Chapter 6 Flashcards
Holistic psychiatric mental health nursing care requires assessment of biological, psychological, sociocultural health status
Integrated care
What two patient characteristics influence the mental status exam?
patient’s educational and sociocultural background
detects changes or abnormalities in intellectual functioning, thought content, judgement, mood, and affect
mental status examination
overtly communicated information
content
how communication occurs, including feelings, intuition, behaviors that accompany speech and thought
process
Are content and process always congruent?
No- patient may deny feeling depressed but appear sad, tearful
What are the categories of mental status exam?
General description, emotional state, experiences, thinking, sensorium and cognition
Why would a nurse assess pupil constriciton or dilation?
Dilated pupils= drug intoxication
Constricted pupils= narcotic addiction
Stooped posture is often common in _____ patients
depressed
This type of patient would likely dress in colorful and unusual attire
Manic patient
What do speech disturbances generally indicate?
A specific brain disturbance
Mumbling is common in patients with _____
Huntington’s chorea
Slurred speech is common in ______ patients
intoxicated
_______ patients often show pressured speech
manic
_______ people are often reluctant to speak at all.
Depressed
What kind of body movements would a patient with anxiety, mania, or stimulant abuse likely exhibit?
Excessive body movement
What kind of body movements would a patient with depression, organic disorder, catatonic schizophrenia, or drug-induced stupor display?
Decreased body movement
What do tics and grimaces suggest a patient has?
Side effects of medications
What disorder do repeated motor movements or compulsions indicate?
Obsessive compuslive disorder
If a patient is repeatedly picking lint or dirt from clothing, what could the real problem be?
Delirium or toxic conditions
patient’s self report of prevailing emotional state
Mood
Most people with ____ report feeling hopeless
Depression
What 3 disorders commonly have suicidal ideation
Depression, anxiety disorders, schizophrenia
How would a nurse judge a patient’s suicidal or homicidal risk?
Assess patient’s plans, ability to carry out those plans (availability of guns)
Patient’s apparent emotional tone
Affect
the absence of emotional expression, as seen by a patient who reports significant life events without showing any emotional response
flat affect
frequent changes from one affective response to another
lability
labile affect is often seen in which disorder?
mania
____ affect and _____ affect are often seen with schizophrenia
flat and incongruent
What are the categories of hallucinations?
Auditory, visual, tactile, gustatory, olfactory
Which type of hallucination is most common?
Auditory (“hearing voices”)
tell patient to do something: to kill oneself, harm another, or join someone in afterlife
command hallucinations
Which disorder do auditory hallucinations suggest?
Schizophrenia
Visual hallucinations suggest….
organicity
tactile hallucinations suggest what 3 disorders?
organic mental disorders, cocaine abuse, delirium tremors
_________ thinking may be a sign of defensiveness or paranoid thinking
circumstantial
_________ associations and ___________ suggest schizophrenia or other psychotic disorders
loose/neologisms
new word or words created by the patient often a blend of other words
neologisms
overproductive speech characterized by rapid shifting from one topic to another and fragmenting ideas- common in schizophrenia
flight of ideas
What are two thought content symptoms that are commonly associated with anxiety disorders?
Obsessions and phobias
Which thought content symptoms suggest schizophrenia? (3)
delusions, depersonalization, ideas of reference
refers to the “how” of a patient’s self-expression
thought process
How is thought process observed?
through speech patterns or forms of verbalization rather than content
What is a clinical implication of a thought process problem often associated with brain damage and psychotic disorders?
Perseveration
What example of thought process disorder represents the highest level of thought disorganization?
Word Salad
A patient with this type of mental disorders may give grossly inaccurate answers when asked questions to assess orientation
Organic Mental Disorders
Which level of orientation remains in tact the lognest?
Orientation to person
ability to recall past events
memory
recall of events, information, people from distant past
Remote memory
recall of events, information, people from past week or so
Recent memory
recall of information or data to which person was just exposed
immediate memory
Which disorders can present with a loss of memory?
organic disorders, dissociative disorders, conversion disorder
How do anxiety and depression affect memory?
impair immediate retention, recent memory
ability to pay attention
concentration
ability to do simple math
calculation
includes talents people express in the arts, athletics, ability to work cooperatively with people, self-definition
intelligence
what skills are assessed in a typical intelligence test?
verbal and mathematical
involves making constructive and adaptive decisions
judgement
ability to understand facts and draw conclusions from relationships
judgement
What aspects are used to evaluate judgement?
evaluated by exploring involvement in activities, relationships, and vocational choices
How would a nurse evaluate judgement?
present hypothetical situations
Which mental disorders have an element of impaired judgement?
organic mental disorders, schizophrenia, psychotic disorders, intoxication, borderline or low IQ, manic patients, those with personality disorders
patient’s understanding of problem/illness
insight
In which mental disorders is insight impaired?
organic mental disorders, psychosis, substance abuse, eating disorders, personality disorders, borderine or low IQ
When should a quote from the patient be included in documentation?
When he/she adds important information to support nurse’s assessment
simplified, scored form of cognitive mental status examination that concentrates only on cognitive aspects of mental functions (excludes questions concerning mood, abnormal psycholgical experiences, content or process thinking)
Mini-Mental Status Exam
battery of tests usually administered to provide comprehensive information
personality tests
What are the names of some common personality tests?
Rorschach test, TAT, Bender Gestalt Test, MMPI
What are some commonly used intelligence tests for adults and children?
WAIS for adult and WISC for children
Measure extent of patient’s problems, help make accurate diagnosis, track patient’s progress over time, document effectiveness/success of treatment
Behavioral Rating Scale
