NURS 2872 - Mental Status Exam

What is a mental status exam and why is it important?

It’s the psychiatric equivalent of a head-to-toe assessment, giving a snapshot of how the patient is doing psychiatrically at the time.

What do you assess in general appearance?

Overall look of the patient: age-appropriate appearance, hygiene, clothing, cleanliness, and grooming.

What is included in the behavior section?

General behavior (cooperative, calm, eye contact) and psychomotor (movements, gait, tremors, restlessness).

What should you do if nothing abnormal is noted in behavior?

Document something like “No abnormal movements noted”; never leave it blank.

What is assessed in speech and communication?

Pace, volume, clarity, and amount of speech; communication ability, e.g., pressured, mute, hyperverbal, aphasia.

What is affect?

The clinician’s objective observation of the patient’s emotional expression.

What is a flat affect?

No emotional expression—no smiling, frowning, or crying.

What is a labile affect?

Rapid and extreme changes in emotion—e.g., laughing, crying, angry in quick succession.

What is mood?

The patient’s subjective statement of how they feel, always placed in quotes.

What is thought content and processes?

Flow and clarity of thought, including coherence, tangentiality, circumstantiality, and loose associations.

What is tangential thinking?

Patient goes off-topic and never returns to the original point.

What is circumstantial thinking?

Patient gives excessive detail but eventually answers the question.

What is loose associations?

Thoughts jump from one idea to another with little logical connection.

What is assessed in orientation and LOC (level of consciousness)?

If the patient is alert and oriented to person, place, date, and situation (oriented x4).

What does disorientation to circumstances look like?

Patient may know who they are and where they are, but misunderstand why they are hospitalized.

What is assessed in cognitive function and calculations?

Patient’s concentration and focus, often judged by observation or simple tasks.

Why might you avoid using math problems to test cognition?

Math ability may reflect education level rather than cognitive impairment.

What is thought perception?

Includes delusions, hallucinations, and obsessions—assessing for any sensory disturbances or false beliefs.

What is a delusion?

A fixed, false belief not based in reality.

What is a hallucination?

A sensory perception (seeing, hearing, smelling, tasting, touching) without external stimulus.

What is the most common type of hallucination in psychiatric illness?

Auditory hallucinations (hearing voices).

What type of hallucinations suggest a possible organic brain issue?

Olfactory (smelling), gustatory (tasting), or tactile (touch).

What is an obsession?

Repetitive, unwanted thoughts that cause anxiety (e.g., OCD).

How do you assess for delusions?

Ask if they feel watched, poisoned, have special powers, or mind-reading abilities.

How do you assess for hallucinations?

Ask if they see or hear things others can’t.

What is assessed under memory?

Recent and remote memory—check for ability to recall recent events vs. long-term memories.

What memory pattern is typical of dementia?

Poor recent memory but intact remote memory.

What is insight?

Whether the patient understands their mental illness and diagnosis.

What is a good screening question for insight?

"Can you tell me what the doctors diagnosed you with?" and "What does that mean to you?"

What is anosognosia?

Lack of insight into one's own mental illness.

What is judgment?

The ability to make decisions in one’s best interest.

What is an example of intact insight but poor judgment?

A heroin addict who knows they are addicted but has no intention of stopping.

What is the most important part of the mental status exam?

The risk assessment.

What is passive suicidal ideation?

Wishing to be dead or not wake up, but no plan or intent to act.

What is active suicidal ideation?

Having intent and/or a specific plan to end one's life.

What should you ask when a patient has passive suicidal thoughts?

"What’s keeping you from committing suicide?"

What are protective factors against suicide?

Fear of hell, family responsibility, pets, religious beliefs.

What is homicidal ideation?

Thoughts or plans to harm or kill someone else.

What must you do if a patient has specific homicidal intent?

Attempt to obtain victim info, warn them and notify police—duty to warn overrides HIPAA.

Why do some patients avoid disclosing homicidal thoughts?

They know it could lead to consequences or hospitalization.

What is a common mistake new nurses make in risk assessments?

Not acting on suicidal or homicidal statements made by the patient.

What is non-suicidal self-injury (NSSI)?

Self-harm behaviors like cutting or burning that are not intended to cause death.

How do you assess NSSI?

Ask how often, where, and when the patient last self-harmed, and check the site if recent.

Why ask about firearm access in risk assessment?

Easy access to firearms is a major risk factor for suicide.

What should you do if a suicidal patient has access to a firearm?

Ask if they’re willing to have family/friends remove it before discharge.

Why is firearm access so dangerous in mental health crises?

Firearms are highly lethal and impulsive actions with a gun are harder to reverse than other methods.