being depressed, the nurse might ask, “On a scale of
1 to 10, with 1 being least depressed and 10 being most
depressed, where would you place yourself right now?”
Thought Process and Content
Thought processrefers to how the client thinks. The
nurse can infer a client’s thought process from speech
and speech patterns. Thought contentis what the
client actually says. The nurse assesses whether or
not the client’s verbalizations make sense, that is,
if ideas are related and flow logically from one to
the next. The nurse also must determine if the client
seems preoccupied, as if talking or paying attention to
someone or something else. When the nurse encoun-
ters clients with marked difficulties in thought process
and content, he or she may find it helpful to ask fo-
cused questions requiring short answers. Common
terms related to the assessment of thought process
and content include the following (APA, 2000):
- Circumstantial thinking:term used when
a client eventually answers a question but
only after giving excessive unnecessary
detail - Delusion:a fixed, false belief not based in
reality - Flight of ideas:excessive amount and rate of
speech composed of fragmented or unrelated
ideas - Ideas of reference:client’s inaccurate
interpretation that general events are per-
sonally directed to him or her such as hear-
ing a speech on the news and believing the
message had personal meaning - Loose associations:disorganized thinking
that jumps from one idea to another with
little or no evident relation between the
thoughts - Tangential thinking:wandering off the
topic and never providing the information
requested - Thought blocking:stopping abruptly in
the middle of a sentence or train of thought;
sometimes unable to continue the idea - Thought broadcasting:a delusional belief
that others can hear or know what the client
is thinking - Thought insertion:a delusional belief that
others are putting ideas or thoughts into the
client’s head—that is, the ideas are not those
of the client - Thought withdrawal:a delusional belief
that others are taking the client’s thoughts
away and the client is powerless to stop it - Word salad: flow of unconnected words that
convey no meaning to the listener
162 Unit 2 BUILDING THENURSE–CLIENTRELATIONSHIP
ASSESSMENT OF SUICIDE OR
HARM TOWARD OTHERS
For the depressed or hopeless client, the nurse must
determine if he or she has suicidal ideation or a lethal
plan. The nurse does so by asking the client directly,
“Do you have thoughts of suicide?” or “What thoughts
of suicide have you had?” Box 8-2 lists assessment
questions that the nurse should ask any client who
has suicidal ideas.
Likewise, if the client is angry, hostile, or making
threatening remarks about a family member, spouse,
or anyone else, the nurse must ask if the client has
thoughts or plans about hurting that person. The
nurse does so by questioning the client directly:- What thoughts have you had about hurting
[person’s name]? - What is your plan?
- What do you want to do to [person’s name]?
When a client makes specific threats or has a plan
to harm another person, health care providers are
legally obligated to warn the person who is the target
of the threats or plan. The legal term for this is duty
to warn.This is one situation in which the nurse must
breach the client’s confidentiality to protect the threat-
ened person.
Sensorium and Intellectual Processes
ORIENTATION
Orientation refers to the client’s recognition of per-
son, place, and time; that is, knowing who and where
he or she is and the correct day, date, and year. This
is often documented as “oriented X 3.” Occasionally a
fourth sphere, situation, is added (whether or not the
client accurately perceives his or her current circum-
stances). Absence of correct information about per-
son, place, and time is referred to as disorientation, or
“oriented X 1” (person only) or “oriented X 2” (person
and place). The order of person, place, and time is sig-
nificant. When a person is disoriented, he or she firstBox 8-2
➤ SUICIDEASSESSMENTQUESTIONS
Ideation:“Are you thinking about killing yourself?”
Plan:“Do you have a plan to kill yourself?”
Method:“How do you plan to kill yourself?”
Access:“How would you carry out this plan? Do you
have access to the means to carry out the plan?”
Where:“Where would you kill yourself?”
When:“When do you plan to kill yourself?”
Timing:“What day or time of day do you plan to kill
yourself?”