Unit 5 - Mental Status Assessment Flashcards
Mental Health
A balance in emotional and cognitive abilities that allow a person to manage life’s stressors
Mental status
a component of mental health that includes emotional and cognitive functioning
Mental illness:
Any disorder that affects the mind
Dx based on DSM-V criteria
Mental Health Assessment
Reflects your observations and impressions, is an evaluation of the individual’s current state.
4 Components of Mental Status Examination
A. Appearance
B. Behaviour
C. Cognition
T. Thought processes
Indications for a Full Mental Status Exam
Affect or behaviour changes
Brain lesions
Aphasia
Symptoms of mental illness
Health history can reveal
Other illnesses
Medications /w side effects
Educational and behavioural level
Personal history
2 components of mental status exam
1. Emotional Appearance Behaviour 2. Cognitive Cognitive functions Thought processes
Appearance - assess:
Posture
Body movements
Dress
Grooming and hygiene
Behavioural - Assess:
Level of consciousness
Facial expression
Speech
Mood and affect
Mood
a sustained and durable emotion that can noticeably affect the person’s worldview
Ex: Season
Affect
the capacity of an individual to vary emotional expression
Ex: Cold day
Cognition
The mental process of how we acquire knowledge
Cognitive functions – assess:
Orientation Attention span Recent memory Remote memory New learning Further assess: Aspasia judgement
Thought processes – assess:
Thought process
Thought content
Perceptions
Risk Assessment
Suicidal thoughts
Assaultive/homicidal ideation
Elopement risk
To assess affect, the nurse should ask the patient:
A. “How do you feel today?”
B. “Would you please repeat the following words?”
C. “How did you arrive at the hospital?”
D. “Has this pain affected your ability to dress yourself?”
A. “How do you feel today?”
Obtunded
b/t lethargy & stupor
Elation
Joy, optimism, over confidence
Euphoria
Excessive well-being
Ambivalence
opposing emotions toward person, object, idea
Lability
Rapid shift of emotions
Inappropriate affect
Affect discordant with content of pt’s speech
A full mental status examination should be completed if the patient:
A. has a change in behaviour and the family is concerned.
B. develops dysphagia.
C. is newly diagnosed with type 2 diabetes mellitus.
D. complains of insomnia.
A. has a change in behaviour and the family is concerned.
Aphasia is best described as:
A. a language disturbance in speaking, writing, or understanding.
B. the impaired ability to carry out motor activities despite intact motor function.
C. the impaired ability to recognize or identify objects despite intact sensory function.
D. a disturbance in executive functioning (planning, organizing, sequencing, abstracting).
A. a language disturbance in speaking, writing, or understanding.
A patient who was recently diagnosed with a seizure disorder plans to continue a career as a pilot. At this time in the interview, the nurse begins to question the patient’s: A. thought process. B. judgement. C. perception. D. intellect.
B. judgement.
A major characteristic of dementia is:
A. impaired short-term and long-term memory.
B. hallucinations.
C. sudden onset of symptoms.
D. cognitive deficits that are substance-induced.
A. impaired short-term and long-term memory.
Mental status assessment documents:
A. emotional and cognitive functioning.
B. intelligence and educational level.
C. artistic or writing ability in the mentally ill person.
D. schizophrenia and other mental health disorders.
A. emotional and cognitive functioning.
Although a full mental status examination may not be required for every patient, the health care provider must address the four main components during a health history and physical examination. The four components are:
A. memory, attention, thought content, and perceptions.
B. language, orientation, attention, and abstract reasoning.
C. appearance, behaviour, cognition, and thought processes.
D. mood, affect, consciousness, and orientation.
C. appearance, behaviour, cognition, and thought processes.
An older adult:
A. experiences a 10-point decrease in intelligence.
B. has diminished recent and remote memory recall.
C. has a slower response time.
D. has difficulty with problem solving.
C. has a slower response time.
Which of the following would cause the nurse to consider screening a patient for suicidal thoughts?
A. The patient does not have off-unit privileges and is restricted to the unit.
B. The patient reveals that he or she has detailed plans to harm another individual.
C. The patient demonstrates grief and despair during the interview.
D. The patient cannot identify the season and is unable to name his or her family members.
C. The patient demonstrates grief and despair during the interview.
Which of the following best illustrates an abnormality of thought process? A. Lability B. Blocking C. Compulsion D. Aphasia
B. Blocking
The mental status examination:
A. should be completed at the end of the physical examination.
B. will not be affected if the patient has a language impairment.
C. is usually not assessed in children younger than 2 years of age.
D. assesses mental health strengths and coping skills, and screens for any dysfunction.
D. assesses mental health strengths and coping skills, and screens for any dysfunction.
