Mental Health Assessment (FINALS KASALI) Flashcards
repeated purposeless behaviors often indicative of
anxiety, such as drumming fingers, twisting locks of hair, or tapping
the foot
Automatism
overall slowed movements
Psychomotor Retardation
maintenance of posture or position over time even
when it is awkward or uncomfortable
Waxy Flexibility
Invented words that have meaning only for the client
Neologism
Client’s pervasive and enduring emotional state.
Subjective
Mood
Outward expression of the client’s emotional state.
Objective
Affect
showing little or a slow-to-respond facial expression
Blunted Affect
displaying a full range of emotional expressions
Broad Affect
showing no facial expression
Flat Affect
displaying a facial expression that is incongruent with mood or situation; often silly or giddy regardless of circumstances
Inappropriate Affect
displaying one type of expression, usually serious or somber
Restricted Affect
a client eventually answers a question but only after giving excessive unnecessary detail
Circumstantial Thinking
excessive amount and rate of speech composed of fragmented or unrelated ideas
Flight of Ideas
client’s inaccurate interpretation that general events are personally directed to him or her, such as hearing a speech on the news and believing the message had personal meaning
Ideas of Reference
disorganized thinking that jumps from one idea to another with little or no evident relation between the thoughts
Loose Associations
wandering off the topic and never providing the information requested
Tangential Thinking
stopping abruptly in the middle of a sentence or train of thought; sometimes unable to continue the idea
Thought Blocking
a delusional belief that others can hear or know what the client is thinking
Thought Broadcasting
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 Insertion
a delusional belief that others are taking the client’s thoughts away and the client is powerless to stop it
Thought Withdrawal
flow of unconnected words that convey no meaning to the listener
Word Salad
a fixed false belief not based in reality
Delusion
s involve the client’s belief that “others” are planning to harm the client or are spying, following, ridiculing, or belittling the client in some way.
Persecutory/paranoid delusions
are characterized by the client’s claim to association with famous people or celebrities, or the client’s belief
that he or she is famous or capable of great feats.
Grandiose Delusion
often center around the second coming of Christ or another significant religious figure or prophet.
Religious Delusion
often center around the second coming of Christ or another significant religious figure or prophet.
Religious Delusion
are generally vague and unrealistic beliefs about the client’s health or bodily functions. Factual information or
diagnostic testing does not change these beliefs.
Somatic Delusion
involve the client’s belief that his or her sexual behavior is known to others; that the client is a rapist, prostitute, or pedophile or is pregnant; or that his or her excessive
masturbation has led to insanity.
Sexual Delusion
are the client’s belief that his or her organs aren’t functioning or are rotting away, or that some body part or feature is horribly disfigured or misshapen.
Nihilistic delusions
Involve the client’s belief that television broadcasts, music, or newspaper articles have special meaning for him or her.
Referential delusion or ideas of reference
Refers to the ability to interpret one’s environment and situation correctly and to adapt one’s behavior and decisions accordingly.
Judgment
the ability to understand the true nature of one’s situation and accept some personal responsibility for that situation.
Insight
Factors Influencing Assessment
Client participation/feedback
Clients health status
Client’s previous experience/misconception about health care
Clients ability to understand
Nurse’s attitude and approach
Contents of the Mental Health Assessment
History
General appearance and motor behavior
Mood and affect
Thought process and content
Sensorium and intellectual processes
Judgment and insight
Self-concept
Roles and relationships
Physiologic and self-care concerns
Mood Descriptions
Happy
Sad
Depressed
Euphoric
Anxious
Angry
Labile (Rapidly changing)
Client’s recognition of person, place, and time.
Orientation
recent and remote, by asking questions with verifiable answers
Memory
Sensorium and Intellectual Processes Assessment
Ability to concentrate
Abstract thinking
Intellectual abilities
What are the types of hallucinations?
Visual hallucinations - sight
Olfactory hallucinations - smell
Gustatory hallucinations - taste
Auditory hallucinations - hearing
Tactile hallucinations - touch
10 stimulus cards of inkblots; client describes perceptions of inkblots; narrative interpretation discusses areas such as coping styles, interpersonal attitudes, characteristics of ideation
Rorschach Test
20 stimulus cards with pictures; client tells a story about the picture; narrative interpretation discusses themes about mood state, conflict, quality of interpersonal relationships
Thematic Apperception Test (TAT)
Client completes a sentence from beginnings such as “I often wish,” “Most people,” and “When I was young.”
Sentence Completion Test
What is the purpose of psychosocial assessment?
to construct a picture of the client’s current emotional state, mental capacity, and behavioral function.
What areas that are often difficult for nurses to assess?
sexuality and self-harm behaviors and suicidality
