Mental Status, Substance Abuse, ad Violence

Pages 188-202 in Course Packet / 5-8 questions on Exam II

Mental status is a person’s ______________ functioning

emotional and cognitive

Optimal functioning aim towards simultaneous ___________ at work, caring relationships, and within the self

life satisfaction

Usually, mental status strikes a balance between ___________ days, allowing person to function socially and occupationally

good and bad

_______ surrounding a traumatic event or illness can tip the balance and cause transient dysfunction

stress

A ___________ is apparent when response is much greater than expected to a traumatic event; behavioral/psychological pattern

mental disorder

__________ is based on observation of patient and patient’s responses to your questions

mental assessment

Mental status ______ be scrutinized directly like characteristics of skin/heart sounds

cannot

Most elementary of mental status function:

consciousness

Basic tool for humans, and its loss has very heavy social impact on the individual

language

Deal with prevailing feelings

mood and affect

Being able to name one’s own person, place, location, and time

orientation

Ability to focus on one specific thing without being distracted by many environmental status

attention

Memory has ____ types

two

Evokes day-to-day events

recent memory

Brings up years worth of experiences

remote memory

Ability to ponder deeper meaning beyond concrete and literal

abstract reasoning

The *way* a person thinks; logical train of thought

thought process

*What* a person thinks; specific ideas, beliefs, use of words

thought content

Awareness of objects through the five senses

perception

Role of the nurse consists of screening for:

preexisting and current mental health conditions

Role of the nurse includes: establishing a ______________

therapeutic relationship

Role of the nurse includes: introducing yourself and exhibiting _______________

caring behaviors

Role of the nurse includes: knowing _________________

yourself and your prejudices

Role of the nurse includes: taking __________________________ into account

age, sex, cultural, developmental, and educational levels

Role of the nurse includes: making it clear that nurse and patient are ______________

equal partners

A ____________ is a systemic check of emotional and cognitive functioning

full mental status examination

A full mental status examination is only necessary to be performed when any abnormal in _______________ is discovered or in certain situations

behavior or affect

Would require a full mental status examination if: patients whose initial screening suggest ________________

anxiety disorder or depression

Would require a full mental status examination: _________ changes, like memory loss, inappropriate social interaction

behavioral

Would require a full mental status examination: _________: trauma, tumor, cerebrovascular accident, or stroke

brain lesions

Would require a full mental status examination: __________: impairment of language ability secondary to brain damage

aphasia

Would require a full mental status examination: symptoms of __________________, especially with acute onset

psychiatric mental illness

Main components of a mental status examination:

objective data

Four main headings of mental status assessment:

A-B-C-T

In older adults, assess _________________ before any other aspect of mental status

sensory status, vision, and hearing

____________ changes may alter alertness and leave person looking confused

vision and hearing

Common in older adults and easily misdiagnosed

confusion

Person’s _________ can be affected by fashion trends, economic status, changes in mental status

appearance

(Appearance) Typically should be erect and position relaxed:

posture

(Appearance) Should be voluntary, deliberate, coordinated, and smooth/even

body movement

(Appearance) Should be appropriate for setting, season, age , gender, and social group. May reflect person’s economic status or deliberate fashion trend

dress

(Appearance) Person should be clean/well-kept; hair neat and clean. A disheveled appearance in previously well-kept person is considered significant finding

grooming and hygiene

(Behavior) Should be awake and alert, aware of stimuli, respond appropriately

level of consciousness

patient opens eyes, answers questions, falls back asleep

lethargy'/lethargic

patient opens eyes to loud voice, responds slowly with confusion, seems unaware of environment

obtunded

patients awakens to vigorous shaking or painful stimuli, but returns to unresponsive sleep

stupor/stuporous

patient remains unresponsive to all stimuli; eyes stay closed

coma/comatose

When assessing level of consciousness, always begin with the __________ stimuli

least noxious

Stimuli for assessing level of consciousness:

verbal, tactile, painful

useful in testing patients who have experienced traumatic brain injury or aging person in whom confusion is common

Glasgow Coma Scale

Three areas in which GCS gives a numerical value:

eye-opening, best verbal response, best motor response

GCS score of 15

best reaction

GCS score of less than 15

indicates some impairment

GCS score of 8 or less

comatose client

GCS score of 3

indicates deep coma

Lowest possible GCS score

3

Should be appropriate to situation and changes appropriately with topic

facial expression

Eye contact and facial expressions such as smiling differ in some ______

cultures

Reduced eye contact is seen in _________

depression or apathy

Extreme facial expressions of happiness, anger, or fright may be seen in _________

anxious patients

Parkinson disease patients may have __________

mask-like, expressionless face

Inappropriate facial expressions may indicate __________

mental illness

Judge quality of _______ by noting that person makes sounds effortlessly and shares conversation appropriately

speech

Pace oof conversation should be:

moderate

Conversation should stream:

fluently

___________ should be clear and understandable

articulation

____________ speech is characteristic of depression or Parkinson’s disease

slow and repetitive

Disorganized speech, nonstop speech, or long periods or silence may indicate:

mental illness or neurological disorder

Loss of ability to speak or write coherently or understand speech/writing due to cerebrovascular accident

aphasia

Ways to asses include pointing to articles in the room or articles from pockets and ask person to name them

word comprehension

ways to assess include asking person to read available print; be aware that this is related to educational level

reading

ways to assess include asking the person to make up and write a sentence; note coherence, spelling, and parts of speech

writing

judge by body language and facial expression and by asking directly “How do you feel?”

mood and affect

Expression of emotions or individual’s emotional state

affect

(affect variation) normal, steady, tranquil mental state

euthymic

(affect variation) mildly diminished range of intensity of emotional expression

constricted

(affect variation) markedly diminished emotional expression

blunted

(affect variation) severely reduced emotional expressiveness

flat

(affect variation) not in keeping with the situation or are incompatible with expressed thoughts/wishes (example: smiling at news of a death of a friend)

inappropriate

Expression of prolonged negative, gloomy, despairing feeling is noted in:

depression

Expression of elation or grandiosity, high energy level, engagement in high-risk but pleasurable activities seen in:

manic phases

Excessive worry seen in:

anxiety and OCD

Eccentric moods not appropriate to situation are seen in:

schizophrenia

Usually assessed through course of the interview, or asked directly when assessing level of consciousness, using tact

orientation

(orientation) day of the week, date, year, season

time

Hospitalized patients may struggle with exact ______, but are fully oriented on remaining items

date

(orientation) where a person lives, address, phone number, present location, type of building, name of city/state

place

(orientation) own name, age, who examiner is, type of worker

person

Check person’s ability to concentrate by noting whether they can complete a thought without wandering

attention span

Distraction/_______________ on task at hand are noted in anxiety, fatigue, attention deficit disorders, or impaired states due to alcohol or drug intoxication

inability to focus

Ask for 24-hour diet recall or by asking the time the person arrived

recent memory

Inability to _________________ is seen in delirium, dementia, depression, and anxiety

recall recent events

Ask person verifiable past events: health past, first job, birthday, etc

remote memory

Remote memory lost when ____________ area for that memory is damaged, such as Alzheimer’s, dementia, or any disease that damages cerebral cortex

cortical storage

Ability to compare and evaluate alternatives and appropriate course of action

Judgement

Test everyday example and ______________ in response to hallucinations or delusions, capacity for violent/suicidal behavior

likelihood of acting

Observe for clarity, content, and perception by inquiring about patient’s:

thoughts and perceptions expressed

The way a person thinks should be logical, goal directed, coherent, and relevant; should be a complete thought:

thought process

What person says should be a consistent and logical:

thought content

person should be consistently aware of reality; should be congruent with yours:

perceptions