ATI. RN Mental Health Nursing
Chapter 1 : Basic Mental Health Nursing Concepts - answer* Provisions o care to
clients in mental health settings is based on standards of care set by the American
Nurses Association, the American Psych Nurses Association and the International
Society of Psych Mental Health Nurses
-both the nursing process and holistic approaches are used in mental health settings
What are the components of the Psychosocial History? - answer1) perception of own
health, beliefs about illness and wellness
2) activity/leisure activities and how the client likes to pass their time
3) use of substances or substance use disorder
4) Stress level and coping abilities
-what are their coping strategies?
-what are their support systems?
5) cultural beliefs and practices
6) spiritual beliefs
7) (MSE) Mental Status Exam
Mental Status Examination: - answerthe level of consciousness is describes used the
following terms and observed behavior included in documentation.
1) Alert: the client is responsive and able to fully respond by opening her eyes and
attending to a normal tone of voice and speech
-she answers questions spontaneously and appropriately
2) Lethargy: the client is able to open her eyes and respond but is drowsy and falls
asleep readily
3) Stupor: the client requires vigorous or painful stimuli (pinching a tendon or rubbing
the sternum) to elicit a brief response. She may not be able to response verbally
4) Coma:
-no response can be achieved from repeated painful stimuli
*abnormal posturing in the client who is comatose
a) DECORTICATE RIGIDITY: flexion and internal rotation of upper-extremity joints and
legs
b) DECERIBATE RIGIDITY: neck and elbow extension, wrist and finger flexion
, * assessing appearance: exam includes the assessment of personal hygiene, grooming,
and clothing choice
*Behavior: assess voluntary and involuntary body movements:
a) mood: provides info about EMOTIONS client is feeling
b) affect: a client's affect is an OBJECTIVE EXPRESSION OF MOOD such as a flat
affect or a lack of facial expression
^ these "SIGNS" can be detected and evaluated as an objective assessment
* cognitive and intellectual abilities:
-assess the client's orientation to time, person, and place
-assess client memory, both recent and remote
a) Immediate: ask the client to repeat a series of numbers or a list of objects ( can the
client count from 1-10 w/o losing their place or forgetting what they were saying/that
they were in the midst of counting to 10; do they lose immediate sight of their task in the
middle of doing it???)
b) Recent: ask the client to recall recent events (ex: visitors from earlier on in the day)
(not immediate
c) Remote
Standardized screening tools? - answer* Mini-Mental State Exam:
-used to objectively assess a client's cognitive status by evaluating the following:
-orientation to time and place
-attention span and ability to calculate by counting backwards by 7
-registration and recalling of objects
-language, including naming of objects, following of commands, and ability to write.
Glasgow Coma Scale :) - answerused to obtain a baseline assessment of a client's level
of consciousness
^ this is an ongoing assessment
1) eye
2) verbal
3) motor response is evaluated a number value based on that response is evaluated
*highest value: 15; indicates that the client is awake and responding appropriately
* 7 or less: indicates client is in a coma
Considerations across the lifespan: - answerA) Children and Adolescents:
assessing:
1) temperament
2) social and environmental factors
Chapter 1 : Basic Mental Health Nursing Concepts - answer* Provisions o care to
clients in mental health settings is based on standards of care set by the American
Nurses Association, the American Psych Nurses Association and the International
Society of Psych Mental Health Nurses
-both the nursing process and holistic approaches are used in mental health settings
What are the components of the Psychosocial History? - answer1) perception of own
health, beliefs about illness and wellness
2) activity/leisure activities and how the client likes to pass their time
3) use of substances or substance use disorder
4) Stress level and coping abilities
-what are their coping strategies?
-what are their support systems?
5) cultural beliefs and practices
6) spiritual beliefs
7) (MSE) Mental Status Exam
Mental Status Examination: - answerthe level of consciousness is describes used the
following terms and observed behavior included in documentation.
1) Alert: the client is responsive and able to fully respond by opening her eyes and
attending to a normal tone of voice and speech
-she answers questions spontaneously and appropriately
2) Lethargy: the client is able to open her eyes and respond but is drowsy and falls
asleep readily
3) Stupor: the client requires vigorous or painful stimuli (pinching a tendon or rubbing
the sternum) to elicit a brief response. She may not be able to response verbally
4) Coma:
-no response can be achieved from repeated painful stimuli
*abnormal posturing in the client who is comatose
a) DECORTICATE RIGIDITY: flexion and internal rotation of upper-extremity joints and
legs
b) DECERIBATE RIGIDITY: neck and elbow extension, wrist and finger flexion
, * assessing appearance: exam includes the assessment of personal hygiene, grooming,
and clothing choice
*Behavior: assess voluntary and involuntary body movements:
a) mood: provides info about EMOTIONS client is feeling
b) affect: a client's affect is an OBJECTIVE EXPRESSION OF MOOD such as a flat
affect or a lack of facial expression
^ these "SIGNS" can be detected and evaluated as an objective assessment
* cognitive and intellectual abilities:
-assess the client's orientation to time, person, and place
-assess client memory, both recent and remote
a) Immediate: ask the client to repeat a series of numbers or a list of objects ( can the
client count from 1-10 w/o losing their place or forgetting what they were saying/that
they were in the midst of counting to 10; do they lose immediate sight of their task in the
middle of doing it???)
b) Recent: ask the client to recall recent events (ex: visitors from earlier on in the day)
(not immediate
c) Remote
Standardized screening tools? - answer* Mini-Mental State Exam:
-used to objectively assess a client's cognitive status by evaluating the following:
-orientation to time and place
-attention span and ability to calculate by counting backwards by 7
-registration and recalling of objects
-language, including naming of objects, following of commands, and ability to write.
Glasgow Coma Scale :) - answerused to obtain a baseline assessment of a client's level
of consciousness
^ this is an ongoing assessment
1) eye
2) verbal
3) motor response is evaluated a number value based on that response is evaluated
*highest value: 15; indicates that the client is awake and responding appropriately
* 7 or less: indicates client is in a coma
Considerations across the lifespan: - answerA) Children and Adolescents:
assessing:
1) temperament
2) social and environmental factors
