MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.

1. The nurse is preparing to assess a client with bulimia nervosa. Which assessment findings should the nurse anticipate?

1. Irregular or absent menses.

2. Damage to teeth enamel.

3. Refusal to consume nutritional supplements.

4. Extreme weight loss.

Page Ref: 152

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis

Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan.

MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.

1. The educator is reviewing the objective findings for binge eating disorder with the nurses. Which statement made by a nurse indicates further teaching is required?

1. "A client with a binge eating disorder experiences marked distress."

2. "A client with a binge eating disorder will eat faster than normal."

3. "A client with a binge eating disorder may abuse laxatives."

4. "A client with a binge eating disorder will eat alone out of embarrassment."

Page Ref: 153

Cognitive Level: Analyzing

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan.

MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.

1. The nurse is caring for an adult client with a history of sexual abuse. Which behavioral and phycological affect should the nurse be aware of that increases the client's vulnerability to health problems?

1. Interdependence.

2. Helplessness.

3. Selflessness.

4. Powerlessness.

Page Ref: 154

Cognitive Level: Understanding

Client Need & Sub: Psychosocial Integrity; Coping Mechanisms

Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: I.2. Synthesize theories and concepts from liberal education to build an understanding of the human experience. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Diagnosis: Assessment

Learning Outcome: 11.1: Understand the major components of psychosocial health and apply to overall health and wellness.

MNL Learning Outcome: 11.2: Recognize factors that relate to the assessment of a patient for substance abuse or exposure to violence.

1. The nurse is preparing to assess the physiological signs of stress in a client. Which findings does the nurse anticipate? Select all that apply.

1. Elevated blood glucose.

2. Increased red blood cells.

3. Decreased blood clotting time.

4. Decreased T lymphocytes.

5. Decreased white blood cells.

Page Ref: 155

Cognitive Level: Analyzing

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 11.1: Understand the major components of psychosocial health and apply to overall health and wellness.

MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.

1. The nurse is preparing to assess a client suspected of synthetic cannabinoid (SCB) toxicity. Which assessment findings should the nurse anticipate? Select all that apply.

1. Respiratory depression.

2. Chest pain.

3. Bradycardia.

4. Tachycardia.

5. Lethargy.

Page Ref: 155

Cognitive Level: Analyzing

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis

Learning Outcome: 11.2: Analyze the health and other impacts of substance abuse and substance use disorder.

MNL Learning Outcome: 11.2: Recognize factors that relate to the assessment of a patient for substance abuse or exposure to violence.

1. The nurse is assessing a client for substance abuse using the CAGE tool. Which question should the nurse ask the client? Select all that apply.

1. "Have people asked you about your drinking or drug use in the past?"

2. "Have people annoyed you by criticizing your drinking or drug use?"

3. "Have you ever felt bad or guilty about your drinking or drug use?"

4. "Have you ever been found guilty for drinking or drug charges?"

5. "Have you ever felt you should cut down on your drinking or drug use?"

Page Ref: 157

Cognitive Level: Applying

Client Need & Sub: Psychosocial Integrity; Coping Mechanisms

Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11.2: Analyze the health and other impacts of substance abuse and substance use disorder.

MNL Learning Outcome: 11.3: Identify risk factors and assessment tools for substance abuse.

1. The educator is discussing with the nursing staff the reasons why women stay in abusive relationships. Which statement made by a nurse indicates further education is required?

1. "Women may be financially dependent on their abusers."

2. "Fear of losing custody of their children keeps a woman from leaving an abusive relationship."

3. "Women are not educated on how to get out of abusive relationships."

4. "Women who stay in an abusive relationship hope that the behavior may change."

Page Ref: 158

Cognitive Level: Applying

Client Need & Sub: Psychosocial Integrity; Abuse and Neglect

Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11.3: Synthesize the importance of intimate partner violence (IPV) screening and violence identification in holistic patient care.

MNL Learning Outcome: 11.4: Recognize the importance of intimate-partner screening and violence identification in holistic patient care.

1. The nurse is assessing a client that begins using a collection of conglomeration words that have no meaning. Which should the nurse document the finding as?

1. Echolalia.

2. Circumlocution.

3. Neologisms.

4. Word salad.

Page Ref: 161

Cognitive Level: Understanding

Client Need & Sub: Psychosocial Integrity; Mental Health Concepts

Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan.

MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.

1. The nurse is preparing to assess a client. Which should the nurse recognize is a risk factor for suicide? Select all that apply.

1. Gender.

2. Sexual orientation.

3. Occupation.

4. Limited education.

5. History of mental illness.

Page Ref: 164

Cognitive Level: Applying

Client Need & Sub: Psychosocial Integrity; Crisis Intervention

Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan.

MNL Learning Outcome: 11.3: Identify risk factors and assessment tools for substance abuse.

1. The nurse is assessing a client for potential warning signs of an impending suicide attempt. Which statement should the nurse be concerned with?

1. "I called my counselor three times this week."

2. "I have lost some weight over the past month."

3. "I feel like crying sometimes."

4. "I feel like such a burden to my family."

Page Ref: 165

Cognitive Level: Analyzing

Client Need & Sub: Psychosocial Integrity; Crisis Intervention

Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan.

MNL Learning Outcome: 11.3: Identify risk factors and assessment tools for substance abuse.

1. The educator is teaching the nursing staff about the potential warnings of an impending suicide. Which should the educator include? Select all that apply.

1. Sudden change in mood.

2. Altered mental status.

3. Increased incidence of alcohol abuse.

4. Purchasing a weapon.

5. Reckless behavior.

Page Ref: 165

Cognitive Level: Applying

Client Need & Sub: Psychosocial Integrity; Crisis Intervention

Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan.

MNL Learning Outcome: 11.3: Identify risk factors and assessment tools for substance abuse.

1. The nurse is preparing to assess a client with an exacerbated anxiety disorder that has a history of asthma and arthritis. Which initial assessment should the nurse perform?

1. Respiratory assessment.

2. Musculoskeletal.

3. Medication history.

4. Psychosocial assessment.

Page Ref: 160

Cognitive Level: Analyzing

Client Need & Sub: Psychosocial Integrity; Stress Management

Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis

Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan.

MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.

1. The nurse is concerned that a client is having a problem with self-concept. Which statement should the nurse recognize support client's concern?

1. "I never have any fun."

2. "I am the oldest in the family."

3. "I think I'm pretty much outgoing."

4. "At times I like to be alone."

Page Ref: 92-93

Cognitive Level: Analyzing

Client Need & Sub: Psychosocial Integrity; Coping Mechanisms

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person's development. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 11.1: Understand the major components of psychosocial health and apply to overall health and wellness.

MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.

1. The nurse suspects a client is having difficulty coping. Which assessment question should the nurse ask when assessing the client's ability to cope?

1. Who is your closest friend?

2. What social groups do you belong to?

3. What is your birth order in your family?

4. Who do you call when you need help?

Page Ref: 164

Cognitive Level: Applying

Client Need & Sub: Psychosocial Integrity; Coping Mechanisms

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person's development. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan.

MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.

1. The nurse is assessing a client self-concept. Which question should the nurse include in the assessment?

1. "Do you have trouble making decisions?"

2. "Can you describe your social life?"

3. "Do you hear voices or see objects?"

4. "Can you describe how you were raised?"

Page Ref: 163

Cognitive Level: Analyzing

Client Need & Sub: Psychosocial Integrity; Coping Mechanisms

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person's development. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 11.1: Understand the major components of psychosocial health and apply to overall health and wellness.

MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.

1. A client with a family history of schizophrenia expresses concern about having a child with the disorder. Which response should the nurse provide the client?

1. "Schizophrenia is a genetic disorder so you are right to be very concerned."

2. "Your family history does increase the risk factors but there are other variables to be considered."

3. "Schizophrenia should not be a significant concern for you."

4. "You should consider being tested before becoming pregnant."

Page Ref: 149

Cognitive Level: Analyzing

Client Need & Sub: Psychosocial Integrity; Mental Health Concepts

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: V.II.2. Conduct a health history, including environmental exposure and a family history that recognizes genetic risks, to identify current and future health problems. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan.

MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.

1. The nurse is using a HITS screening tool to assess the client for domestic violence. Which type of abuse should the nurse understand the client is being screened for? Select all that apply.

1. Emotional.

2. Financial.

3. Physical.

4. Psychological.

5. Sexual.

Page Ref: 159

Cognitive Level: Applying

Client Need & Sub: Psychosocial Integrity; Abuse and Neglect

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: V.II.2. Conduct a health history, including environmental exposure and a family history that recognizes genetic risks, to identify current and future health problems. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11.3: Synthesize the importance of intimate partner violence (IPV) screening and violence identification in holistic patient care.

MNL Learning Outcome: 11.4: Recognize the importance of intimate-partner screening and violence identification in holistic patient care.

1. The nurse is reviewing phase II of the cycle of abuse with a client. Which information should the nurse discuss?

1. The perpetrator is threatening.

2. The perpetrator becomes loving and kind.

3. The abusive incidence occurs.

4. The tension prior to the abuse is building.

Page Ref: 158

Cognitive Level: Applying

Client Need & Sub: Psychosocial Integrity; Abuse and Neglect

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: V.II.2. Conduct a health history, including environmental exposure and a family history that recognizes genetic risks, to identify current and future health problems. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11.3: Synthesize the importance of intimate partner violence (IPV) screening and violence identification in holistic patient care.

MNL Learning Outcome: 11.4: Recognize the importance of intimate-partner screening and violence identification in holistic patient care.

1. The nurse is reviewing the traits of a perpetrator of violence with a community group. Which traits should the nurse include? Select all that apply.

1. Low self-esteem.

2. Social withdrawal.

3. Limited ability to cope.

4. Reckless behavior.

5. Possessive behavior.

Page Ref: 158

Cognitive Level: Applying

Client Need & Sub: Psychosocial Integrity; Abuse and Neglect

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: V.II.2. Conduct a health history, including environmental exposure and a family history that recognizes genetic risks, to identify current and future health problems. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis

Learning Outcome: 11.3: Synthesize the importance of intimate partner violence (IPV) screening and violence identification in holistic patient care.

MNL Learning Outcome: 11.2: Recognize factors that relate to the assessment of a patient for substance abuse or exposure to violence.

1. The nurse caring for a client experiencing back pain, nausea, and fatigue inquiries about current stressors. The client states, "I am sick. Why are you asking me about all of this stress stuff?" Which information should the nurse provide the client?

1. "Stress can impact our body by producing a variety of symptoms."

2. "Your nausea and fatigue are most often related to increase of stress in life."

3. "Screening for stress is required for every client."

4. "I am assessing your ability to cope with additional stressors."

Page Ref: 154-155

Cognitive Level: Analyzing

Client Need & Sub: Psychosocial Integrity; Coping Mechanisms

Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan.

MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.