ATI Mental Health Exam

The client is responsive and able to fully respond by opening their eyes and attending to a normal tone of voice and speech. What is the level of consciousness? - Alert The client is able to open their eyes and respond but is drowsy and falls asleep readily. What is the level of consciousness? - Lethargic The client requires vigorous or painful stimuli (pinching a tendon or rubbing the sternum) to elicit a brief response. They might not be able to respond verbally. What is the level of consciousness? - Stuporous The client is unconscious and does not respond to painful stimuli. What is the level of consciousness? - Comatose How to test a client's immediate memory - Ask the client to repeat a series of numbers or a list of objects How to test a client's recent memory - Ask the client to recall recent events, such as visitors from the current day, or the purpose of the current mental health appointment or admission How to test a client's remote memory - Ask the client to state a fact from his past that is verifiable, such as his birth date or his mother's maiden name How to assess a client's ability to calculate - Ask the client to count backward from 100 in sevens How to assess a client's ability to think abstractly - Ask the client to interpret something complex such as, "A bird in the hand is worth two in the bush." Glasgow coma scale - Used to obtain a baseline assessment of a client's level of consciousness; highest score is 15 and indicates that the client is awake and responding appropriately; a score of 7 or less indicates that the client is in a coma Serious mental illness - Includes disorders classified as severe and persistent mental illnesses; clients often have difficulty with ADLs; can be chronic or recurrent A charge nurse is discussing mental status exams with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (Select all that apply) A. "To assess cognitive ability, I should ask the client to count backward by sevens." B. "To assess affect, I should observe the client's facial expression." C. "To assess language ability, I should instruct the client to write a sentence." D. "To assess remote memory, I should have the client repeat a list of objects." E. "To assess the client's abstract thinking, I should ask the client to identify our most recent presidents." - A. Counting backward by sevens is an appropriate technique to assess a client's cognitive ability. B. Observing a client's facial expression is appropriate when assessing affect. C. Writing a sentence is an indication of language ability. Remote language is tested by asking the client to state a fact from his past that his verifiable (date of birth). Abstract thinking is tested by asking the client to interpret something. A nurse is planning care for a client who has a mental health disorder. Which of the following actions should the nurse include as a psychobiological intervention? A. Assist the client with systematic desensitization therapy. B. Teach the client appropriate coping mechanisms. C. Assess the client for comorbid health conditions. D. Monitor the client for adverse effects of the medications. - D. Monitoring for adverse effects of medications is an example of a psychobiological intervention. Systematic desensitization is cognitive and behavioral. Teaching coping mechanisms is a counseling or health teaching. Assessing for comorbid conditions is health promotion and maintenance. A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following actions should the nurse identify as the priority?