Mental Health Assessment

Question 1

Assessment

Answer 1

1. Screening: general info gathered
2. Initial Assessment
3. On-going: communication every time; risk assessment

Question 2

Initial Contact with pt

Answer 2

assess and refer to services that are:

• least restrictive
• most effective
• most cost-conscious

Question 3

When interviewing…

Answer 3

Never ask why!!

Question 4

Interview Do

Answer 4

get specific and measurable information (high priority)

Question 5

Interview Do

Answer 5

Set clear goals:

• explain what you are doing
• tell them to let you know that if they get uncomfortable you can stop
• only student and instructor will be seeing info

Question 6

Systems Review

Answer 6

drug history
psychiatric history
medications/medical problems
substance/process addictions

Question 7

Mental Status Exam

Answer 7

Summary of preliminary assessment; DSM-IV; NANDA; nursing assessment forms/checklists vary from agency to agency

Question 8

MSE General Attitude & Behavior

Answer 8

behavior during interview
appearance: grooming, age, general state of health
facial expressions: (affect)
   *flat or blunt: cant read anything 
   *appropriate: fits what is going on 
   *labial: up and down
posture
mood activity: appropriate; increased/decreased; tremors; dystonia's; hyperactivity

Question 9

MSE Stream of Mental Activity

Answer 9

productivity, progression, language

Question 10

MSE Emotional State/Reaction

Answer 10

mood, affect, vegetative signs of depression

Question 11

MSE Mental Trend Thought Concept

Answer 11

• perception: hallucinations, illusions, derealization
• cognitive style: obsessions, delusions, experiences of influence, ideas of reference, though broadcasting, thought insertion

Question 12

MSE Mental Grasp and Capacity

Answer 12

• consciousness
• concentration and attention span
• orientation to time, place, person, situation
• memory (immediate recall, recent, remote, amnesia)
• intellectual functioning; disorders of counting, -general knowledge, judgment, insight
• thinking: form of thought, content of thought legal status

Question 13

Nursing Interventions Foci

Answer 13

safety, structure, support
symptom management
verbal strategies to guide problem-solving
facilitation and education

Question 14

Interdisciplinary Treatment Plan (ITP)

Answer 14

• helps to demonstrate the collaborative care of the patient
• used in place of separate plans of care for each discipline
• evaluation considers: patient progress, reassessment; goal of revision, need for referral to other level of care, effectiveness of nursing interventions