Mental health PN ATI
Mood *** provides information about the emotion that a client is feeling.
Affect *** an objective expression of mood, such as flat affect or lack of facial expression.
Alert *** 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
lethargic *** the client is able to open her eyes and respond but is drowsy and falls asleep readily.
Stuporous *** The 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 *** the client is unconscious and does not respond to painful stimuli
decorticate rigidity *** flexion and internal rotation of upper extremity joints and legs
decerebrate rigidity *** neck and elbow extension, with wrists and fingers flexed
immediate memory *** the ability to hold something in mind for just a few seconds
recent memory *** -The ability to recall events of the past few days
remote memory *** very long-term recall, such as birth date, mother's maiden name
, Confabulation *** the act of filling in memory gaps
What does MMSE stand for? *** mini mental status exam
Glasgow Coma Scale *** This 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.... *** trust 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. *** Home 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? *** Diagnostic and Statistical Manual of Mental Disorders, 5th edition
What is the DSM-5 used for? *** diagnostic tool used to identify mental health diagnosis
What do nurses use the DSM-5 for? *** identify diagnosis and diagnosis criteria to guide data collection,
to identify nursing diagnoses, and to assist in the planning, implementation, and evaluation of care.
Mood *** provides information about the emotion that a client is feeling.
Affect *** an objective expression of mood, such as flat affect or lack of facial expression.
Alert *** 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
lethargic *** the client is able to open her eyes and respond but is drowsy and falls asleep readily.
Stuporous *** The 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 *** the client is unconscious and does not respond to painful stimuli
decorticate rigidity *** flexion and internal rotation of upper extremity joints and legs
decerebrate rigidity *** neck and elbow extension, with wrists and fingers flexed
immediate memory *** the ability to hold something in mind for just a few seconds
recent memory *** -The ability to recall events of the past few days
remote memory *** very long-term recall, such as birth date, mother's maiden name
, Confabulation *** the act of filling in memory gaps
What does MMSE stand for? *** mini mental status exam
Glasgow Coma Scale *** This 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.... *** trust 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. *** Home 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? *** Diagnostic and Statistical Manual of Mental Disorders, 5th edition
What is the DSM-5 used for? *** diagnostic tool used to identify mental health diagnosis
What do nurses use the DSM-5 for? *** identify diagnosis and diagnosis criteria to guide data collection,
to identify nursing diagnoses, and to assist in the planning, implementation, and evaluation of care.
