ATI - RN Mental Health Nursing Questions & Answers

What do you assess for during a Mental Status Exam (MSE)? - ANSWERS1. level of consciousness 2. physical appearance 3. behavior 4. cognitive and intellectual abilities alert - ANSWERSable to fully respond by opening eyes, attend to normal tone of voice and speech, and answer questions spontaneously and appropriately lethargy - ANSWERSable to open eyes and respond, but is drowsy and falls asleep readily obtundation - ANSWERSneeds to be lightly shaken to elicit a response; may be confused and slow to respond stupor - ANSWERSrequires painful stimuli (e.g. pinch a tendon, rub sternum) to elicit a brief response; may not be able to respond verbally coma - ANSWERSno response from repeated painful stimuli decorticate rigidity - ANSWERSflexion and internal rotation of upper extremity joints and legs (arms toward midline) decerebrate rigidity - ANSWERSneck and elbow extension, wrist and finger flexion (arms away from midline) mood - ANSWERSsubjective data about emotions that are felt affect - ANSWERSobjective data about expression of mood How do you assess recent memory? - ANSWERSHave patient recall a series of number or list of objects. How do you assess remote memory? - ANSWERSHave patient state a verifiable fact (e.g. birthdate). How do you assess level of knowledge? - ANSWERSAsk patient what they know about their illness or hospitalization. How do you assess ability to calculate? - ANSWERSAsk patient to count backward from 100 in serials of 7. How do you assess ability to think abstractly? - ANSWERSSee if patient can interpret an idiom/saying. How do you assess judgment? - ANSWERSAsk patient a hypothetical question to see how they would answer (i.e. is it logical). What do you assess for during a Mini-Mental State Exam? - ANSWERS1. orientation 2. attention span and ability to calculate 3. registration and recall of objects 4. language (e.g. naming objects, following commands, and writing ability) What is evaluated in the Glasgow Coma Scale? - ANSWERSeye, verbal, and motor response Glasgow Coma Scale - what is the lowest to highest value? - ANSWERS3 (coma) to 15 (awake and responding appropriately) Axis I of the DSM-IV - ANSWERSall mental health dx except those found in Axis II Axis II of the DSM-IV - ANSWERSpersonality disorder dx, mental retardation Axis III of the DSM-IV - ANSWERSany general medical dx (e.g. asthma) Axis IV of the DSM-IV - ANSWERSpsychosocial problems, problems that may affect dx/treatment/prognosis of mental disorders Axis V of the DSM-V - ANSWERSglobal assessment of functioning (GAF) What are some mental health nursing interventions? - ANSWERS1. counseling 2. milieu therapy 3. promotion of self-care activities 4. psychobiological interventions 5. cognitive and behavioral therapies 6. health teaching 7. health promotion and maintenance 8. case management counseling - ANSWERS- using therapeutic communication skills - assisting with problem solving - crisis intervention - stress management milieu therapy - ANSWERS- orienting patient to physical setting - identifying rules and boundaries of setting - ensuring a safe environment for patient - assisting patient to participate in appropriate activities promotion of self-care activities - ANSWERS- offering assistance - allowing time for patient to complete self-care task - setting incentives to promote patient self-care psychobiological interventions - ANSWERS- administering prescribed medications - providing teaching to patient/family - monitoring for side effects and effectiveness of therapy cognitive and behavioral therapies - ANSWERS- modeling - operant conditioning - systematic desensitization health teaching - ANSWERSteaching social and coping skills health promotion and maintenance - ANSWERS- assisting patient with smoking cessation - monitoring other health conditions case management - ANSWERScoordinating holistic care to include medical, mental health, and social services intrapersonal communication - ANSWERScommunication within one's self; "self-talk" allows the RN to: - assess a patient/situation - critically think about it before verbalizing interpersonal communication - ANSWERScommunication among a small group (2 or more people) where information is exchanged public communication - ANSWERScommunication within a large group (e.g. community teaching)