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Psychiatric Nursing > Mental Status Examination > Flashcards

Mental Status Examination Flashcards

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1
Q

Constructing a picture of the client’s current emotional state, mental capacity, and behavioral function

A

Mental Status Examination

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2
Q

Conducted through interviews

A

Mental Status Examination

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3
Q

What’s the appropriate body language?

A

(SOLER)
Sit squarely
Open Posture
Lean Forward
Eye Contact
Relax

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4
Q

What’s the rationale of facing the client squarely?

A

Shows involved

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5
Q

What’s the rationale of maintaining an open posture?

A

Makes patient feel engaged and welcome

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6
Q

What’s the rationale of leaning forward?

A

Shows interest in what the client is saying

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7
Q

What’s the rationale of eye contact?

A

Reflects that you are listening

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8
Q

What’s the rationale of staying calm or relax in the process of body language?

A

reflects focus of interviewer

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9
Q

What must be used in phrasing the questions?

A

-Use open ended questions
- Use direct questioning if unable to organize thoughts or is having difficulty with open-ended questions
-Focus on one behavior or symptom
-Use non-judgmental language and a matter of fact tone

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10
Q

Parts of MSE

A

-Identifying the data
- History
- General Description
- Emotion
- Thoughts Process and Content
- Sensorium and Cognition
- Judgment and Insight
- Self- Concept
- Roles and Relationships

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11
Q

The reason for seeking treatment

A

Chief Complaint

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12
Q

Describes the precipitating events that lead to the chief complaint

A

History of Present Illness

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13
Q

Factors that attribute the History of Present Illness

A

-Stressor
- Coping Mechanisms used
- Significant behavioral changes according to SO
- Condition on arrival

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14
Q

Assess for initial onset or relapse

A

Psychiatric History

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15
Q

What history are included in the Psychiatric History?

A

-History of psychosocial distress
- History of psychiatric condition

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16
Q

Reveals any significant previous or current medical condition that contributed to the psychiatric condition

A

Medical History

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17
Q

Medical History examples are

A

-Previous or current medical condition
-Medications (recent/current prescription, OTC herbal medications)
- Drug/Food Allergies
- Dietary restrictions

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18
Q

Checks for any heredo-familial condition and family dynamics

A

Family History

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19
Q

Part in Family History that helps focused on mental illness

A

Genogram

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20
Q

Part in Family History that describes the significant relationships between family members

A

Family Dynamics

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21
Q

In history, it has 5 kind of history

A

-Chief Complaint
- History of Present Illness
- Psychiatric History
- Medical History
- Family History

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22
Q

Appearance is included in the general description, what must be checked in the appearance?

A

-Check the type, condition, and appropriateness of clothing (for age, season, setting)
- Take note of the hygiene
- Observe posture and level of eye contact
- Note any evidence of scars, tattoos, or other distinguishing skin marks

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23
Q

Types of General Description

A

Appearances
Attitude
Motor Activity
Speech Pattern

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24
Q

Factors of attitude in the General Description

A

-Level of Cooperation
- Level of Friendliness
- Apathy
- Suspicious/ Guarded Behavior

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25
Q

Answers questions willingly

A

Cooperative

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26
Q

Refuses to answer questions

A

Uncooperative

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27
Q

Sociable and responsive

A

Friendly

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28
Q

Types of Aggressive

A

-Mild
-Moderate
- Severe
- Extreme

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29
Q

Type of aggressive that presents sarcastic

A

Mild

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30
Q

Types of aggressive that displays displacement

A

Moderate

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31
Q

Types of aggressive that makes threat or physical violence

A

Severe

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32
Q

Types of aggressive that shows physical acts of violence against others

A

Extreme

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33
Q

Refuses to participate in interview process

A

Apathy

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34
Q

-Continuously scan environment
- Questions motives of the interviewer
- Refuses to answer questions

A

Suspicious / Guarded Behavior

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35
Q

Types of Motor Activity in General Description

A

-Automatisms
- Waxy Flexibility
- Echopraxia
- Psychomotor retardation

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36
Q

Repeated purposeless behaviors often indicative of anxiety

A

Automatisms

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37
Q

Maintenance of posture or position over time even when it is awkward or uncomfortable

A

Waxy Flexibility

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38
Q

Involuntary repetition of the movements of another person

A

Echopraxia

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39
Q

Overall slowed movements

A

Psychomotor retardation

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40
Q

Psychomotor retardation defined as an overall slowed movements. What factors that contribute to the overall slowed movements

A

-Movements are very slow
- Thinking and speech are very slow
- Posture is slumped

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41
Q

A form of language impairment, affecting the production or comprehension of speech and the ability to read or write

A

Aphasia

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42
Q

Speed, volume, and tone

A

Speech Pattern

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43
Q

Aphasia means

A

-Difficulty forming words
- Use of incorrect words
- Difficulty thinking of words

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44
Q

Refers to the client’s pervasive and enduring emotional state

A

Mood

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45
Q

Is the outward expression of the client’s emotional state

A

Affect

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46
Q

What are the types of moods?

A

-Euthymic
- Depressed
- Irritable
- Anxious
- Elated
- Euphoric
- Fearful
- Guilty
- Labile

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47
Q

Neutral mood

A

Euthymic

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48
Q

Overwhelming feeling of sadness

A

Depressed

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49
Q

Easily annoyed and provoked to anger

A

Irritable

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50
Q

Demonstrates or verbalizes feelings of apprehension

A

Anxious

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51
Q

Expresses feelings of joy and intense pleasure

A

Elated

52
Q

Grandiose sense of elation

A

Euphoric

53
Q

Demonstrates or verbalizes feelings of apprehension associated with real or perceived danger

A

Fearful

54
Q

Expresses a feeling of discomfort associated with real or perceived wrongdoing.

A

Guilty

55
Q

Exhibits mood swings that range from euphoria to depression with no apparent stimuli

A

Labile

56
Q

What are the types of affect?

A

-Congruent Affect
- Blunted Affect
- Flat Affect
- Inappropriate Affect

57
Q

Outward emotional expression is consistent with mood.

A

Congruent Affect

58
Q

Minimal outward expression is observed.

A

Blunted Affect

59
Q

Absence of outward emotional expression

A

Flat Affect

60
Q

Displays a facial expression that is incongruent with mood or situation.

A

Inappropriate Affect

61
Q

Refers to how a person thinks

A

Thought Process

62
Q

Is what the person thinks and says

A

Thought Content

63
Q

are written reports of verbal interactions with clients.

A

Process Recordings

64
Q

They are verbatim (to the extent that this is possible) accounts, written by the nurse or student as a tool for improving interpersonal communication techniques.

A

Process Recordings

65
Q

What are the alterations in thought process?

A

-Flight of ideas
- Loose Associations
- Word Salad
-Circumstantiality
- Tangentiality
- Neologisms
- Clang Association
- Perseveration
- Verbigeration
- Echolalia
- Latency of Response
- Poverty of speech
- Mutism

66
Q

-Repeated and rapid changing of the subject.
-Verbalizations are continuous and rapid, and flow from one to another.

A

Flight of ideas

67
Q

Sudden shifting from one topic to another without any connection

A

Loose Associations

68
Q

Words in succession without any connection or continuity of thought

A

Word Salad

69
Q

-Detailed and lengthy talking about a subject.
-Verbalizations are lengthy and tedious, has numerous details but eventually gets to the point.

A

Circumstantiality

70
Q

Verbalizations that are lengthy and tedious, never reach an intended point.

A

Tangentiality

71
Q

Making up non-sensical-sounding words which only have meaning to client

A

Neologisms

72
Q

Repetition of words that sound alike or rhyme but are otherwise not connected

A

Clang Association

73
Q

Repetition of word or phrases in response to different questions

A

Perseveration

74
Q

Obsessive repetition of random words without stimulus

A

Verbigeration

75
Q

Parrot-like repetition of another’s words

A

Echolalia

76
Q

Delayed response to a presented stimulus

A

Latency

77
Q

Speaks very little and in monosyllables

A

Poverty of Speech

78
Q

Does not speak at all

A

Mutism

79
Q

A part of alterations in thought content that indicates fixed, false beliefs

A

Delusion

80
Q

A belief that someone is out to get him or her in some way

A

Persecutory

81
Q

An idea that he or she is all- powerful or of great importance

A

Grandiose

82
Q

An idea that whatever is happening in the environment is about him or her

A

Reference

83
Q

A belief that his or her behavior and thoughts are being controlled by external forces.

A

Control

84
Q

A belief that he or she has a dysfunctional body part.

A

Somatic

85
Q

A belief that he or she is dead, decomposed or annihilated, having lost one’s own internal organs or even not existing entirely as a human being.

A

Nihilistic

86
Q

A belief that an individual’s partner is unfaithful.

A

Jealous

87
Q

A belief that one has special religious power

A

Religious

88
Q

A belief that others know about one’s sexual activity and that it causes illness

A

Sexual

89
Q

Stopping abruptly in the middle of a sentence unable to continue the idea

A

Thought blocking

90
Q

Verbalizing about a persistent thought or feeling that he or she is unable to eliminate from consciousness

A

Obsessions

91
Q

Speaking in a way that indicates his or her words or actions have power

A

Magical Thinking

92
Q

Persistent interpretation of the actions of others as threatening or demeaning

A

Paranoia

93
Q

Thoughts about harming self

A

Suicidal Ideation

94
Q

Thoughts about harming others

A

Homicidal Ideation

95
Q

Irrational fears of a specific object or social situation

A

Phobias

96
Q

-Responses contain very minimal information
- Vague responses or stereotypical cliches

A

Poverty of Content

97
Q

Types of Sensory-Perceptual Alterations

A

-Hallucination
- Illusion
- Depersonalization
- Derealization

98
Q

False sensory perceptions or perceptual experiences that do not really exist

A

Hallucination

99
Q

Type of Hallucinations that pertains to hearing voices/sounds that do not exist

A

Auditory

100
Q

Types of hallucinations that pertains to seeing images that do not exist

A

Visual

101
Q

Types of hallucinations that pertains to feeling unrealistic sensations on the skin

A

Tactile

102
Q

Types of hallucinations that pertains to smelling odors that do not exist

A

Olfactory

103
Q

Types of hallucinations that pertains to false perception of unpleasant taste

A

Gustatory

104
Q

Misinterpretation of a renal external stimuli

A

Illusion

105
Q

The individual verbalizes feeling “outside the body”; visualizing him-or herself from afar

A

Depersonalization

106
Q

The individual verbalizes that the environment feels “strange or unreal”. A feeling that the surroundings have changed

A

Derealization

107
Q

Types of Sensorium and Cognition

A

-Orientation
- Memory
- Memory Alterations
- Testing for Confabulation
- Tests for ability to concentrate
- Test for abstract thinking

108
Q

Refers to a person’s recognition of person, place, and time

A

Orientation

109
Q

Time, place, person

A

Disorientation

110
Q

Person, place, time

A

Re-orientation

111
Q

Ability to store and retrieve information when needed

A

Memory

112
Q

Short term memory assessment

A

-Let the patient memorize three random objects
-After about 5 minutes, let the patient recall the names you let him/her memorize.

113
Q

Long-term Assessment

A

-Let the patient recall a significant historical event or any significant general information

114
Q

Memory Alterations factors

A

-Retrograde Amnesia
-Anterograde Amnesia
-Confabulation

115
Q

Inability to remember memories prior to onset of amnesia, but still able to learn new ones

A

Retrograde Amnesia

116
Q

Inability to create new memories, leading to partial or complete inability to recall recent past memories, while long-term memories before onset remain intact

A

Anterograde Amnesia

117
Q

Memory error characterized by production of fabricated, distorted, or misinterpreted memories about self or the world

A

Confabulation

118
Q

-Participants listen to audio recordings of several lists of words centered around a theme, known as the critical word.
-The participants are later asked to recall the words on their list.
-If the participant recalls the critical word, which was never explicitly stated in the list, it is considered a confabulation.

A

Testing for Confabulation
DRM (Deese-Roediger-McDermott) Paradigm

119
Q

What procedure is used to test for ability to concentrate?

A

Serial Sevens

120
Q

Serial Sevens

A

-Begin with the number 100, subtract 7, subtract 7 again, and so on.
-Have the client repeat the days of the week backward.
-Have the patient repeat the months of the year backwards
Perform a three- part task

121
Q

-Is the ability to make associations or interpretations about a situation or comments.
-Interpret a common proverb.

A

Test for Abstract Thinking

122
Q

Refers to the ability to interpret one’s environment and situation correctly and to adapt one’s behavior and decisions accordingly.

A

Judgment and Insight

123
Q

is the ability to understand the true nature of one’s situation and accept some personal responsibility for the situation.

A

Insight

124
Q

Shift the responsibility for something to another object or person.

A

“Passing the buck”

125
Q

Expecting problems to be solved with little or no effort

A

Poor Insight

126
Q

Is the way one views self in terms of personal worth and dignity.

A

Self-Concept

127
Q

Characteristics of Self-Concept

A

-Let the client describe himself or herself and what characteristics he or she likes and what he or she would change.
-Ask for usual coping strategies

Psychiatric Nursing (16 decks)

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