TOPIC 5: NURSING PROCESS AND MENTAL STATUS EXAMINATION (MSE)

Question 1

ENUMERATE:

What are the NURSING PROCESS in psychiatric nursing?

Answer 1

• Assessment
• Nursing Diagnosis
• Outcome Identification
• Planning
• Implementation
• Evaluation

Question 2

IDENTIFY:

It is the psychologicalequivalent of a physicalexamthat describes thementalstate and behaviors of the person being seen.

Answer 2

Mental Status Exam(MSE)

Question 3

IDENTIFY:

A psychological exam which includes both objective observations of the clinician and subjective descriptions given by the patient.

Answer 3

Mental Status Exam(MSE)

Question 4

MENTAL STATUS EXAMINATION

Focuses on the client’s cognitive abilities:

(GIVE AT LEAST THREE)

Answer 4

• Orientation to person, time, place, date, season, day of the week
• Ability to interpret proverbs
• Ability to perform math calculations
• Memorization and short-term recall
• Naming common objects in the environment
• Ability to follow multistep commands
• Ability to write or copy a simple drawing

Question 5

MENTAL STATUS EXAMINATION

What are the PURPOSES of Psychosocial Assessment (MSE)?

(ENUMERATE)

Answer 5

• To construct picture of client’s current emotional state, mental capacity, and behavioral function
• To form basis for plan of care
• To establish clinical baseline to evaluate effectiveness of treatment and interventions

Question 6

MENTAL STATUS EXAMINATION

What are the FACTORS influencing assessment?

(GIVE AT LEAST THREE)

Answer 6

• Client participation/feedback
• Client’s health status
• Client’s previous experiences/ misconceptions about health care
• Client’s ability to understand
• Nurse’s attitude and approach

Question 7

MENTAL STATUS EXAMINATION

How to CONDUCT the MSE?

Answer 7

• Provide a comfortable, private, safe environment Obtain input from family and friends (with client’s permission)
• Ask questions that are open-ended or closed-ended as needed

OPEN-ENDED QUESTIONS = can ellicit more information
**CLOSED-ENDED QUESTIONS **= answerable by “yes” or “no” only

Question 8

MENTAL STATUS EXAMINATION

CONTENT of the Assessment

(REVIEW ONLY)

Answer 8

• History
• General appearance and motor behavior
• Mood and affect
• Thought process and content
• Sensorium and intellectual processes
• Sensory-perceptual alterations
• Judgment and insight
• Self-concept
• Roles and relationships
• Physiologic and self-care concerns

Thought process and content
* Assessment of suicide or harm toward others; if the client is having suicidal ideas, then assessment of lethality should follow

Sensorium and intellectual processes
* Orientation, memory, concentration, ability to think abstractly