388: Week 4 - Mental Status Exam

Question 1

When should mental status health exams be initiated?

Answer 1

Whenever you are in a psych/mental health setting or working with mental health ptsWha

Question 2

What 5 domains should be assessed during a mental status health exam?

Answer 2

1. General appearance
2. Emotional state
3. Thought processes
4. Thought content
5. Sensorium and cognition

Question 3

When assessing an ind “General Appearance” what should the RN take note of?

Answer 3

• Appearance (facial expression, clothing, grooming, cleanliness)
• Overt behavior and psychomotor activity (psychomotor retardation, stupor, excitement, pacing)
• Physiological signs (pallor, flush, tears)
• Attitude toward the interviewer (suspicious, guarded)
• Impulse control (ability to resist the impulse to do something that is harmful to self or others)
• Reliability as an interviewee (is the pt confused, uncooperative, deaf, stuporous [catatonic stupor], language or speech challenges)

Question 4

When assessing an ind “Emotional State” what should the RN take note of?

Answer 4

• Affect (pts present emotional responsiveness, inferred from the pt facial expression, including the amount and range of emotional expressive behavior -> sad, angry, constricted, flat, blunted, labile, overly reactive)
• Mood (pervasive and sustained emotion that colors the person’s perception of the world -> depressed, irritable, anxious, angry, expansive, euphoric)

Question 5

When assessing an ind “Thought Process” what should the RN take note of?

Answer 5

• Speech characteristics and rate of flow -> quantity of speech (talkative, spontaneous), quality of speech (emotional, whispered, monotone, mumbled, slurred), Rate of flow (fast, slow, hesitant, pressured, stacatto)
• Associations -> disconnecting thoughts?
• Abstractions and abstract reasoning -> is loss of this process present?
• Perceptual disorders -> Hallucinations, illusions, depersonalization, de-realization, heightened/dulled/distorted perceptions
• Delusions -> fixed false belief that you cannot talk pt out of (paranoia, delusions of grandeur, nihilistic
• Recurrent themes, preoccupations, obsessions, compulsions (themes of death, suicidal thinking)

Question 6

What are Hallucinations?

Answer 6

• false sensory perceptions
• auditory -> hearing voices that are not there
• visual -> seeing things that are not there

Question 7

What are Illusions?

Answer 7

-False interpretations of sensory information

Question 8

What are heightened, fulled or distorted perceptions?

Answer 8

-seeing things that are distorted, sensory information is heightened or vice versa

Question 9

What are Delusions? What are the 3 types?

Answer 9

• Fixed false belief that you cannot talk an ind out of
  1. Paranoia
  2. Delusions of grandeur (thinking that one is Jesus or the pope)
  3. Nihilistic (thinking that you are going to die on a certain date, or that the world will end on a certain date)

Question 10

When assessing an ind “Sensorium and Cognition” what should the RN take note of?

Answer 10

• orientation (person, place and time)
• Concentration
• Memory (recent/short-term, remote/long-term, registration, retention and recall)
• Intelligence
• Reading and writing
• Abstract (clock drawing)
• Judgment
• Insight (ability to understand ones own circumstances and their realities)