NUR 172 Block 2 Psych Exam 1 (MCC) 319
Q&A/ Already Graded A+.
Other assessment content - Answer: Look for appearance/ motor behavior such as
- hygiene/ grooming (are they just homeless?, phobia?)
- Appropriate dress for age, weather, culture, environment
- Posture (physical ailment, self-esteem - are they hunched)
- Eye contact
- Unusual movements. mannerisms (automatism, psychomotor retardation, waxy flexibility)
- Speech difficulties or differences (neologisms)
Automatisms - Answer: Repeated purposeless behaviors often indicative of anxiety, such as
drumming fingers, twisting locks of hair, or tapping the foot
Psychomotor retardation - Answer: Overall slowed movements
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,Waxy flexibility - Answer: Maintenance of posture or position over time even when it is
awkward or uncomfortable
Neologisms - Answer: Invented words that have meaning only for the person who created it;
usually the client
What thought process/ content do we assess for in the client? - Answer: Clarity of ideas
Self-harm or suicide urges
Homicidal and or thoughts to harm others
What does SI stand for? - Answer: Suicidal ideations
What does HI stand for? - Answer: Homicidal ideations
What is Duty to warn? - Answer: This is enacted when you are assessing a patient for HI.
- When a client makes specific threats or has a plane to harm another person, healthcare
providers are legally obligated to warn the person who is the target of the threats or plan. This is
one situation in which the nurse must break the client's confidentiality to protect the
threatened person.
What are hallucinations? - Answer: Sensory impressions without external stimuli
What are Illusions? - Answer: Real stimuli misinterpreted
What are delusions? - Answer: fixed false beliefs
What is judgment (interpretation of environment)? - Answer: Judgment refers to the ability to
interpret one's environment and situation correctly and to adapt one's behavior and decisions
accordingly
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,What does it mean if a patient has impaired judgment? - Answer: Problems with judgment may
be evidenced as the client describes recent behavior and activities that reflect a lack of
reasonable care for self or others. For example, the client may spend large sums of money on
frivolous items when he or she cannot afford basic necessities such as food or clothing.
- Decision making ability is important for the patient's safety.
What is Insight? - Answer: -Understanding one's own part in current situation
- Insight is the ability to understand the true nature of one's situation and accept some personal
responsibility for that situation. The nurse frequently can infer insight from the client's ability to
describe realistically the strengths and weaknesses of his or her behavior.
Example of poor insight would be a client who places all blame on others for his own behavior,
saying, "It's my wife's fault that I drink and get into fights, because she nags me all the time."
What is self-concept? - Answer: - Personal view of self
- Description of physical self
- Personal qualities or attributes
How can you assess for self-concept in a patient? - Answer: To assess a client's self-concept, the
nurse can ask the client to describe himself or herself and what characteristics he or she likes
and what he or she would change.
What are roles/ relationships? - Answer: - What role does the patient play in their life?
- Current roles the patient plays
- Satisfaction with those roles
- Success at those roles
- Significant relationships
- Support systems (anyone they can rely on, are they someone to be relied on by others?)
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, What questions could you ask when assessing for relationships of your client? - Answer: Do you
feel close to your family?
Do you have or want a relationship with a significant other?
Are your relationships meeting your needs for companionship or intimacy?
Can you meet your sexual needs satisfactorily?
Have you been involved in any abusive relationships?
- any support systems?
What is the SAD PERSONS scale? - Answer: Used to determine if a person is at risk for suicide
What does SAD PERSONS stand for? - Answer: Sex (Males over 65, loss of SO suicide; Females
likely depression)
Age
Depression
Previous Attempts
ETOH and other drugs
Rational thinking loss
Social supports lacking
Organized plan
No spouse
Sickness (terminal)
What are some physiologic and self care considerations of a patient? - Answer: - Eating habits
- Sleep patterns
- Health problems
- Compliance with prescribed medications
- Ability to perform activities of daily living effectively
** We know that the physical status of a person interplays with the psychosocial status
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Q&A/ Already Graded A+.
Other assessment content - Answer: Look for appearance/ motor behavior such as
- hygiene/ grooming (are they just homeless?, phobia?)
- Appropriate dress for age, weather, culture, environment
- Posture (physical ailment, self-esteem - are they hunched)
- Eye contact
- Unusual movements. mannerisms (automatism, psychomotor retardation, waxy flexibility)
- Speech difficulties or differences (neologisms)
Automatisms - Answer: Repeated purposeless behaviors often indicative of anxiety, such as
drumming fingers, twisting locks of hair, or tapping the foot
Psychomotor retardation - Answer: Overall slowed movements
Page 1 of 67
,Waxy flexibility - Answer: Maintenance of posture or position over time even when it is
awkward or uncomfortable
Neologisms - Answer: Invented words that have meaning only for the person who created it;
usually the client
What thought process/ content do we assess for in the client? - Answer: Clarity of ideas
Self-harm or suicide urges
Homicidal and or thoughts to harm others
What does SI stand for? - Answer: Suicidal ideations
What does HI stand for? - Answer: Homicidal ideations
What is Duty to warn? - Answer: This is enacted when you are assessing a patient for HI.
- When a client makes specific threats or has a plane to harm another person, healthcare
providers are legally obligated to warn the person who is the target of the threats or plan. This is
one situation in which the nurse must break the client's confidentiality to protect the
threatened person.
What are hallucinations? - Answer: Sensory impressions without external stimuli
What are Illusions? - Answer: Real stimuli misinterpreted
What are delusions? - Answer: fixed false beliefs
What is judgment (interpretation of environment)? - Answer: Judgment refers to the ability to
interpret one's environment and situation correctly and to adapt one's behavior and decisions
accordingly
Page 2 of 67
,What does it mean if a patient has impaired judgment? - Answer: Problems with judgment may
be evidenced as the client describes recent behavior and activities that reflect a lack of
reasonable care for self or others. For example, the client may spend large sums of money on
frivolous items when he or she cannot afford basic necessities such as food or clothing.
- Decision making ability is important for the patient's safety.
What is Insight? - Answer: -Understanding one's own part in current situation
- Insight is the ability to understand the true nature of one's situation and accept some personal
responsibility for that situation. The nurse frequently can infer insight from the client's ability to
describe realistically the strengths and weaknesses of his or her behavior.
Example of poor insight would be a client who places all blame on others for his own behavior,
saying, "It's my wife's fault that I drink and get into fights, because she nags me all the time."
What is self-concept? - Answer: - Personal view of self
- Description of physical self
- Personal qualities or attributes
How can you assess for self-concept in a patient? - Answer: To assess a client's self-concept, the
nurse can ask the client to describe himself or herself and what characteristics he or she likes
and what he or she would change.
What are roles/ relationships? - Answer: - What role does the patient play in their life?
- Current roles the patient plays
- Satisfaction with those roles
- Success at those roles
- Significant relationships
- Support systems (anyone they can rely on, are they someone to be relied on by others?)
Page 3 of 67
, What questions could you ask when assessing for relationships of your client? - Answer: Do you
feel close to your family?
Do you have or want a relationship with a significant other?
Are your relationships meeting your needs for companionship or intimacy?
Can you meet your sexual needs satisfactorily?
Have you been involved in any abusive relationships?
- any support systems?
What is the SAD PERSONS scale? - Answer: Used to determine if a person is at risk for suicide
What does SAD PERSONS stand for? - Answer: Sex (Males over 65, loss of SO suicide; Females
likely depression)
Age
Depression
Previous Attempts
ETOH and other drugs
Rational thinking loss
Social supports lacking
Organized plan
No spouse
Sickness (terminal)
What are some physiologic and self care considerations of a patient? - Answer: - Eating habits
- Sleep patterns
- Health problems
- Compliance with prescribed medications
- Ability to perform activities of daily living effectively
** We know that the physical status of a person interplays with the psychosocial status
Page 4 of 67
