WEEK 9- MENTAL HEALTH ASSESSMENT Flashcards
NEUROLOGCAL, MENTAL STATUS
Outline the considerations of relational practice during a mental status examination.
Relational practice is inquiry-based practice and core to nursing.
From a relational perspective, the nurse–patient relationship is
influenced by personal, socioeconomic, and political factors in the
lives of the nurse and the patient.
Relational practice is respectful, nonjudgemental, and reflexive
engagement.
Identify components of a mental health history.
history
- biographical info
- reason for seeking care
- past health, injuries, illness, hospitalization
- family health history
- current health, allergies, meds, vaccines
Discuss screening recommendations for depression & assess using recommended tools.
Depression
Two simple questions
“Over the past 2 weeks, have you felt down, depressed or hopeless?”
“Over the past 2 weeks, have you felt little interest or pleasure doing things?”
Identify the components of a mental status examination, expected findings & abnormal findings & potential causes.
appearance
behavior
cognition
thinking
Outline developmental considerations of a mental health assessment- children
concept of language as a social tool of communication (3-5)
abstract thinking (12-15)
suicide 2nd leading cause of death
70% mental health issues come from childhood
Distinguish onset, duration & nursing implications of Delirium
delirium: disturbance in attention and awareness - disturbance in cognition
Sudden; hours to days
Acute; temporary; reversible10-30% older adults
Presence of an underlying medical disorder (UTI, hypoxia
Describe the Montreal Cognitive Assessment tool
To assess cognitive function
attention/executive functioning, visuospatial, and language
30 items
Takes 10 minutes
Score of 27.4/30- no cognitive decline
22.1/30 Mild Cognitive Decline (MCL)
16.2/30 Severe – Alzheimer’s
Describe the suicide risk assessment.
-warning signs:
- plan
- self arm
- prior attempts
- sleep issues
- social withdrawal
- death themes
ask questions
“do u feel like hurting yourself?”
Identify the reason for using the mini-mental state exam & the components of assessment.
The Mini-Mental State Examination (MMSE)
can be used instead of the full mental status examination when
time is limited.
It is commonly used to assess a patient’s
cognitive status when there is a concern of cognitive impairment.
In the 2nd week of being in the hospital the nurse assess the client’s orientation. The nurse asks the client their name, where they are and the time of year – The client responds that he is Mr. X and he is on a cruise ship and it is winter. The nurse would document:
Client is oriented to person and time
The nurse knows that a client with depression may display the following behaviours ( Select all that Apply)
- social withdrawal
- lack of appetite
- feeling tired
As part of the process of assessing a client with dementia the nurse recognizes these known factors:
dementia is progressive
- cognitive impairment
-
The nurse knows that new learning is an assessment of new memories. This is assessed by asking the client to:
listen to 3 words, repeat them over a period of time. for example, 10 min, 20min, 30min
Mental status assessment includes assessing behaviour of the client. When a client states that they are very sad but start laughing out loud after a few minutes. The nurse can:
incongruences with mood and affect.
A client is preparing for discharge from the hospital after being newly diagnosed with tremors and seizures. The client explains to the nurse that he is going to continue with his mountain climbing hobby. What might the nurse question with this kind of information provided?
bad judgment
