NUR 222 Mental Health Final Study Guide-1
MENTAL HEALTH ASSESSMENT COMPONENTS
Psychosocial history
o Cultural beliefs and practices
o Spiritual and religious beliefs
Mental Status Examination
o Lethargic: Opens eyes and responds, but drowsy
o Stuporous: Requires painful stimuli to elicit response.
o Comatose: Does not respond to painful stimuli
Physical appearance
Behavior
o Mood: Emotion
o Affect: Expression of mood
Cognitive and intellectual abilities
o Immediate memory: Repeat series of numbers
o Recent memory: Recall visitors earlier that day
o Remote: State verifiable fact from past.
STANDARDIZED SCREENING TOOLS
MINI -MENTAL STATE EXAMINATION (MMSE)
Assesses problems with memory and other cognitive function
Maximum score is 30.
o 24-30 = no cognitive impairment
o 18-23 = mild cognitive impairment
o 0-17 = severe cognitive impairment
Items Assessed
Visuospatial: Copy intersecting pentagons
Language: Repeat sentences, comprehend instructions, write a short sentence. Recognize and name common objects.
Concentration: Subtraction task or spell WORLD backwards
Working memory: Repeat 3 words
Memory recall: Short-term memory recall task
Orientation: Time and place
GLASGOW COMA SCALE
Assesses a patient’s level of consciousness
Maximum score is 15
o 15 = client is awake and responding appropriately.
o 7 or less = client is in a coma
Items Assessed
Eye response: 4 = opens spontaneously, 3 = open to verbal command, 2 = open to pain, 1 = none
Verbal response: 5 = oriented, 4 = confused, 3 = inappropriate words, 2 = incomprehensible sounds, 1 = none
Motor response: 6 = obeys commands, 5 = localizing pain, 4 = withdrawal from pain, 3 = flexion to pain, 2 = extension to pain, 1 = none
KUBLER-ROSS STAGES OF GRIEF (5)
1
,NUR 222 Mental Health Final Study Guide-1
1. Denial = “It can’t be true”
2. Anger
2
,NUR 222 Mental Health Final Study Guide-1
3. Bargaining = “If only I had done more”
4. Depression
5. Acceptance
ERIKSON’S STAGES OF PSYCHOSOCIAL DEVELOPMENT (8)
1. Trust vs Mistrust (Birth to 18 months)
a. Infants must learn that adults can be trusted.
b. Unresponsive caregivers can engender feelings of anxiety, fear, and mistrust.
c. May develop a sense of mistrust for people in the world in the future.
2. Autonomy vs Shame/Doubt (1-3 years)
a. Toddlers need to learn to control actions and act on their environments.
b. A 2-year-old child may want to dress herself. Even if the outfits aren’t appropriate, her input in the decision has an effect on her sense
of independence.
c. IF denied the opportunity to act on her environment, she may begin to doubt her abilities.
d. May lead to low self-esteem and feelings of shame.
3. Initiative vs. Guilt (3-6 years)
a. Preschool age children are capable of initiating activities and asserting control over their world through social interactions and play.
b. Learn to plan and achieve goals while interacting with others.
c. Children will develop self-confidence and feel sense of purpose.
d. If unsuccessful due to over-controlling parents, may develop feelings of guilt.
4. Industry vs Inferiority (6-12 years)
a. Children either develop a sense of pride and accomplishment in schoolwork, sports, social activities, and family life, or they feel inferior
and inadequate because they feel they don’t measure up.
b. If children do not learn to get along with others or have negative experiences at home or with peers, inferiority complex might develop.
5. Identity vs. Role confusion (12-18 years)
a. Adolescents struggle with questions such as “Who am I?” and “What do I want to do with my life?”
b. If successful, have a strong sense of identity and are able to remain true to their beliefs and values in the face of problems and other
people’s perspectives.
c. If unsuccessful, may develop a weak sense of self and experience role confusion.
6. Intimacy vs. Isolation (20s-40s)
a. Learning to share your life with others.
b. If do not develop intimate relationship, may experience feelings of loneliness and emotional isolation.
7. Generativity vs. Stagnation (40s-60s)
a. Finding your life’s work and contributing to the development of others through activities such as volunteering, mentoring, and raising
children.
b. Childbirth or caring for others.
c. Those who do not master this task may feel they are not leaving a mark on the world in a meaningful way.
8. Integrity vs. Despair (60s-end of life)
a. Reflection on life and feeling a sense of satisfaction or a sense of failure.
b. People who feel proud of their accomplishments feel a sense of integrity.
c. People who are unsuccessful feel their life has been wasted. Focus on what they should have done.
LEGAL AND ETHICAL ISSUES
3
, NUR 222 Mental Health Final Study Guide-1
RIGHTS OF CLIENTS IN MENTAL HEALTH SETTINGS
Right to medical/dental care Refuse treatment Interpretive services
4
MENTAL HEALTH ASSESSMENT COMPONENTS
Psychosocial history
o Cultural beliefs and practices
o Spiritual and religious beliefs
Mental Status Examination
o Lethargic: Opens eyes and responds, but drowsy
o Stuporous: Requires painful stimuli to elicit response.
o Comatose: Does not respond to painful stimuli
Physical appearance
Behavior
o Mood: Emotion
o Affect: Expression of mood
Cognitive and intellectual abilities
o Immediate memory: Repeat series of numbers
o Recent memory: Recall visitors earlier that day
o Remote: State verifiable fact from past.
STANDARDIZED SCREENING TOOLS
MINI -MENTAL STATE EXAMINATION (MMSE)
Assesses problems with memory and other cognitive function
Maximum score is 30.
o 24-30 = no cognitive impairment
o 18-23 = mild cognitive impairment
o 0-17 = severe cognitive impairment
Items Assessed
Visuospatial: Copy intersecting pentagons
Language: Repeat sentences, comprehend instructions, write a short sentence. Recognize and name common objects.
Concentration: Subtraction task or spell WORLD backwards
Working memory: Repeat 3 words
Memory recall: Short-term memory recall task
Orientation: Time and place
GLASGOW COMA SCALE
Assesses a patient’s level of consciousness
Maximum score is 15
o 15 = client is awake and responding appropriately.
o 7 or less = client is in a coma
Items Assessed
Eye response: 4 = opens spontaneously, 3 = open to verbal command, 2 = open to pain, 1 = none
Verbal response: 5 = oriented, 4 = confused, 3 = inappropriate words, 2 = incomprehensible sounds, 1 = none
Motor response: 6 = obeys commands, 5 = localizing pain, 4 = withdrawal from pain, 3 = flexion to pain, 2 = extension to pain, 1 = none
KUBLER-ROSS STAGES OF GRIEF (5)
1
,NUR 222 Mental Health Final Study Guide-1
1. Denial = “It can’t be true”
2. Anger
2
,NUR 222 Mental Health Final Study Guide-1
3. Bargaining = “If only I had done more”
4. Depression
5. Acceptance
ERIKSON’S STAGES OF PSYCHOSOCIAL DEVELOPMENT (8)
1. Trust vs Mistrust (Birth to 18 months)
a. Infants must learn that adults can be trusted.
b. Unresponsive caregivers can engender feelings of anxiety, fear, and mistrust.
c. May develop a sense of mistrust for people in the world in the future.
2. Autonomy vs Shame/Doubt (1-3 years)
a. Toddlers need to learn to control actions and act on their environments.
b. A 2-year-old child may want to dress herself. Even if the outfits aren’t appropriate, her input in the decision has an effect on her sense
of independence.
c. IF denied the opportunity to act on her environment, she may begin to doubt her abilities.
d. May lead to low self-esteem and feelings of shame.
3. Initiative vs. Guilt (3-6 years)
a. Preschool age children are capable of initiating activities and asserting control over their world through social interactions and play.
b. Learn to plan and achieve goals while interacting with others.
c. Children will develop self-confidence and feel sense of purpose.
d. If unsuccessful due to over-controlling parents, may develop feelings of guilt.
4. Industry vs Inferiority (6-12 years)
a. Children either develop a sense of pride and accomplishment in schoolwork, sports, social activities, and family life, or they feel inferior
and inadequate because they feel they don’t measure up.
b. If children do not learn to get along with others or have negative experiences at home or with peers, inferiority complex might develop.
5. Identity vs. Role confusion (12-18 years)
a. Adolescents struggle with questions such as “Who am I?” and “What do I want to do with my life?”
b. If successful, have a strong sense of identity and are able to remain true to their beliefs and values in the face of problems and other
people’s perspectives.
c. If unsuccessful, may develop a weak sense of self and experience role confusion.
6. Intimacy vs. Isolation (20s-40s)
a. Learning to share your life with others.
b. If do not develop intimate relationship, may experience feelings of loneliness and emotional isolation.
7. Generativity vs. Stagnation (40s-60s)
a. Finding your life’s work and contributing to the development of others through activities such as volunteering, mentoring, and raising
children.
b. Childbirth or caring for others.
c. Those who do not master this task may feel they are not leaving a mark on the world in a meaningful way.
8. Integrity vs. Despair (60s-end of life)
a. Reflection on life and feeling a sense of satisfaction or a sense of failure.
b. People who feel proud of their accomplishments feel a sense of integrity.
c. People who are unsuccessful feel their life has been wasted. Focus on what they should have done.
LEGAL AND ETHICAL ISSUES
3
, NUR 222 Mental Health Final Study Guide-1
RIGHTS OF CLIENTS IN MENTAL HEALTH SETTINGS
Right to medical/dental care Refuse treatment Interpretive services
4
