Chapter 1 - Basic Mental Health Nursing Concepts

Question 1

Mental Status Examination

Level of consciousness

Answer 1

alert
lethargy - drowsy
stupor - requires vigorous/painful stimuli for brief response
coma - no response

Question 2

Decorticate rigidity

Answer 2

flexion and internal rotation of upper-extremity joints and legs

Question 3

Decerebrate rigidity

Answer 3

neck and elbow extension, wrist and finger flexion

Question 4

Mental Status Examination

Physical appearance

Answer 4

expected - hygiene, dressed appropriately

Question 5

Mental Status Examination

Behavior

Answer 5

in/voluntary movements, eye contact
mood - emotion felt
affect - objective expression of a mood (flat affect or lack of facial expression)

Question 6

Mental Status Examination

Cognitive and intellectual abilities

Answer 6

orientation to time/person/place
memory (immediate/recent/remote-verified data from past like DOB)
knowledge - understanding of current illness
calculate - math
abstract thinking
objective assessment of perception of illness
response to a hypothetical question
rate, volume, quality of speech

Question 7

Mini-Mental State Examination

Answer 7

objectively assess cog status
orientation time/place
attention span, count backwards by 7
register/recall objects
language, following commands, writing

Question 8

Glasgow Coma Scale

Answer 8

evaluate eye, verbal, motor response
15 = awake and appropriate
7 or less = coma

Question 9

Considerations

Children and Adolescents

Answer 9

mentally healthy = trust world/others
Standardized assessment tool = HEADSS (Home, Education/employment, peer group Activities, Drugs, Sexuality, Suicide/depression

Question 10

Considerations

Older Adult

Answer 10

comp assessment of: functional ability, economic/social status, environment, physical
Geriatric Depression Scale
Michigan Alcoholism Screening Test
Mini-Mental Status Exam
Pain assessments

Question 11

Mental Health Nursing Interventions

Answer 11

Counseling
Milieu therapy
Promotion of self-care activities
Psychobiological interventions
Cognitive/Behavioral therapies
Health teaching
Health promotion/Health maintenance
Case management

Question 12

Mental Health Nursing Interventions

Counseling

Answer 12

Ther. communication skills
assisting with problem solving
crisis intervention
stress management

Question 13

Mental Health Nursing Interventions

Milieu therapy

Answer 13

orienting client to physical setting
identifying rules and boundaries of setting
ensuring safe environment
assisting client to participate in appropriate activities

Question 14

Mental Health Nursing Interventions

Promotion of self-care activities

Answer 14

offering assistance with self-care tasks
allowing time for client to complete self-care tasks
setting incentives to promote self-care

Question 15

Mental Health Nursing Interventions

Psychobiological interventions

Answer 15

admin meds
provide teaching about meds
monitor for adverse effects and effectiveness

Question 16

Mental Health Nursing Interventions

Cognitive and behavioral therapies

Answer 16

modeling
operant conditioning
systematic desensitization

Question 17

Mental Health Nursing Interventions

Health teaching

Answer 17

teaching social and coping skills

Question 18

Mental Health Nursing Interventions

Health promotion and health maintenance

Answer 18

assist client with cessation of smoking

monitor other health conditions

Question 19

Mental Health Nursing Interventions

Case management

Answer 19

coordinating holistic care: medical, mental health, social services