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D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/eChapter 5Question 1Type: MCSA

The nurse is caring for a woman in the emergency room who is complaining of chest pain. She states that she was walking from her apartment to the grocery store when the pain became very severe. She reported that people were following her. She said she couldn’t really see them but she could hear them talking about “grabbing me.” While the woman is explaining the event, she alternates between wringing her hands and manipulating the items in her purse over and over. The nurse would obtain what further assessment data in this situation?

1. Spiritual affiliations

2. Dietary preferences and habits

3. Review of systems

4. Focused psychosocial interview

Correct Answer: 4

Rationale 1: A spiritual assessment and dietary preferences are important, but the psychosocial interview would be a priority given the behaviors exhibited.

Rationale 2: A spiritual assessment and dietary preferences are important, but the psychosocial interview would be a priority given the behaviors exhibited.

Rationale 3: The physical examination is conducted after the interviewing is complete.

Rationale 4: The woman is exhibiting bizarre behavior and her story indicates some paranoia; therefore, a focused psychosocial interview is warranted.

Global Rationale: The woman is exhibiting bizarre behavior and her story indicates some paranoia; therefore, a focused psychosocial interview is warranted. A spiritual assessment and dietary preferences are important, but the psychosocial interview would be a priority given the behaviors exhibited. The physical examination is conducted after the interviewing is complete.

Cognitive Level: ApplyingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health.

Question 2Type: MCSA

D’Amico/Barbarito Health & Physical Assessment in Nursing, 2/eCopyright 2012 by Pearson Education, Inc.

The nurse is interviewing a client prior to a physical examination. The client tells the nurse that she has been experiencing a lot of aches, pains, and abdominal discomfort. The nurse may suspect which of the following factors that impact physical health?

1. Income

2. Stress

3. Ethnicity

4. Occupation

Correct Answer: 2

Rationale 1: Income may influence physical and emotional health in some way, but stress is most likely having the greatest impact with the symptoms being reported.

Rationale 2: Stress is most likely having the greatest impact with the symptoms being reported. Emotional stress affects the immune system and typically causes individuals to be less attentive to their personal health. Individuals under stress may also use mood-altering substances to “feel better.”

Rationale 3: Ethnicity may influence physical and emotional health in some way, but stress is most likely having the greatest impact with the symptoms being reported.

Rationale 4: Occupation may influence physical and emotional health in some way, but stress is most likely having the greatest impact with the symptoms being reported.

Global Rationale: All of the above factors may influence physical and emotional health in some way, but stress is most likely having the greatest impact with the symptoms being reported. Emotional stress affects the immune system and typically causes individuals to be less attentive to their personal health. Individuals under stress may also use mood-altering substances to “feel better.”

Cognitive Level: RememberingClient Need: Health Promotion and MaintenanceClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 5.3: Identify factors affecting psychosocial health.


The nurse is interviewing an overweight teenager who looks downward and speaks softly when answering questions. The nurse identifies a problem with client’s self-concept. Which of the following findings would support the nurse’s conclusions?

1. Increased desire 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

Correct Answer: 4

Rationale 1: The increased desire to form lasting relationships may be seen in individuals with healthy or unhealthy self-concepts.

Rationale 2: Decreased ability to form attachments to other people results from many factors not limited to poor self-concept.

Rationale 3: Decreased ability to maintain stable employment results from many factors not limited to poor self-concept.

Rationale 4: Problems with self-concept may manifest in feelings of worthlessness, anxiety, and/or depression, among other issues.

Global Rationale: Problems with self-concept may manifest in feelings of worthlessness, anxiety, and/or depression, among other issues. Decreased ability to maintain stable employment and to form attachments to other people results from many factors not limited to poor self-concept. The increased desire to form lasting relationships may be seen in individuals with healthy or unhealthy self-concepts.

Cognitive Level: RememberingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 5.1: Describe psychosocial functioning.


A 7-year-old client was just admitted to the hospital following an appointment in the pediatric oncology clinic. His mother, who is distraught over his recent leukemic relapse, accompanies the child. She is crying and asking, “What did I do wrong? ... Why does he deserve this? ... Why can’t it be me?” The nurse understands that these statements indicate which of the following?

1. Ineffective coping

2. Emotional emptiness

3. Spiritual distress

4. Psychologic anxiety

Correct Answer: 3


Rationale 1: Those types of statements are common responses to a serious diagnosis and do not indicate ineffective coping.

Rationale 2: Emotional emptiness is not an acceptable term to describe behaviors indicating distress.

Rationale 3: Questions such as “What did I do wrong?” and “Why does he deserve this?” indicate spiritual distress.

Rationale 4: Further evidence would be required before determining psychologic anxiety.

Global Rationale: Questions such as “What did I do wrong?” and “Why does he deserve this?” indicate spiritual distress. Further evidence would be required before determining psychologic anxiety. Emotional emptiness is not an acceptable term to describe behaviors indicating distress. Those types of statements are common responses to a serious diagnosis and do not indicate ineffective coping.

Cognitive Level: AnalyzingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: DiagnosisLearning Outcome: 5.3: Identify factors affecting psychosocial health.


The nurse has gathered assessment data on a client admitted for suicidal tendencies. The nurse develops appropriate nursing diagnoses and formulates goals to achieve client outcomes. The nurse is utilizing which step of the nursing process?

1. Implementation

2. Evaluation

3. Planning

4. Assessment

Correct Answer: 3

Rationale 1: Implementation is the process of performing certain interventions designed to move the client toward achievement of the goal.

Rationale 2: Evaluation is the process whereby the progress toward achieving the goals is reviewed and documented.

Rationale 3: During the planning phase of the nursing process, nursing diagnoses are formulated after data have been assessed, and then goal setting takes place.

Rationale 4: Assessment is the process by which data are collected.


Global Rationale: During the planning phase of the nursing process, nursing diagnoses are formulated after data have been assessed, and then goal setting takes place. Implementation is the process of performing certain interventions designed to move the client toward achievement of the goal. Evaluation is the process whereby the progress toward achieving the goals is reviewed and documented. Assessment is the process by which data are collected.

Cognitive Level: RememberingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health.


The nurse is assessing a client in an outpatient mental health setting. The assessment tool outlines criteria for psychosocial health. The nurse understands that this term may be defined as which of the following?

1. The state of being emotionally balanced and socially astute.

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

3. Becoming spiritually and psychologically mature.

4. The state of being mentally, emotionally, socially, and spiritually well.

Correct Answer: 4

Rationale 1: Emotionally balanced is another way of referring to emotionally well, though the term is not often used. Being socially astute is a characteristic that one may develop but is not necessary for social wellness.

Rationale 2: Mental stability is a component of psychosocial health and includes psychologic health. Being physically fit may influence psychosocial health, but individuals may be not physically fit but still in good psychosocial health

Rationale 3: Many would argue that children are not spiritually and psychologically mature, yet may exhibit psychosocial health, so being spiritually and psychologically mature are not criteria for psychosocial health.

Rationale 4: Psychosocial health is defined as being mentally, emotionally, socially, and spiritually well.

Global Rationale: Psychosocial health is defined as being mentally, emotionally, socially, and spiritually well. Mental stability is a component of psychosocial health and includes psychologic health. Being physically fit may influence psychosocial health, but individuals may be not physically fit but still in good psychosocial health. Many would argue that children are not spiritually and psychologically mature, yet may exhibit psychosocial health, so being spiritually and psychologically mature are not criteria for psychosocial health. The same is true with being emotionally balanced and socially astute. Emotionally balanced is another way of referring to emotionally well, though the term is not often used. Being socially astute is a characteristic that one may develop but is not necessary for social wellness.


Cognitive Level: RememberingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health.


The nurse is conducting a class on health promotion and uses the following definition: “The ability to perform daily tasks vigorously and alertly, with energy left over for enjoying leisure-time activities and meeting emergency demands.” The nurse is stressing which of the following areas?

1. Physical fitness

2. Emotional health

3. Physical health

4. Psychologic well-being

Correct Answer: 1

Rationale 1: Physical fitness is the ability to perform daily tasks vigorously and alertly, with energy left over for enjoying leisure-time activities and meeting emergency demands.

Rationale 2: Physical fitness is an important component of physical and emotional health.

Rationale 3: Physical fitness is an important component of physical and emotional health.

Rationale 4: Physical fitness influences mental alertness and emotional stability, as well as a general feeling of well-being, which some may call psychologic fitness.

Global Rationale: Physical fitness is the ability to perform daily tasks vigorously and alertly, with energy left over for enjoying leisure-time activities and meeting emergency demands. Physical fitness is an important component of physical and emotional health. Physical fitness influences mental alertness and emotional stability, as well as a general feeling of well-being, which some may call psychologic fitness.

Cognitive Level: RememberingClient Need: Health Promotion and MaintenanceClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 5.1: Describe psychosocial functioning.



The nurse is caring for a client admitted for severe weight loss and depression. The client has recently experienced the loss of three close family members and has withdrawn from all social activities. In developing the plan of care, the nurse would correctly choose which of the following nursing diagnoses?

1. Powerlessness

2. Anxiety

3. Dysfunctional grieving

4. Spiritual distress

Correct Answer: 3

Rationale 1: Powerlessness refers to feelings of a loss of control with the situation.

Rationale 2: Anxiety infers feelings of apprehension.

Rationale 3: Clients experiencing tremendous loss often develop depression as part of their reaction to grief. However, this depression should also be seen with other stages of the grieving process such as denial, anger, bargaining, and acceptance. Clients remaining in one stage of the grieving process may not be progressing toward acceptance.

Rationale 4: Spiritual distress infers the client would be at odds with her feelings.

Global Rationale: Clients experiencing tremendous loss often develop depression as part of their reaction to grief. However, this depression should also be seen with other stages of the grieving process such as denial, anger, bargaining, and acceptance. Clients remaining in one stage of the grieving process may not be progressing toward acceptance. There are not enough data to support the remaining nursing diagnoses. Powerlessness refers to feelings of a loss of control with the situation. Anxiety infers feelings of apprehension. Spiritual distress infers the client would be at odds with her feelings.

Cognitive Level: AnalyzingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health.


The nurse is reviewing the plan of care for a client and notes that the following goal has not been met: “Client will verbalize three positive things about himself.” The nurse would correctly choose to do which of the following?

1. Tell the client three things that he does well.

2. Ask other clients to tell the client what he does well.


3. Determine barriers to achieving the goal.

4. Do nothing as long as the client appears better.

Correct Answer: 3

Rationale 1: Telling the client things that he does well will not aid in the achievement of the goal.

Rationale 2: Involving other clients in the plan of care may be a violation of the client’s privacy and is not appropriate.

Rationale 3: The nursing process must be approached in a cyclic and systematic fashion in order to best meet the identified needs of clients. When goals are not met within established time frames, the nurse must examine potential reasons for this and develop new interventions and time frames for goal achievement.

Rationale 4: Ignoring the absence of progression toward the established goal will not aid the client in improving.

Global Rationale: The nursing process must be approached in a cyclic and systematic fashion in order to best meet the identified needs of clients. When goals are not met within established time frames, the nurse must examine potential reasons for this and develop new interventions and time frames for goal achievement. The goal statements are based upon the client’s achievements. Telling the client things that he does well will not aid in the achievement of the goal. Involving other clients in the plan of care may be a violation of the client’s privacy and is not appropriate. Ignoring the absence of progression toward the established goal will not aid the client in improving.

Cognitive Level: ApplyingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: EvaluationLearning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health.

Question 10Type: MCMA

A client is admitted to the orthopedic unit after breaking an arm after a fall. The client appears disheveled and has a body odor. The family arrives and expresses surprise at the client’s appearance. They report that this is not the normal appearance of the client and that they are usually clean and meticulously groomed. Which of the following assessments does the nurse need to complete in order to formulate relevant nursing diagnoses and a plan of care for this patient?

Standard Text: Select all that apply.

1. Food preferences

2. Psychosocial assessment

3. Memory assessment and orientation


4. Family medical history

5. Body systems examination

Correct Answer: 2,3,4,5

Rationale 1: Food preferences. Collection of dietary preferences is completed on clients when they are admitted to a facility, however, this information will not provide an explanation for the changes being noted in the client’s behaviors.

Rationale 2: Psychosocial assessment. The client’s appearance indicates there has been some change in mental outlook or condition. These changes may be the result of psychosocial issues and they must be investigated.

Rationale 3: Memory assessment and orientation. The client’s appearance indicates there has been some change in mental outlook or condition. The client’s memory and level of orientation will provide information relating to potential causes. This assessment will also provide an indication as to the seriousness of the problems being noted.

Rationale 4: Family medical history. The client’s presentation is indicative of a problem. Some disorders may be genetic, thus requiring investigation.

Rationale 5: Body systems examination. The assessment of the client’s body systems will yield clues as to the cause of the changes being noted in behavior.

Global Rationale: Collection of dietary preferences is completed on clients when they are admitted to a facility, however, this information will not provide an explanation for the changes being noted in the client’s behaviors. The client’s appearance indicates there has been some change in mental outlook or condition. These changes may be the result of psychosocial issues and they must be investigated. The client’s memory and level of orientation will provide information relating to potential causes. This assessment will also provide an indication as to the seriousness of the problems being noted. Some disorders may be genetic, thus requiring investigation. The assessment of the client’s body systems will yield clues as to the cause of the changes being noted in behavior.

Cognitive Level: AnalyzingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health.


The nurse is reviewing the care plan for a client who is being treated for schizophrenia. The client had been hearing voices for quite some time, but now doesn’t state or deny that voices are heard. The nurse notes that the established goals have been met—the client is interacting appropriately with staff and family, is well-groomed, and has expressed excitement about the discharge. The nurse is using which step of the nursing process?

1. Goal setting


2. Implementation

3. Diagnosis

4. Evaluation

Correct Answer: 4

Rationale 1: Goal setting occurs after a diagnosis has been formulated.

Rationale 2: Implementation is the process of performing certain interventions designed to move the client toward achievement of the goal.

Rationale 3: The diagnosis is formulated after data have been collected.

Rationale 4: Evaluation is the process whereby the progress toward achieving the goals is reviewed and documented. The nurse’s recorded observations indicate the goals of the nursing care plan have been achieved.

Global Rationale: Evaluation is the process whereby the progress toward achieving the goals is reviewed and documented. The nurse’s recorded observations indicate the goals of the nursing care plan have been achieved. Implementation is the process of performing certain interventions designed to move the client toward achievement of the goal. The diagnosis is formulated after data have been collected, and goal setting occurs after a diagnosis has been formulated.

Cognitive Level: ApplyingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: EvaluationLearning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health.


The nurse is admitting a client to a psychiatric facility and is planning to conduct a psychosocial assessment. The nurse would correctly choose which of the following tools to obtain this data?


1. Healthy Day Measures

2. Multidimensional Health Profile

3. Emotional Readiness Assessment Profile

4. Holmes Social Readjustment Scale

5. Duke Social Support and Stress Scale


Correct Answer: 1,2,4,5

Rationale 1: Healthy Day Measures. The Healthy Day Measures is used by the Centers for Disease Control and Prevention. The scale is used to measure the quality of life.

Rationale 2: Multidimensional Health Profile. The Multidimensional Health Profile is a tool used to assess psychosocial problems. The tool specifically targets stress, coping, social supports, and mental health.

Rationale 3: Emotional Readiness Scale. The Emotional Readiness Scale is not a true test, and therefore not a valid test to assess psychosocial variables in a client.

Rationale 4: Holmes Social Readjustment Scale. The Holmes Social Readjustment Scale is used to measure the stressors in a client’s life.

Rationale 5: Duke Social Support and Stress Scale. The Duke Social Support and Stress scale is an instrument to measure family and nonfamily support and stress.

Global Rationale: The Healthy Day Measures is used by the Centers for Disease Control and Prevention. The scale is used to measure the quality of life. The Multidimensional Health Profile is a tool used to assess psychosocial problems. The tool specifically targets stress, coping, social supports, and mental health. The Emotional Readiness Scale is not a true test, and therefore not a valid test to assess psychosocial variables in a client. The Holmes Social Readjustment Scale is used to measure the stressors in a client’s life. The Duke Social Support and Stress scale is an instrument to measure family and nonfamily support and stress.



While being interviewed, a client admits to the nurse that she has been hearing voices and sounds for the past three days. Which of the following would be the nurse’s best response in this situation?

1. “How long have you been hearing these voices?”

2. “Tell me about what the voices tell you to do.”

3. “These must be other things you are hearing.”

4. “Do the voices bother you during the night only?”

Correct Answer: 2

Rationale 1: Knowing the length of time a person has had auditory hallucinations is helpful but is not the most important next question. Also, the client already said that she had been hearing the voices for 3 days.


Rationale 2: The most appropriate next question after the client tells the nurse she hears voices is asking the client if the voices tell her what she must do. Command hallucinations are dangerous and may lead to self-destructive behavior or harm to other people or property.

Rationale 3: Telling the client that there cannot be voices may indicate your lack of belief regarding in what is being said. This may cause refusal to answer additional questions.

Rationale 4: Asking whether or not the voices are bothersome to the client only at night does not yield helpful information as hallucinations are not a normal phenomenon and treatment goals would include eliminating the hallucinations. Additionally, the goal of the interview is to obtain the information most important to the treatment plan and is not to dwell on the hallucinations, thereby reinforcing them to the patient.

Global Rationale: The most appropriate next question after the client tells the nurse she hears voices is asking the client if the voices tell her what she must do. Command hallucinations are dangerous and may lead to self-destructive behavior or harm to other people or property. Telling the client that there cannot be voices may indicate your lack of belief regarding in what is being said. This may cause refusal to answer additional questions. Knowing the length of time a person has had auditory hallucinations is helpful but is not the most important next question. Also, the client already said that she had been hearing the voices for 3 days. Asking whether or not the voices are bothersome to the client only at night does not yield helpful information as hallucinations are not a normal phenomenon and treatment goals would include eliminating the hallucinations. Additionally, the goal of the interview is to obtain the information most important to the treatment plan and is not to dwell on the hallucinations, thereby reinforcing them to the patient.



The nurse is caring for a confused client. The nurse informs the client of the date, day of the week, time, and location each time the room is entered. The nurse is utilizing which step of the nursing process?

1. Implementation

2. Evaluation

3. Planning

4. Assessment

Correct Answer: 1

Rationale 1: Implementation is the process of performing certain interventions designed to move the client toward achievement of the goal. A confused client needs reorientation as part of the nursing care provided.


Rationale 2: Evaluation is the process whereby the progress toward achieving the goals is reviewed and documented.

Rationale 3: During the planning phase of the nursing process, nursing diagnoses are formulated after data have been assessed, and then goal setting takes place.

Rationale 4: Assessment is the phase of obtaining subjective and objective data about the client.

Global Rationale: Implementation is the process of performing certain interventions designed to move the client toward achievement of the goal. A confused client needs reorientation as part of the nursing care provided. Assessment is the phase of obtaining subjective and objective data about the client. During the planning phase of the nursing process, nursing diagnoses are formulated after data have been assessed, and then goal setting takes place. Evaluation is the process whereby the progress toward achieving the goals is reviewed and documented.

Cognitive Level: ApplyingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health.


The nurse is completing the psychosocial history on a newly admitted adult client. The client reports trouble concentrating, rapid heartbeats, irritability, and inability to make decisions. The nurse suspects which of the following?

1. Stress reaction

2. Role confusion

3. Impending heart attack

4. Dysfunctional anxiety

Correct Answer: 1

Rationale 1: A high level of stress may result in symptoms such as irritability, indecisiveness, confusion, pounding heart or pulse, and trouble concentrating, among other symptoms.

Rationale 2: There are no data to support the concern of role confusion.

Rationale 3: Symptoms of an impending heart attack may include irritability, confusion, and a pounding heart rate but there are other more classic symptoms that typically also appear.

Rationale 4: Symptoms of anxiety include some of the above symptoms, but there is not enough evidence to call it dysfunctional.


Global Rationale: A high level of stress may result in symptoms such as irritability, indecisiveness, confusion, pounding heart or pulse, and trouble concentrating, among other symptoms. Symptoms of an impending heart attack may include irritability, confusion, and a pounding heart rate but there are other more classic symptoms that typically also appear. Symptoms of anxiety include some of the above symptoms, but there is not enough evidence to call it dysfunctional. There are also no data to support the concern of role confusion.

Cognitive Level: ApplyingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: DiagnosisLearning Outcome: 5.2: Define psychosocial health.


An elderly, hard-of-hearing client is observed not participating with conversation and sits quietly in the corner of the room. This client’s physical ailment is impacting which psychosocial dimension?

1. Mental

2. Emotional

3. Social

4. Spiritual

Correct Answer: 3

Rationale 1: Mental functioning refers to the ability to cognitively process and interact with the environment.

Rationale 2: The emotional dimension is subjective and includes one’s feelings.

Rationale 3: Psychosocial health includes mental, emotional, social, and spiritual dimensions. When one part is missing or dysfunctional, all other parts of the individual are affected. Social functioning refers to the ability to form relationships with others.

Rationale 4: Spirituality refers to the beliefs and values that give meaning to life.

Global Rationale: Psychosocial health includes mental, emotional, social, and spiritual dimensions. When one part is missing or dysfunctional, all other parts of the individual are affected. Social functioning refers to the ability to form relationships with others. The emotional dimension is subjective and includes one’s feelings. Mental functioning refers to the ability to cognitively process and interact with the environment. Spirituality refers to the beliefs and values that give meaning to life.

Cognitive Level: AnalyzingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis


Learning Outcome: 5.1: Describe psychosocial functioning.


The adult caregiver of an elderly client states, “When my mother takes ill, you can predict I’ll be sick in about 6 weeks.” This statement demonstrates:

1. The client has a communicable disease.

2. The caregiver has uncared for health problems.

3. The caregiver is more ill than the client.

4. The caregiver is experiencing emotional stress.

Correct Answer: 4

Rationale 1: There is no indication the caregiver has an underlying health problem such as a communicable disease.

Rationale 2: There is no indication the caregiver has an underlying health problem such as uncared for health problems.

Rationale 3: There is no indication the caregiver is more ill than the client.

Rationale 4: Emotional health affects health in several ways. Stress affects the immune system, leading to increased susceptibility to infections. During periods of stress or change, the individual is less likely to adhere to positive health behaviors.

Global Rationale: Emotional health affects health in several ways. Stress affects the immune system, leading to increased susceptibility to infections. During periods of stress or change, the individual is less likely to adhere to positive health behaviors. There is no indication the caregiver has an underlying health problem such as a communicable disease, uncared for health problems, or is more ill than the client.

Cognitive Level: AnalyzingClient Need: Health Promotion and MaintenanceClient Need Sub: Nursing/Integrated Concepts: Nursing Process: EvaluationLearning Outcome: 5.3: Identify factors affecting psychosocial health.


A client tells the nurse, “I want to make sure my children have every possible opportunity to complete their education.” The nurse realizes this client’s philosophy on education will influence which aspect of her children’s health?


1. Attempt to meet immediate needs.

2. Help to elevate self-esteem.

3. Ongoing family disturbances.

4. Can lead to mental illness.

Correct Answer: 2

Rationale 1: Focus on immediate needs is seen more in those individuals from lower socioeconomic groups. This is not associated with an increased emphasis and achievement of educational goals.

Rationale 2: The higher the income, the more likely that individuals and families will achieve higher levels of education. The advantage contributes to the feelings of high self-worth and high self-esteem.

Rationale 3: Individuals from lower socioeconomic groups face a focus on immediate needs. This focus promotes a sense of low self-esteem. Continued feelings of this nature may result in family disturbances.

Rationale 4: Mental illness may be seen and remain untreated in lower socioeconomic groups as a result of ongoing focus on the meeting of immediate needs. This focus is often linked directly to a lack of education as seen in this population.

Global Rationale: The higher the income, the more likely that individuals and families will achieve higher levels of education. The advantage contributes to the feelings of high self-worth and high self-esteem. In lower socioeconomic groups, energies are spent in attempts to achieve more immediate needs. This focus promotes a concern on those present issues, resulting in less health promotion and future focused goals. Family disturbances and mental illness are seen in lower socioeconomic groups.

Cognitive Level: AnalyzingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: DiagnosisLearning Outcome: 5.3: Identify factors affecting psychosocial health.


Because of statements made by the client during a physical assessment, the nurse believes the client is at risk for developing a major illness. Which of the following statements would cause the nurse to fear for this client?

1. “Look at that person’s pants! Don’t they realize how ugly they are?”

2. “That sounds like a good idea! I think I will try that at home.”

3. “I just love spending time outside. It energizes me!”

4. “I set aside a period of time each day for myself.”


Correct Answer: 1

Rationale 1: There are different characteristics and behaviors a person demonstrates that can be categorized along the continuum of being psychosocially healthy vs. being psychosocially unhealthy. Those who are unhealthy psychosocially are at risk for the onset of an illness. Those who are psychosocially unhealthy will demonstrate pessimism, will openly laugh at others, are a “challenge” to be around, have little fun, and are self-absorbed.

Rationale 2: Individuals who are psychosocially healthy will demonstrate a zest for life and are adaptable to change.

Rationale 3: Individuals who are psychosocially healthy will demonstrate respect for nature.

Rationale 4: Individuals who are psychosocially healthy will demonstrate a zest for life, manage time well, and demonstrate coping skills.

Global Rationale: There are different characteristics and behaviors a person demonstrates that can be categorized along the continuum of being psychosocially healthy vs. being psychosocially unhealthy. Those who are unhealthy psychosocially are at risk for the onset of an illness. Individuals who are psychosocially healthy will demonstrate a zest for life, manage time well, are adaptable to change, demonstrate coping skills, and respect nature. Those who are psychosocially unhealthy will demonstrate pessimism, will openly laugh at others, are a “challenge” to be around, have little fun, and are self-absorbed.

Cognitive Level: AnalyzingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: DiagnosisLearning Outcome: 5.1: Describe psychosocial functioning.


A client with hypertension stops into the clinic for his weekly blood pressure measurement. He tells the nurse that he is in a hurry because he started a new job and has to get back to work. Evidence that this client is responding to the new job in a stressful way would be:

1. Elevated blood pressure.

2. Respirations 16 and regular.

3. Temperature within normal limits.

4. Heart rate 86 and regular.

Correct Answer: 1

Rationale 1: Physical signs of stress include elevated blood pressure, pulse, and respirations, dilated pupils, increased blood volume. and elevated blood glucose level.


Rationale 2: Respirations of 16 are within normal limits for an adult.

Rationale 3: Normal body temperature does not indicate a stressful condition.

Rationale 4: Heart rate of 86 is within normal limits for an adult.

Global Rationale: Physical signs of stress include elevated blood pressure, pulse, and respirations, dilated pupils, increased blood volume, and elevated blood glucose level. Respirations of 16 are within normal limits for an adult. Normal body temperature does not indicate a stressful condition. Heart rate of 86 is within normal limits for an adult.

Cognitive Level: ApplyingClient Need: Health Promotion and MaintenanceClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 5.1: Describe psychosocial functioning.


The nurse is assessing a client’s spiritual and belief patterns and is currently asking the client about participation in organized religion. The nurse is on which step of the HOPE assessment with this client?

1. H

2. O

3. P

4. E

Correct Answer: 2

Rationale 1: H is for spiritual resources.

Rationale 2: O is for participation in organized religion.

Rationale 3: P is for personal spiritual practices.

Rationale 4: E is for effects of healthcare and end-of-life issues.

Global Rationale: The pneumonic HOPE is described as: H for spiritual resources, O for participation in organized religion, P for personal spiritual practices, and E for effects of healthcare and end-of-life issues.

Cognitive Level: ApplyingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment


Learning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health.


A client is admitted to the psychiatric unit with complaints consistent with an anxiety disorder. During the assessment the nurse learns a client has a history of asthma and arthritis. Which of the following should the nurse do with this information?

1. Begin the respiratory assessment.

2. Begin the musculoskeletal status assessment.

3. Begin a review of the client’s current medications.

4. Begin the psychosocial assessment.

Correct Answer: 4

Rationale 1: There is no indication the client is currently experiencing respiratory compromise, so the assessment of this system is not an immediate concern.

Rationale 2: Although the patient has a history of arthritis there is no indication that the client is experiencing immediate concerns related to the musculoskeletal system.

Rationale 3: A review of the client’s current medications will be included in the admission assessment but are not an immediate need.

Rationale 4: The client in the question is being admitted for concerns related to an anxiety disorder. The admitting issues take priority in the collection of data. Some physical problems have associated or underlying psychosocial problems. Examples of these physical problems include arthritis and asthma. The nurse should spend time on the psychosocial assessment with this client.

Global Rationale: The client in the question is being admitted for concerns related to an anxiety disorder. The admitting issues take priority in the collection of data. Some physical problems have associated or underlying psychosocial problems. Examples of these physical problems include arthritis and asthma. The nurse should spend time on the psychosocial assessment with this client. There is no indication the client is currently experiencing respiratory compromise so the assessment of this system is not an immediate concern. Although the patient has a history of arthritis there is no indication that the client is experiencing immediate concerns related to the musculoskeletal system. A review of the client’s current medications will be included in the admission assessment but are not immediate.

Cognitive Level: ApplyingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 5.3: Identify factors affecting psychosocial health.



The nurse is concerned that a client is having a problem with self-concept. Which of the following statements would cause the nurse to have this 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.”

Correct Answer: 1

Rationale 1: There are a variety of questions that can be asked to assess a client’s self concept. The client’s response provides information to the nurse about problems or concerns with this characteristic. Clients who are unable to explain a social life or who do not have any fun may be depressed or out of touch with reality.

Rationale 2: Birth order in the family is not implicated in the client.

Rationale 3: An outgoing client is not at high risk for problems with self-concept.

Rationale 4: Occasional desire to be alone does not indicate a problem with self-concept.

Global Rationale: There are a variety of questions that can be asked to assess a client’s self-concept. The client’s response provides information to the nurse about problems or concerns with this characteristic. Clients who are unable to explain a social life or who do not have any fun may be depressed or out of touch with reality. Birth order in the family is not implicated in the client. An outgoing client is not at high risk for problems with self-concept. Occasional desire to be alone does not indicate a problem with self-concept.

Cognitive Level: AnalyzingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health.


The nurse believes a client is having difficulty coping with current illness and hospitalization. Which of the following assessment questions would best help the nurse identify the client’s coping ability?

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?

Correct Answer: 4

Rationale 1: Questions about friends assess the client’s Roles & Relationships.

Rationale 2: Questions about social groups assess the client’s Roles & Relationships.

Rationale 3: Questions about birth order focus on the client’s Family History.

Rationale 4: Questions that are helpful to gather additional information about a client’s stress and coping mechanisms include: What do you do for relaxation? For recreation? What is your greatest source of comfort when you are feeling upset? Who do you call for help? What is your current level of stress?

Global Rationale: Questions that are helpful to gather additional information about a client’s stress and coping mechanisms include: What do you do for relaxation? For recreation? What is your greatest source of comfort when you are feeling upset? Who do you call for help? What is your current level of stress? Questions about friends and social groups assess the client’s Roles & Relationships, whereas questions about birth order focus on the client’s Family History.

Cognitive Level: ApplyingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health.


During an assessment the nurse observes the client jumping from one idea to another, unable to completely answer any of the assessment questions. The nurse recognizes this speech pattern as being:

1. Circumlocution.

2. Flight of ideas.

3. Neologisms.

4. Echolalia.

Correct Answer: 2

Rationale 1: Circumlocution means the client is demonstrating numerous digressions.

Rationale 2: The speech pattern where thoughts and ideas jump is termed flight of ideas.


Rationale 3: Neologisms are the coining of new words that have significance to the client.

Rationale 4: Echolalia is the constant repetition of words or phrases that the client hears others say.

Global Rationale: The speech pattern where thoughts and ideas jump is termed flight of ideas. Circumlocution means the client is demonstrating numerous digressions. Neologisms are the coining of new words that have significance to the client. Echolalia is the constant repetition of words or phrases that the client hears others say.

Cognitive Level: AnalyzingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: DiagnosisLearning Outcome: 5.1: Describe psychosocial functioning.


A client voices concerns about becoming pregnant. The client reports her mother had a history of schizophrenia. The client is fearful of having a child with the same disorder. What is the best initial response by the nurse?

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.”

Correct Answer: 2

Rationale 1: Telling the patient to be very concerned does not present the maximum amount of information.

Rationale 2: Schizophrenia does have genetic links. Individuals having a family history have a greater incidence of also displaying the disorder. There are, however, other variables such as environment that should be considered.

Rationale 3: Advising the client that it should not be a significant concern both downplays the actual risk and minimizes the client’s concerns.

Rationale 4: There are no tests that can be run for this disease.

Global Rationale: Schizophrenia does have genetic links. Individuals having a family history have a greater incidence of also displaying the disorder. There are, however, other variables such as environment that should be considered. Telling the patient to be very concerned does not present the maximum amount of information. Advising the client that it should not be a significant concern both downplays the actual risk and minimizes the client’s concerns. There are no tests that can be run for this disease.

Cognitive Level: Analyzing


Client Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 5.2: Define psychosocial health.


A client is seen at the ambulatory care clinic for a routine physical examination. During the examination, the client discusses having gained more than 25 pounds in the past year despite not changing the level of activity or dietary intake. What response by the nurse is indicated?

1. “You must be eating more than you realize.”

2. “Do you think increasing exercise might help you with your excessive weight gain?”

3. “Tell me about any changes in your stress levels.”

4. “This weight gain is likely the result of aging.”

Correct Answer: 3

Rationale 1: Telling the client that he is indeed eating more than realized is confrontational.

Rationale 2: Encouraging the client to increase exercise may be beneficial but the nurse must first assess for potential causes.

Rationale 3: Periods of stress may result in obesity. In addition, some individuals will use comfort foods during periods of stress.

Rationale 4: Many people do gain weight as they age but there is no indication that this is correct for this individual.

Global Rationale: Periods of stress may result in obesity. In addition, some individuals will use comfort foods during periods of stress. Telling the client that he is indeed eating more than realized is confrontational. Encouraging the client to increase exercise may be beneficial but the nurse must first assess for potential causes. Many people do gain weight as they age but there is no indication that this is correct for this individual.

Cognitive Level: AnalyzingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 5.3: Identify factors affecting psychosocial health.



A client is admitted to the psychiatric care unit. During the admission process, while the nurse is explaining the use of the call light the client smiles and says, “Apples, corn, dogs, my foot.” The nurse correctly documents the client is demonstrating which of the following speech patterns?

1. Neologisms

2. Clanging

3. Word salad

4. Echolalia

Correct Answer: 3

Rationale 1: Neologisms refer to the coining of new words.

Rationale 2: Clanging refers to engaging in a conversation in which the words rhyme.

Rationale 3: The grouping of words together in a manner that does not make sense is known as word salad.

Rationale 4: Echolalia is the constant repetition of words by the client that have been said by others.

Global Rationale: The grouping of words together in a manner that does not make sense is known as word salad. Neologisms refer to the coining of new words. Clanging refers to engaging in a conversation in which the words rhyme. Echolalia is the constant repetition of words by the client that have been said by others.

Cognitive Level: UnderstandingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 5.1: Identify factors affecting psychosocial health.


The nurse is attempting to assess a client who appears agitated. The client believes the nurse is trying to hurt him and is not cooperating with the nurse. What actions by the nurse are indicated?


1. Advise the client that the healthcare provider will be contacted unless the client complies.

2. Restrain the client using leather restraints.

3. Speak to the client in a calm voice.

4. Explain actions to the client as they are done.


5. Medicate the client.

Correct Answer: 3,4

Rationale 1: Advise the client that the healthcare provider will be contacted unless the client complies. Telling the client that the healthcare provider will be called in this manner may be viewed as threatening. This action may further upset the client.

Rationale 2: Restrain the client using leather restraints. The use of restraints in the psychiatric setting is limited. Restraints should be a last resort and only indicated when the client may harm himself or another individual. There is no indication either of these criteria has been met.

Rationale 3: Speak to the client in a calm voice. Speaking in a calm voice may help to diffuse the situation and relax the client.

Rationale 4: Explain actions to the client as they are done. Explaining activities to the client may help to reduce the fears being experienced by the client.

Rationale 5: Medicate the client. The administration of medications simply to quiet the client is considered a form of chemical restraint. In addition, it is beyond the scope of practice to medicate the client without specific orders from the healthcare provider.

Global Rationale: Telling the client that the healthcare provider will be called in this manner may be viewed as threatening. This action may further upset the client. The use of restraints in the psychiatric setting is limited. Restraints should be a last resort and indicated only when the client may harm himself or another individual. There is no indication either of these criteria has been met. Speaking in a calm voice may help to diffuse the situation and relax the client. Explaining activities to the client may help to reduce the fears being experienced by the client. The administration of medications simply to quiet the client is considered a form of chemical restraint. In addition, it is beyond the scope of practice to medicate the client without specific orders from the healthcare provider.

Cognitive Level: AnalyzingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 5.4: Discuss the application of the nursing process in assessment of psychosocial health.


A client has presented to the ambulatory care clinic with complaints of back pain, nausea, and fatigue. When the nurse questions the client about recent stressors the client becomes irritated and states, “I am sick. Why are you asking me about all of this stress stuff?” Which of the following responses by the nurse is most appropriate?

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

2. “Your nausea and fatigue are most often related to an overabundance of stress in life.”


3. “Asking about stress is required for every client.”

4. “We all have stress and I need to see how much you have.”

Correct Answer: 1

Rationale 1: Stress is associated with a variety of physical ailments, including back pain, nausea, and fatigue. The nurse has a responsibility to provide education to the client concerning the reasons behind the questions being asked.

Rationale 2: The final diagnosis as to the cause of the ailments being reported has not been completed. It is premature for the nurse to equate an overabundance of stress to the physical concerns reported.

Rationale 3: Stress assessment may be a requirement for many data collections but this does not provide an adequate response to the client.

Rationale 4: Telling the client that all people have stress downplays the client’s individual needs and is inappropriate.

Global Rationale: Stress is associated with a variety of physical ailments, including back pain, nausea, and fatigue. The nurse has a responsibility to provide education to the client concerning the reasons behind the questions being asked. The final diagnosis as to the cause of the ailments being reported has not been completed. It is premature for the nurse to equate an overabundance of stress to the physical concerns reported. Stress assessment may be a requirement for many data collections but this does not provide an adequate response to the client. Telling the client that all people have stress downplays the client’s individual needs and is inappropriate.

Cognitive Level: AnalyzingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 5.3: Identify factors affecting psychosocial health.


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