Assessing Mental Status Including Risk for Substance Use

Chapter 6

What does mental health status refer to?

• a clients level of cognitive and emotional functioning

A ___ mental status is needed for clear thinking, appropriate responses, and effective functioning in daily activities.

• healthy

Define mental disorders

• conditions characterized by cognitive and emotional disturbances, abnormal behaviors, and impaired functioning

What books provide detailed info on mental disorders?

• DSM-TR and ICD

What are some components that contribute to mental disorders?

• environment, psychological, genetic, chemical, social, or other factors

Is the following statement true or false?

LGBTQ+ youth are at increased risk for substance use, depression, anxiety, suicidal ideation, and suicide attempts.

• true

What doe nurses look for in mental health assessments? (4)

• Assessing mental status

• Screening for substance use

• Assessing suicide risk

• Identifying mental health disorders and needed interventions

What factors influence mental health? (8)

• biophysical factors

  • history of mental health disorder, traumatic brain injury, chronic medical condition

• changes in neurological system

• economic and social factors

• lifestyle considerations

• exposire to violence

• psychological factors

  • poor decision making/self control

  • low developmental level/self esteem

• spritual factors

• cultural factors

The ___ syndrome manifests in behavioral, cognitive, and physiologic phenomena after repeated substance use.

• dependence

What can substance use lead to? (5)

• Strong desire to take the drug

• Difficulty controlling substance use

• Continued use despite harmful consequences

• Avoidance of responsibilities

• Withdrawal symptoms when use is reduced or stopped

Estimated ___ cases of Alzheimer disease worldwide.

• 50 million

Is the following statement true or false?

White individuals are nearly twice as likely to develop Alzheimer's disease than African American individuals.

• false

• it is actually the other way around, African Americans are twice as likely to develop Alzheimer’s

Is the following statement true or false?

Hispanic individuals are nearly twice as likely to develop Alzheimer's disease.

• true

How does the AUDIT (interview version) work?

• stands for Alcohol Use Disorders Identification Test

• begin by asking about use of alcoholic beverages during the past year

• code answers in terms of standard drinks

How does the Quick Inventory of Depressive Symptomatology assessment tool work?

• self report

• checkmark one response to each item that is most appropriate to how you have been feeling over the past 7 days

How does the modified SAD PERSONS suicide risk assessment work?

• used to assess likelihood of a suicide attempt

• consider risk factors within the context of clinical presentation

List the points to look for during a comprehensive mental status examination. (14)

• general appearance

• level of consciousness

• posture

• gait

• body movements

• dress

• grooming

• hygiene

• facial depressions

• behavior and affect

• speech

• mood, feeling, expressions

• thought processes and perceptions

• cognitive abilities

What is the Glasgow Coma Scale used for?

• rating response to stimuli

• indicating levels of consciousness and need for emergency attention

Define and list some examples of collaborative problems

• differ from client concerns as they cannot be prevented by nursing interventions

  • but physiologic complications of medical condition can be detected and monitored by nurse

• some can be obtained with a general impression

  • stroke

  • increased intracranial pressure

  • seizures

  • meningitis

  • depression

What are some abnormal findings during a mental health assessment?

• lethargy

• obtunded

• stupor

• coma

Define lethargy

• client opens eyes, answers questions, and falls back asleep

Define obtunded

• client opens eyes to loud voice, responds slowly with confusion, and seems unaware of environment

Define stupor

• client awakens to vigorous shake or painful stimuli but returns to unresponsive sleep

What are some sources of speech problems?

• dysphonia

• cerebellar dysarthria

• dysarthria

• aphasia

• wernicke aphasia

• broca aphasia

Define dysphonia

• voice volume disorder caused by laryngeal disorder or impairment of cranial nerve X

Define cerebellar dysarthria

• irregular uncoordinated speech caused by multiple sclerosis

Define dysarthria

• defect in muscular control of speech related to lesions of nervous system, parkinson disease, or cerebellar disease

Define aphasia

• rapid speech that lacks meaning caused by a lesion in posterior superior temporal lobe

Compare Wernicke aphasia to Broca aphasia

• Wernicke aphasia

  • rapid speech that lacks meaning

  • caused by lesion in posterior superior temproal lobe

• Broca aphasia

  • slowed speech with difficult articulation but clear meaning

  • caused by lesion in posterior inferior frontal lobe