Mental health PN ATI
Mood - ANSprovides information about the emotion that a client is feeling.
Affect - ANSan objective expression of mood, such as flat affect or lack of facial expression.
Alert - ANSclient 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
lethargic - ANSthe client is able to open her eyes and respond but is drowsy and falls asleep
readily.
Stuporous - ANSThe client requires vigorous or painful stimuli (pinching a tendon or rubbing the
sternum) to elicit a brief response. She might not be able to respond verbally.
Comatose - ANSthe client is unconscious and does not respond to painful stimuli
decorticate rigidity - ANSflexion and internal rotation of upper extremity joints and legs
decerebrate rigidity - ANSneck and elbow extension, with wrists and fingers flexed
immediate memory - ANSthe ability to hold something in mind for just a few seconds
recent memory - ANS-The ability to recall events of the past few days
remote memory - ANSvery long-term recall, such as birth date, mother's maiden name
Confabulation - ANSthe act of filling in memory gaps
What does MMSE stand for? - ANSmini mental status exam
Glasgow Coma Scale - ANSThis examination is used to obtain baseline data of a client's level
of consciousness and for ongoing evaluation. Eye, verbal, and motor response is checked and a
number value based on response is assigned. Highest possible value is 15, indicates awake
and responsive, a score of 8 or less indicates that the client is in a coma
Mentally healthy children and adolescence.... - ANStrust others, view the world as safe,
accurately interpret their environments. master development tasks, and use appropriate coping
skills
Things to look for when using the HEADSSS psychosocial interview to evaluate risk factors in
an adolescent. - ANSHome environment, (what are the relationships like at home)
, education/employment, (how is their performance in school or work)
activities, (does the client participate in sports or other activities?)
drug and substance use,
sexuality,
suicide/depression, (is the client at risk for self harm?)
savagery (is the client exposed to abuse in the home or violence in his neigborhood?)
What is the DSM-5? - ANSDiagnostic and Statistical Manual of Mental Disorders, 5th edition
What is the DSM-5 used for? - ANSdiagnostic tool used to identify mental health diagnosis
What do nurses use the DSM-5 for? - ANSidentify diagnosis and diagnosis criteria to guide data
collection, to identify nursing diagnoses, and to assist in the planning, implementation, and
evaluation of care.
Counseling - ANS- using therapeutic communication skills
- assisting with problem solving
- crisis intervention
- stress management
milieu therapy - ANS-orienting the client to the physical setting
-identifying rules and boundaries of the setting
-ensuring a safe environment for the client
-assisting the client to participate in appropriate activities
promotion of self-care activities - ANSOffering assistance with self-care tasks
Allowing time for the client to complete self-care tasks
Setting incentives to promote client self-care
Psychobiological interventions - ANS-administering prescribed medications,
-providing teaching to the client/family about medications,
-monitoring for adverse effects and effectiveness of pharmacological therapy
What are cognitive and behavioral therapies? - ANSmodeling
operant conditioning
systematic desensitization
Health education - ANSreinforcing teaching about social and coping skills
Health promotion and health maintenance - ANSassisting the client with cessation of smoking,
monitoring other health conditions
Mood - ANSprovides information about the emotion that a client is feeling.
Affect - ANSan objective expression of mood, such as flat affect or lack of facial expression.
Alert - ANSclient 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
lethargic - ANSthe client is able to open her eyes and respond but is drowsy and falls asleep
readily.
Stuporous - ANSThe client requires vigorous or painful stimuli (pinching a tendon or rubbing the
sternum) to elicit a brief response. She might not be able to respond verbally.
Comatose - ANSthe client is unconscious and does not respond to painful stimuli
decorticate rigidity - ANSflexion and internal rotation of upper extremity joints and legs
decerebrate rigidity - ANSneck and elbow extension, with wrists and fingers flexed
immediate memory - ANSthe ability to hold something in mind for just a few seconds
recent memory - ANS-The ability to recall events of the past few days
remote memory - ANSvery long-term recall, such as birth date, mother's maiden name
Confabulation - ANSthe act of filling in memory gaps
What does MMSE stand for? - ANSmini mental status exam
Glasgow Coma Scale - ANSThis examination is used to obtain baseline data of a client's level
of consciousness and for ongoing evaluation. Eye, verbal, and motor response is checked and a
number value based on response is assigned. Highest possible value is 15, indicates awake
and responsive, a score of 8 or less indicates that the client is in a coma
Mentally healthy children and adolescence.... - ANStrust others, view the world as safe,
accurately interpret their environments. master development tasks, and use appropriate coping
skills
Things to look for when using the HEADSSS psychosocial interview to evaluate risk factors in
an adolescent. - ANSHome environment, (what are the relationships like at home)
, education/employment, (how is their performance in school or work)
activities, (does the client participate in sports or other activities?)
drug and substance use,
sexuality,
suicide/depression, (is the client at risk for self harm?)
savagery (is the client exposed to abuse in the home or violence in his neigborhood?)
What is the DSM-5? - ANSDiagnostic and Statistical Manual of Mental Disorders, 5th edition
What is the DSM-5 used for? - ANSdiagnostic tool used to identify mental health diagnosis
What do nurses use the DSM-5 for? - ANSidentify diagnosis and diagnosis criteria to guide data
collection, to identify nursing diagnoses, and to assist in the planning, implementation, and
evaluation of care.
Counseling - ANS- using therapeutic communication skills
- assisting with problem solving
- crisis intervention
- stress management
milieu therapy - ANS-orienting the client to the physical setting
-identifying rules and boundaries of the setting
-ensuring a safe environment for the client
-assisting the client to participate in appropriate activities
promotion of self-care activities - ANSOffering assistance with self-care tasks
Allowing time for the client to complete self-care tasks
Setting incentives to promote client self-care
Psychobiological interventions - ANS-administering prescribed medications,
-providing teaching to the client/family about medications,
-monitoring for adverse effects and effectiveness of pharmacological therapy
What are cognitive and behavioral therapies? - ANSmodeling
operant conditioning
systematic desensitization
Health education - ANSreinforcing teaching about social and coping skills
Health promotion and health maintenance - ANSassisting the client with cessation of smoking,
monitoring other health conditions
