Chapter 1: Basic Mental Health Nursing Concepts

A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following actions should the nurse identify as the priority?

a

Coordinate holistic care with social services.

b

Identify the client’s perception of their mental health status.

c

Include the client’s family in the interview.

d

Teach the client about their current mental health disorder.

b Identify the client’s perception of their mental health status.

The first action the nurse should take when using the nursing process is assessment, identifying the client’s perception of their mental health status provides important information about the client’s psychosocial history.

A charge nurse is discussing mental status examinations with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Select all that apply.

a

“To assess cognitive ability, I should ask the client to count backward by sevens.”

b

“To assess affect, I should observe the client’s facial expression.”

c

“To assess language ability, I should instruct the client to write a sentence.”

d

“To assess remote memory, I should have the client repeat a list of objects.”

e

“To assess the client’s abstract thinking, I should ask the client to identify our most recent presidents.”

a “To assess cognitive ability, I should ask the client to count backward by sevens.”

b “To assess affect, I should observe the client’s facial expression.”

c “To assess language ability, I should instruct the client to write a sentence.”

A nurse is planning care for a client who has a mental health disorder. Which of the following actions should the nurse include as a psychobiological intervention?

a

Assist the client with systematic desensitization therapy.

b

Teach the client appropriate coping mechanisms.

c

Assess the client for comorbid health conditions.

d

Monitor the client for adverse effects of medications.

d Monitor the client for adverse effects of medications.

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Assisting with systematic desensitization therapy is a cognitive and behavioral, teaching appropriate coping mechanisms is a counseling or health teaching, assessing for comorbid health conditions is health promotion and maintenance, rather than a psychobiological intervention.

Basic Mental Health Nursing Concepts

Standards of Care

• Based on guidelines from:

  • American Nurses Association (ANA)

  • American Psychiatric Nurses Association (APNA)

  • International Society of Psychiatric-Mental Health Nurses

Nursing Process & Holistic Approach

• Use the nursing process in all mental health settings

• Provide holistic care, addressing:

  • Biological needs (e.g., physical health, medications)

  • Social factors (e.g., support systems)

  • Psychological needs (e.g., coping mechanisms, mood)

  • Spiritual needs (e.g., meaning, beliefs)

Client Assessment Methods

• Observation (e.g., behavior, appearance)

• Interviewing (collect subjective data)

• Physical examination

• Collaboration with the healthcare team and client

General Assessment Guidelines

Perform physical assessment based on client condition or facility policy

• Use touch appropriately to show care, but always respect personal space

Ask about:

• Sleep difficulties, incontinence, falls/injuries, depression, dizziness, energy levels

Include family/significant others as appropriate

Get a complete medical history

After interviewing, summarize and ask for client feedback

Assessment is ongoing with every client interaction

Psychosocial History (General Assessment)

Client’s perception of their health, beliefs about illness/wellness

• Use therapeutic communication like OPEN-ended questions

Activity and leisure habits

Substance use history (including any use disorders)

Stress levels and coping:

• Usual coping methods

• Support systems

Cultural Beliefs and Practices

Understand the client’s culture and integrate it into the plan of care

Consider culture-related factors that affect care

Ask:

• Are there cultural dietary habits or health beliefs?

• How does the client’s culture view their diagnosis?

Key Points:

• Cultural awareness helps avoid stereotyping and stigmatizing

• Use interpreters when needed

Spiritual and Religious Beliefs

Affects how clients find meaning, hope, purpose, peace

Definitions:

• Spirituality: Internal values, moral beliefs, view on life purpose (not always tied to religion)

• Religion: Formal system of worship, faith, and rituals

Nursing Actions:

• Assess beliefs and support systems

• Help clients find spiritual/religious resources if requested

Spirituality vs Religion

Internal values, moral beliefs, view on life purpose

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Formal system of worship, faith, and rituals

Can include view on life purpose

Mental Status Examination (MSE)

Level of Consciousness

• Alert: Opens eyes, responds to normal voice, answers appropriately

• Lethargic: Drowsy but can respond; easily falls asleep

• Stuporous: Responds only to painful stimuli (e.g., sternal rub); limited or no verbal response

• Comatose: Unresponsive to all stimuli

  • Abnormal posturing in comatose clients:

    • Decorticate rigidity: Flexed arms/legs; internal rotation

    • Decerebrate rigidity: Extended arms/legs; wrist/finger flexion

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Physical Appearance

• Hygiene & grooming

• Nutrition

• Clothing choice (appropriateness for weather/situation)

• Age appearance vs. actual age

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Behavior

• Assess voluntary & involuntary movements

• Observe eye contact

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Mood vs. Affect

• Mood: Client's subjective emotional state (e.g., sad, happy)

• Affect: Observable expression of mood (e.g., flat affect = no emotion)

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Cognitive and Intellectual Abilities

• Orientation: Time, person, place

• Memory:

  • Immediate: Repeat numbers or words

  • Recent: Recall events from earlier in the day

  • Remote: Recall verifiable past events (e.g., birth date)

• Knowledge level: Understanding of their illness/hospitalization

• Calculation ability: Can they subtract by 7s from 100?

• Abstract thinking: Can they explain similarities/differences (e.g., “How are cars and trains alike?”)

• Perception of illness: Insight into their condition

• Judgment: Hypothetical scenario response (e.g., “What would you do if there were a fire in your room?”)

• Language: Assess fluency, clarity, meaningfulness, and appropriateness

Level of Consciousness

Alert: Opens eyes, responds to normal voice, answers appropriately

Lethargic: Drowsy but can respond; easily falls asleep

Stuporous: Responds only to painful stimuli (e.g., sternal rub); limited or no verbal response

Comatose: Unresponsive to all stimuli

• Abnormal posturing in comatose clients:

  • Decorticate rigidity: Flexed arms/legs; internal rotation

  • Decerebrate rigidity: Extended arms/legs; wrist/finger flexion

Physical Appearance

Hygiene & grooming

Nutrition

Clothing choice (appropriateness for weather/situation)

Age appearance vs. actual age

Behavior

Assess voluntary & involuntary movements

Observe eye contact

Mood vs. Affect

Client's subjective emotional state (e.g., sad, happy)

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Observable expression of mood (e.g., flat affect = no emotion)

Cognitive and Intellectual Abilities

Orientation: Time, person, place

Memory:

• Immediate: Repeat numbers or words

• Recent: Recall events from earlier in the day

• Remote: Recall verifiable past events (e.g., birth date)

Knowledge level: Understanding of their illness/hospitalization

Calculation ability: Can they subtract by 7s from 100?

Abstract thinking: Can they explain similarities/differences (e.g., “How are cars and trains alike?”)

Perception of illness: Insight into their condition

Judgment: Hypothetical scenario response (e.g., “What would you do if there were a fire in your room?”)

Language:

• Assess fluency, clarity, meaningfulness, and appropriateness

Immediate Memory

Ask the client to repeat a series of numbers or a list of objects.

Recent Memory

Ask the client to recall recent events (visitors from the current day) or the purpose of the current mental health appointment or admission.

Remote Memory

Ask the client to state a fact from their past that is verifiable (their birth date or their mother’s maiden name). 

Mental Health Screening Tools

Adverse Childhood Experiences Questionnaire (ACE)

• Identifies history of trauma or abuse during childhood

Brief Patient Health Questionnaire (Brief PHQ)

• Screens for depression and other mental health conditions

Mini-Mental State Examination (MMSE)

• Assesses cognitive status using the following areas:

  • Orientation to time and place

  • Attention and calculation (e.g., count backward by 7s)

  • Registration and recall of objects

  • Language: Naming objects, following commands, writing ability

Pain Assessment Tools

Visual Analogue Scale (VAS)

Wong-Baker FACES Pain Rating Scale

Faces Pain Scale–Revised

McGill Pain Questionnaire (MPQ)

Pain Assessment in Advanced Dementia (PAINAD) scale

Children and Adolescents

Challenges in Diagnosis:

• Limited vocabulary to express feelings

• Broad range of "normal" behavior by age

Common Issues:

• Mood, anxiety, behavioral, developmental, eating disorders

• Risk for self-injury or suicide

Standardized Tool – HEADSSS:

• Home: Family relationships, living situation

• Education/Employment: School performance or job status

• Activities: Sports, hobbies, peer interaction

• Drug/Alcohol: Use of tobacco, alcohol, or illicit drugs

• Sexuality: Sexual activity or encounters

• Suicide/Depression: Risk factors, signs of depression

• Safety: Abuse or violence exposure in home/neighborhood

Older Adults

Comprehensive Assessment Should Include:

• Functional ability (can they manage dressing, daily tasks?)

• Economic and social status

• Environmental safety (stairs, home layout, etc.)

Screening Tools:

• Geriatric Depression Scale (short form)

• Michigan Alcoholism Screening Test: Geriatric Version

• MMSE (Mini-Mental State Exam)

Interviewing Tips:

• Use quiet, well-lit space (accommodate hearing/vision issues)

• Ask for name and pronoun preferences

• Sit or stand at eye level with client (avoid towering over)

SDOMH – Social Determinants of Mental Health

Includes how life circumstances (work, housing, education, community) affect mental health

Examples:

• Access to care

• Economic inequality

• Discrimination

Nurses must tailor interventions based on these social factors

Trauma-Informed Care

Screen for interpersonal violence and trauma

Understand that trauma affects behavior and relationships

Key Components:

• Recognize that trauma can impact both individuals and groups

• Identify signs of trauma

• Support organized responses to trauma (helping clients cope effectively)

• Avoid re-traumatization during care

DSM-5-TR (2022)

Used by mental health professionals to diagnose disorders using standard criteria

Guides assessment, planning, implementation, and evaluation

NANDA (North American Nursing Diagnosis Association)

Used for appropriate nursing interventions

Serious Mental Illness

Includes severe and persistent mental illnesses

Often affects ADLs (Activities of Daily Living)

Typically lifelong with remission and exacerbation phases

Role and Life Changes: Common Role Transitions

Loss of employment

Divorce

Retirement

Grand-parenthood

Widowhood

Death of a guardian

Becoming a caregiver or care recipient

Role and Life Changes: Types of Role Change

Predicted: e.g., planned retirement

Unexpected: e.g., sudden illness/injury requiring care

Role and Life Changes: Assessing Ability & Evaluating Success

Factors to Assess:

• Health status & functional abilities

• Living situation and job status

• Personality traits (e.g., attitudes)

• Input from client, caregivers, family

• Access to community resources

• Use of medications and support services

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Signs of Successful Adaptation

• Identifies positive coping behaviors

• Recognizes maladaptive coping behaviors

• Participates in community resources

• Uses stress reduction techniques

• Maintains housing and employment