Mental Status Examination

Question 1

What are the steps to the nursing assessment

Answer 1

• Establish therapeutic relationship
• Information on patients current problem
• Assess physical status and obtain baseline
• Assess for risk factors
• Assess psychosocial
• Goals of treatment
• Plan for care

Question 2

What are some conditions that mimic that of a mental illness

Answer 2

• Brain tumour
• Heart Failure
• Sleep Apnea
• Hypothyroidism
  -Hyperthyroidism

Question 3

What is the first step in the MSE and what do you look for

Answer 3

Appearance (observed)
- Grooming and dressed
- level of hygiene
- pupil dilation or constriction
- facial expression
- height, weight, nutritional status
- Presence of tattoos or piercings, scars
- does the appearance and age make sense, go together

Question 4

what is the second step in the MSE and what to look for

Answer 4

Behaviour (observed)
- what the person is actually doing during the interview
- mannerism
- body movements (excessive or minimal)
- abnormal movements (tremors, tardive dyskinesia)
- level of eye contact
- rapport (how open or closed off the patient was)

Question 5

what is the third step in the MSE and what to look for

Answer 5

Speech (Observed)
- how fast or slow they are speaking
- what is the volume of their speech
- what is their tone
- how are they articulating
- what is the organization of their speech
- what is the quantity of their speech

Question 6

what is the fourth step in the MSE and what to look for

Answer 6

Mood (Observed and Inquired)
affect
- appropriateness
- range of facial expressions
- stability
mood
- tone
- irritability
- stability
- degree

Question 7

what is the fifth step in the MSE and what to look for

Answer 7

Thought (Observed and Inquired)
According to the persons thought content or thought process
- Thought content: delusions, preoccupations or obsessions, dark thoughts
- Thought Process: disorganized, coherent, flight of ideas, neologisms, thought blocking

Question 8

what is the sixth step on the MSE and what to look for

Answer 8

Perception (observed and inquired)
- critical for determining severe mental health illness

Hallucinations (false perception involving all of the senses)
- sensory involvement (auditory, visual, tactile)
- Content of auditory hallucinations (command hallucination)
- how real is the hallucination
- level of associated distress

Illusion (misperception of reality) seeing insects on a patterned wall

Dissociations (feeling that the world around is not real)
- depersonalization
- derealization

Question 9

what is the seventh step in the MSE and what to look for

Answer 9

Cognition (inquired)
- person’s current capacity to process information

• orientation to reality
• level of consciousness
• memory functioning
• knowledge or intelligence
• language
• abstraction
• attention and concentration
• visual or spatial processing
• insight (patients acknowledgement and understanding of problems, evaluated by exploring questions)
• judgement (patients general problem solving ability, evaluated by exploring recent decision making)

Question 10

what is the last step in the MSE and what to look for

Answer 10

Ideas of harming self or others
- target of ideation
- frequency of ideation
- intent
- Ask patient if they have a plan (specificity, lethality of means, menas to carry out the plan, opportunity to carry out the plan)

Question 11

What are the EPS

Answer 11

extrapyramidal symptoms
- they are the adverse effects of medication

• pseudoparkinsonism: stiffening of the muscles, impaired gait, reduced movements, tremors)
• dystonia: contraction of muscles, mostly in the head and neck)
• akathisia: being restless, pacing and fidgeting)
• tardive dyskinesia: involuntary tonic muscular contractions

Question 12

what are the goals pertaining to mental health

Answer 12

• maintain safety
• restrain self mutilation
• improve thought process or perceptual disturbances
• control treatment related behaviour
• manage stress level
• reach mood equilibrium

Question 13

what are the basic levels of interventions

Answer 13

• coordination of care
• health teaching and promotion
• milieu therapy (activities meeting patients needs)
• pharmacological, biological therapies (herbal remedies)

Question 14

what are advanced level interventions

Answer 14

• psychotherapy
• consultation to other disciplines

Question 15

what should always come after interventions

Answer 15

EVALUATION
- ongoing, specific
- seeing if goals were attained or if they need to be modified
- were the interventions successful?