W3 Mental Health Assessment & Care Planning Flashcards
1
Q
What is the role of assessment in mental health nursing?
A
Assessment evaluates the person’s needs and plans their treatment.
2
Q
What are the three types of assessments typically undertaken for mental illness?
A
- Comprehensive holistic assessment
- Mental State Examination (MSE)
- Risk assessment
3
Q
What is a comprehensive holistic assessment?
A
It provides an overall assessment of the person in various contexts: family, social, biological, physical, and spiritual.
4
Q
What domains are included in a comprehensive holistic assessment?
A
- Reason for referral
- Current living situation
- Presenting problem(s)
- History of presenting problem
- Family history
- Personal history
- Children or parenting issues
- Forensic history
- Previous/current illness
- Personality
- Safety and risk issues
- Substance use or misuse issues
5
Q
What does a Mental State Examination (MSE) assess?
A
It assesses an individual’s mental and emotional functioning through systematic observation.
6
Q
What is the primary goal of a risk assessment?
A
To enhance the safety and well-being of the individual and those around them.
7
Q
What are the five steps of the Nursing Process?
A
- Assessment
- Diagnosis
- Planning
- Intervention
- Evaluation
8
Q
What are core principles underpinning assessment in mental health?
A
- Trauma-informed care
- Strength-based approach
- Recovery-oriented care
- Shared decision-making
- Involving family
9
Q
What methods are used for assessment in mental health settings?
A
- Clinical Interview
- Observation
- Questionnaires and Rating Scales
10
Q
What should be done before assessing a patient?
A
- Normalize the process
- Explain the process clearly
- Seek permission to ask questions
- Engage the person
- Conditional confidentiality
11
Q
What are some communication techniques to optimize the assessment process?
A
- Open-ended vs Closed questions
- Choice of questions
- Active listening
- Reflecting
- Summarising
12
Q
What areas are covered in the initial comprehensive holistic assessment?
A
- Personal information
- Social history
- Family history
- Education
- Physical health
- Lifestyle factors
- Risk assessments
- Strengths and protective factors
- Views of the person on their current situation
13
Q
True or False: The Mental State Examination is used only at the initial assessment.
A
False
14
Q
What is the definition of ‘mood’ in the context of the Mental State Examination?
A
Mood is the pervasive and sustained emotion subjectively experienced and reported by the patient.
15
Q
What is the difference between mood and affect?
A
Mood is the internal emotional state; affect is the external expression of that emotion.
16
Q
What are some types of delusions identified in thought content assessment?
A
- Bizarre
- Grandiose
- Persecutory
- Reference
- Thought withdrawal
- Thought insertion
- Thought broadcasting
- Somatic
17
Q
What are hallucinations?
A
False sensory perceptions not associated with external stimuli.
18
Q
Fill in the blank: The Nursing Process consists of five steps: Assessment, Diagnosis, Planning, Intervention, and _______.
A
Evaluation
19
Q
What is the significance of recording a patient’s mood verbatim during the MSE?
A
To accurately capture the patient’s self-reported emotional state.
20
Q
What should be observed regarding a patient’s behavior during the MSE?
A
- Reactions to meeting the clinician
- Eye contact
- Movement patterns
- Emotional expressions
21
Q
What is ‘thought blocking’ in the context of thought form assessment?
A
An interruption in the train of speech before the thought is completed.
22
Q
What is the importance of the initial mental health assessment upon admission?
A
It enables the treating team to understand the person and work with them therapeutically.
23
Q
What are suicidal and homicidal thoughts part of?
A
Thought content.
24
Q
What does perception relate to?
A
Feeling and the five senses.
25
Name the types of hallucinations.
* Auditory
* Visual
* Tactile
* Gustatory
* Olfactory
26
What is cognition?
The mental processes of knowing and becoming aware.
27
What is the purpose of the Mini Mental State Examination?
To assess several elements of cognition.
28
List the elements evaluated in cognition.
* Memory
* Orientation
* Concentration
* Language
29
What is insight?
The awareness of one's own mental condition.
30
How is insight evaluated?
Based on subtle direct questions and overall impression from assessment.
31
What is judgement?
The ability to make sound decisions.
32
What type of questions may assess judgement?
Questions about general problem-solving.
33
What components are included in a comprehensive assessment?
* Mental state examination
* Risk assessment
34
What should a comprehensive assessment aim to communicate?
The person's mental health issues.
35
What is the purpose of assessing the presenting problem?
To understand the current issue and clarify expectations.
36
What factors may increase a person's level of risk?
* Vulnerability
* Self-harm/suicide
* Mental instability
* Risk to others
37
What are the categories of risks assessed in mental health?
* Vulnerability
* Self-harm/suicide
* Mental instability
* Risk to others
38
What is risk in the context of mental health?
The likelihood of an event happening with potentially harmful or beneficial outcomes.
39
What are static risk factors?
Historical factors that are not subject to change.
40
What are dynamic risk factors?
Factors subject to change over time.
41
What is the preferred method for understanding risk?
Structured clinical judgment.
42
What are early warning signs of increased risk?
* Sleep disturbance
* Anxiety
43
What is a Mental State Examination (MSE)?
A snapshot of a person’s current mental state at a single point in time.
44
What components are included in the MSE?
* General Appearance
* Behaviour
* Speech
* Mood and Affect
* Perception
* Thought Content
* Thought Process/Form
* Cognition
* Insight
* Judgement
45
What acronym can help remember the MSE components?
P A M S G O T J I M I
46
What barriers can affect conducting an MSE?
* Lack of rapport
* Physical environment
* Age and health literacy
* Cultural and language barriers
* Stigma
* Cognitive impairment
* Influence of mood-altering substances
47
What are static risk factors?
Static Risk Factors: Characteristics that do not change (e.g., gender, personal history, medical and mental health history, offending history, family history).
48
What are dynamic risk factors?
Dynamic Risk Factors: Subject to change (e.g., age, substance use, clinical acuity/stability, psychosocial stressors).
49
What are protective factors?
Protective Factors: May reduce the impact of a problem or mitigate negative outcomes (e.g., personal strengths, skills, support systems).
50
List some early warning signs that may precede an increase in risk.
* Sleep disturbance
* Anxiety
* Feelings of being targeted or picked on
* Withdrawal
* Drug use
* Pacing
51
What risks can a person pose to themselves?
* Self-harm (non-suicidal self-injury)
* Suicide
* Self-neglect
* Reputation damage
* Medication non-adherence
* Physical health issues
* Legal issues related to offending
52
What risks can a person pose to others?
* Interpersonal violence
* Sexual assault/abuse
* Harassment
* Property damage
* Stalking
53
What are examples of risks from others?
* Assault
* Sexual exploitation/abuse
* Financial exploitation/abuse
* Verbal abuse
54
What is iatrogenic risk?
Iatrogenic Risks: Risks associated with mental health care (e.g., diagnosis/labelling, stigma, medication side effects, trauma from restraint/seclusion).
55
What is a key strategy in managing risk of self-harm and suicide?
Engage the treating team.
56
True or False: It is important to take any threats of suicide seriously.
True
57
What are some verbal de-escalation techniques?
* Use a calm voice
* Speak slowly and clearly
* Actively listen and paraphrase concerns
* Set clear behavioral limits
* Identify the person’s needs and concerns
58
What is seclusion in mental health care?
Seclusion: ‘The sole confinement of a person to a room or enclosed space where they cannot leave.’
59
What is bodily restraint?
Bodily Restraint: ‘A form of physical or mechanical restraint that prevents a person from moving freely.’
60
What is the leading cause of death for young people aged 15-49 in Australia?
Suicide.
61
What are some modifiable risk factors for suicide?
* Substance use
* Lifestyle choices
62
What are some non-modifiable risk factors for suicide?
* History of self-harm or suicide
* Family disruptions due to separation or divorce
* Disability
* Education level
* Employment
63
What does the DSM-5-TR stand for?
Diagnostic and Statistical Manual 5-TR.
64
What is a care plan in mental health nursing?
A structured and individualized document that outlines specific goals, interventions, and strategies for care and support.
65
List key components that should be included in a care plan.
* Unique aspects of the person (including strengths)
* The person’s goals
* Collaborative planning
* Evidence-based interventions
* Strategies for crisis prevention and management
* Legal considerations
* Date of next review
66
What is the purpose of safety planning?
To contain or ameliorate the risk indicated by a risk assessment.
67
Fill in the blank: The number one aim of safety planning is to keep the person _______.
safe
68
What is the Safewards model?
An evidence-based model to reduce conflict and containment within mental health services.
69
What are some strategies used in sensory modulation rooms?
* Engaging the client individually
* Utilizing therapeutic communication skills
* Using equipment to calm and distract the client
70
What is the significance of understanding a client's early warning signs?
It allows the mental health nurse to implement early interventions and strengthen the therapeutic relationship.
71
What is a 'Code Grey' in a clinical setting?
A hospital-wide coordinated clinical and security response to actual or potential aggression or violence.
72
What should students not do during a 'Code Grey'?
Students are NOT expected to restrain the client.
73
What medications are commonly used in chemical restraint of clients?
* Diazepam
* Olanzapine
* Risperidone
74
What is the importance of monitoring and documenting after medication administration?
It is essential to monitor vital signs and the medication's effect, especially post administration.
75
Fill in the blank: It is vital to use the _______ methods of administration where possible.
[least restrictive]
76
What should be done if PRN medications are not documented?
The mental health nurse will need to obtain a phone order for the client for administration.
77
What is Neuroleptic Malignant Syndrome (NMS)?
A serious side effect associated with some antipsychotic medications.
78
True or False: Debriefing for clients and students occurs post-incident.
True
79
What does the Mental Health and Wellbeing Act, 2022 (Victoria) require?
To work with people in the least restrictive environment.
80
What should be incorporated when minimizing distress in interventions?
The person's care preferences.
81
What can be observed in a client toward the early evening?
Increased confusion.
82
What is the purpose of debriefing after a 'Code Grey' incident?
To understand the clinical urgency of the situation.
83
List three established strategies to assist a person in distress.
* Redirecting the person
* Preventing increased distress or aggression
* Utilizing personal strategies for agitation/stress
84
What is the recommended order of medication administration?
Begin with tablets and syrup, then move to intramuscular injection if required.
85
What should be the focus when working with mental health clients?
Utilising a continuum of interventions to achieve desired outcomes.
86
Fill in the blank: Close attention to monitoring and documentation of _______ is essential post administration.
[vital signs]
87
What can occur if a client has not had the medication before?
Adverse events and respiratory depression.
88
What is the significance of using least restrictive interventions?
To minimize any associated distress.
89
What role do preceptors or buddy nurses play during a 'Code Grey'?
They may direct students to hold open doors or stay with co-clients.
90
What does the continuum of interventions aim to achieve?
Desired outcomes while minimizing distress.
91
What should be done to minimize the type and range of medications administered?
Best practice to reduce side effects.
92
What is essential to document alongside medication administration?
Client's vital signs and co-morbidities.
93
What are the three main types of assessments used in mental health nursing?
Comprehensive holistic assessment, Mental state examination (MSE), and Risk assessment.
94
What is the purpose of a comprehensive holistic assessment?
To understand the person within their family, social, biological, physical, and spiritual contexts.
95
List three areas covered in a comprehensive holistic assessment.
Presenting problem, family history, substance use.
96
What is the purpose of the Mental State Examination (MSE)?
To provide a structured assessment of a person's mental and emotional functioning.
97
What does a risk assessment aim to do?
Identify and evaluate potential risks the individual may pose to themselves or others.
98
Which of the following is NOT a component of the MSE?
A) Judgement
B) Mood and Affect
C) Respiratory rate
D) Thought content
C) Respiratory rate
99
Which approach is NOT a core principle underpinning assessment?
A) Recovery-oriented care
B) Shared decision-making
C) Punitive care
D) Trauma-informed care
C) Punitive care
100
Which of these is a form of formal thought disorder?
A) Tangentiality
B) Empathy
C) Hallucination
D) Flat affect
A) Tangentiality
101
True or False: The MSE provides a 'snapshot' of a person’s current mental state at a single point in time.
True
102
True or False: Insight and judgement are interchangeable terms in the MSE.
False
103
True or False: Asking about hallucinations is part of the perception component in the MSE.
True
104
Fill in the blank: __________ is the awareness of one's own mental condition.
Insight
105
Fill in the blank: __________ are false beliefs sustained despite evidence to the contrary.
Delusions
106
Fill in the blank: The assessment method that involves structured observation of behavior, thoughts, and feelings is called the __________.
Mental State Examination (MSE)
107
A patient reports feeling watched and believes the newsreader is sending them messages. What type of delusion might this indicate?
Delusion of reference
108
During an MSE, you observe that a person changes emotional expression rapidly and inappropriately to context. What type of affect is this?
Labile affect
109
If a person is unable to recall recent events or orient themselves to place and time, which domain of the MSE is affected?
Cognition
110
A patient presents well-dressed and groomed, but reports hearing voices commenting on their actions. What two MSE domains are involved?
General appearance and perception
111
You ask a person, 'What would you do if you found a stamped, addressed envelope on the ground?' Which MSE domain are you assessing?
Judgement
112
What are the four categories of risk typically assessed in mental health?
Vulnerability, Self-harm/Suicide, Mental instability, Risk to others
113
What is iatrogenic risk in mental health care?
Risks posed by mental health services themselves, such as stigma, trauma from coercive treatments, and medication side effects.
114
What are static risk factors?
Historical factors that do not change, such as gender, personal history, and family history.
115
What are dynamic risk factors?
Factors that can change over time, such as substance use, age, and psychosocial stressors.
116
What are protective factors?
Elements that may reduce the impact of a problem or mitigate negative outcomes, such as support systems or personal strengths.
117
Which of the following is a dynamic risk factor?
A) Age
B) Gender
C) Family history
D) Previous suicide attempt
A) Age
118
Which is considered a protective factor?
A) Substance use
B) Social isolation
C) Strong family support
D) History of violence
C) Strong family support
119
Which type of risk is associated with medication side effects and coercive treatment?
A) Risk to others
B) Self-harm risk
C) Iatrogenic risk
D) Aggression risk
C) Iatrogenic risk
120
True or False: Risk factors always mean a person will attempt suicide.
False
121
True or False: The presence of protective factors eliminates the need for a risk assessment.
False
122
True or False: Aggression in mental health clients is often a result of multiple personal and environmental factors.
True
123
Fill in the blank: The most commonly used diagnostic manual in Australia is the __________.
DSM-5-TR
124
Fill in the blank: A __________ risk factor is one that does not change, such as family history.
Static
125
Fill in the blank: __________ planning involves identifying triggers and coping strategies collaboratively with the person.
Safety
126
A client presents with a history of depression, recent job loss, and increasing social isolation. What type of risk factors are present?
Dynamic risk factors
127
A nurse is completing a safety plan. What should be included?
Warning signs, coping strategies, reasons to live, crisis contacts, and restriction of lethal means.
128
A person with schizophrenia reports hearing voices telling them to hurt someone. What type of risk is this?
Mental instability and risk to others
129
You are assessing a client who has poor insight, is homeless, and has limited support. What risk category are they most likely to fall under?
Vulnerability
130
A nurse observes a client pacing, withdrawing, and not sleeping well. What might these be considered?
Early warning signs of increasing risk
