NURS 509 Study Guide Test exam-Health Assesment
(Chamberlain College of Nursing)
Chapter 5
Behavior/Mental Health Assessment and Modification for Age
• Unexplained conditions lasting >6weeks should
prompt screening for depression, anxiety, or
both
• PRIME-MD (Primary Care Evaluation of Mental
Disorders). 26 questions and take 10 minutes to
complete. Used for the 5 most common=anxiety,
depression, alcohol, somatoform, and eating disorders.
• Patient indications for Mental Health Screening:
1. Medically unexplained physical symptoms-more than
half have depression and
anxiety disorders
2. Multiple physical or somatic symptoms or high
symptom count 3.High severity of the
presenting somatic symptoms, chronic pain
4.Symptoms for more than 6 weeks
5. Physician rating as a “difficult encounter”
6. Recent stress
7.Low-self rating of overall
health 8.Frequent use of
health care services
9.Substance abuse.
CAGE=substance-related and addictive disorders
Modification for Age
Elderly:
• -Complain of memory problems but usually is due to
benign forgetfulness
• -Retrieve and process data more slowly and take
longer to learn new information
• -Slower motor responses and their ability to perform
complex task may diminish
• -Important to distinguish age-related changes from
manifestations of mental disorders
• More susceptible to delirium which can be the first
sign of infection, problems with medications, or
impending dementia
Infant:
• Assess mental status of a newborn=observing newborn
activities
• 1.Look at human faces and turn to parents voice
• 2.Ability to shout out repetitive stimuli
• 3. Bond with caregiver
• 4.Self-soothe
Normal VS. Abnormal Findings and Interpretation
NURS 509 Study Guide Test exam-Health Assesment
(Chamberlain College of Nursing)
, NURS 509 Study Guide Test exam-Health Assesment
(Chamberlain College of Nursing)
• Mood disorders: compulsions, obsessions, phobias, and
anxieties
• -Lethargic: drowsy, but open their eyes and look at you,
respond to questions, and then fall asleep.
• -Obtunded: open their eyes and look at you but
respond slowly and are somewhat confused.
• -Agitated depression: crying, pacing, and handwringing
• -Depression: the hopeless slumped posture and slowed
movements.
• -Grooming and personal hygiene may deteriorate:
Depression, schizophrenia, and dementia
• -Manic Episode: the agitated and expansive movement of
a manic episode
• -Obsessive-Compulsive Disorder: Excessive fastidiousness
• -Lesion parietal cortex: one side neglect in the
opposite parietal cortex, usually in the
nondominant side
• -Parkinsonism: facial immobility
• -Paranoia: anger, hostility, suspiciousness, or evasiveness
• -Mania: Elation and euphoria
• Schizophrenia: flat affect and remoteness
• Apathy (dull affect with detachment and indifference):
dementia, anxiety, and depression
• Hallucination: schizophrenia, alcohol withdrawal, and
systemic toxicity
• Amnestic Disorders: impaired memory or new learning
ability and reduce social or occupational functioning but
lack the global features of delirium and or dementia.
Anxiety and depression, and intellectual disability may
also
cause recent memory impairment.
• Calculating ability: poor performance = dementia or aphasia
Variations and abnormalities in thought processes:
1. Circumstantiality: The mildest thought disorder, consisting of
speech with unnecessary detail, indirections, and delay in
reaching the point. Some topics may have a meaningful
connection
Occurs in people with obsessions
2. Derailment: Tangential, speech with shifting from topics
that are loosely connected or unrelated. The patient is
unaware of the lack of association. Schizophrenia,
manic episodes, and other psychotic disorders
3. Flight of ideas: an almost continuous flow of accelerated
speech with abrupt changes from one topic to the next.
Changes are based on understandable associations, play on
words, or distracting stimuli, but ideas are not well
connected.
Manic episodes
4. Neologisms: invented or distorted words, or words
with new and highly idiosyncratic meanings
-Schizophrenia: psychotic disorders, and aphasia
5. Incoherence: Speech that is incomprehensible and illogical,
with lack of meaningful connections, abrupt changes in
topic, or disordered
NURS 509 Study Guide Test exam-Health Assesment
(Chamberlain College of Nursing)
,NURS 509 Study Guide Test exam-Health Assesment
(Chamberlain College of Nursing)
NURS 509 Study Guide Test exam-Health Assesment
(Chamberlain College of Nursing)
, NURS 509 Study Guide Test exam-Health Assesment
(Chamberlain College of Nursing)
grammar or word use. Flight of ideas, when severe, may produce
incoherence
-Schizophrenia
6. Blocking: Sudden interruption of speech in mid-sentence
or before the idea is completed “losing the thought”
-Schizophrenia
7. Confabulation: Fabrication of facts or events, to fill in the
gaps from impaired memory
-Korsakoff syndrome from alcoholism
8. Perseveration: persistent repetition of words or ideas
-Schizophrenia or other psychotic disorders
9. Echolalia: Repetition of the words and phrases of others
-Manic episodes or Schizo
10. Clanging: Speech with choice of words based on sound, rather
than meaning, as in rhyming and punning. Example: “look at my
eyes and nose, wise eyes and rosy nose. To to one, the ayes
have it!”
-Schizo and manic episodes
Abnormalities of Perception
1. Illusions: misinterpretations of real external stimuli,
such as mistaking rustling leaves for the sounds of
voices
-Grief, delirium, PTSD, Schizo
2.Hallucinations: Perception-like experiences that seem
real but, unlike illusions, lack actual external stimulation.
The person may or may not recognize the experiences as
false. May be auditory, visual, olfactory, gustatory, tactile,
or somatic.
-PTSD, Schizo, delirium, dementia,
alcoholism Abnormalities of Thought Content
1.Compulsions
-repetitive behaviors feel driven to perform in response to an
obsession (anxiety disorders)
2.Obessions
-Recurrent persistent thoughts,
images, or urges 3.Phobias
-Persistent irrational thoughts, compelling desire to avoid
provoking stimulus
4. Anxieties
5. Feelings of unreality
6.Feelings of
Depersonalization 7.Delusions
Erotomanic: the belief that another person is in love with
the individual
Somatic: involves body functions
Unspecified: includes delusions of reference without a
prominent persecutory or grandiose component
Speech Patterns
NURS 509 Study Guide Test exam-Health Assesment
(Chamberlain College of Nursing)
(Chamberlain College of Nursing)
Chapter 5
Behavior/Mental Health Assessment and Modification for Age
• Unexplained conditions lasting >6weeks should
prompt screening for depression, anxiety, or
both
• PRIME-MD (Primary Care Evaluation of Mental
Disorders). 26 questions and take 10 minutes to
complete. Used for the 5 most common=anxiety,
depression, alcohol, somatoform, and eating disorders.
• Patient indications for Mental Health Screening:
1. Medically unexplained physical symptoms-more than
half have depression and
anxiety disorders
2. Multiple physical or somatic symptoms or high
symptom count 3.High severity of the
presenting somatic symptoms, chronic pain
4.Symptoms for more than 6 weeks
5. Physician rating as a “difficult encounter”
6. Recent stress
7.Low-self rating of overall
health 8.Frequent use of
health care services
9.Substance abuse.
CAGE=substance-related and addictive disorders
Modification for Age
Elderly:
• -Complain of memory problems but usually is due to
benign forgetfulness
• -Retrieve and process data more slowly and take
longer to learn new information
• -Slower motor responses and their ability to perform
complex task may diminish
• -Important to distinguish age-related changes from
manifestations of mental disorders
• More susceptible to delirium which can be the first
sign of infection, problems with medications, or
impending dementia
Infant:
• Assess mental status of a newborn=observing newborn
activities
• 1.Look at human faces and turn to parents voice
• 2.Ability to shout out repetitive stimuli
• 3. Bond with caregiver
• 4.Self-soothe
Normal VS. Abnormal Findings and Interpretation
NURS 509 Study Guide Test exam-Health Assesment
(Chamberlain College of Nursing)
, NURS 509 Study Guide Test exam-Health Assesment
(Chamberlain College of Nursing)
• Mood disorders: compulsions, obsessions, phobias, and
anxieties
• -Lethargic: drowsy, but open their eyes and look at you,
respond to questions, and then fall asleep.
• -Obtunded: open their eyes and look at you but
respond slowly and are somewhat confused.
• -Agitated depression: crying, pacing, and handwringing
• -Depression: the hopeless slumped posture and slowed
movements.
• -Grooming and personal hygiene may deteriorate:
Depression, schizophrenia, and dementia
• -Manic Episode: the agitated and expansive movement of
a manic episode
• -Obsessive-Compulsive Disorder: Excessive fastidiousness
• -Lesion parietal cortex: one side neglect in the
opposite parietal cortex, usually in the
nondominant side
• -Parkinsonism: facial immobility
• -Paranoia: anger, hostility, suspiciousness, or evasiveness
• -Mania: Elation and euphoria
• Schizophrenia: flat affect and remoteness
• Apathy (dull affect with detachment and indifference):
dementia, anxiety, and depression
• Hallucination: schizophrenia, alcohol withdrawal, and
systemic toxicity
• Amnestic Disorders: impaired memory or new learning
ability and reduce social or occupational functioning but
lack the global features of delirium and or dementia.
Anxiety and depression, and intellectual disability may
also
cause recent memory impairment.
• Calculating ability: poor performance = dementia or aphasia
Variations and abnormalities in thought processes:
1. Circumstantiality: The mildest thought disorder, consisting of
speech with unnecessary detail, indirections, and delay in
reaching the point. Some topics may have a meaningful
connection
Occurs in people with obsessions
2. Derailment: Tangential, speech with shifting from topics
that are loosely connected or unrelated. The patient is
unaware of the lack of association. Schizophrenia,
manic episodes, and other psychotic disorders
3. Flight of ideas: an almost continuous flow of accelerated
speech with abrupt changes from one topic to the next.
Changes are based on understandable associations, play on
words, or distracting stimuli, but ideas are not well
connected.
Manic episodes
4. Neologisms: invented or distorted words, or words
with new and highly idiosyncratic meanings
-Schizophrenia: psychotic disorders, and aphasia
5. Incoherence: Speech that is incomprehensible and illogical,
with lack of meaningful connections, abrupt changes in
topic, or disordered
NURS 509 Study Guide Test exam-Health Assesment
(Chamberlain College of Nursing)
,NURS 509 Study Guide Test exam-Health Assesment
(Chamberlain College of Nursing)
NURS 509 Study Guide Test exam-Health Assesment
(Chamberlain College of Nursing)
, NURS 509 Study Guide Test exam-Health Assesment
(Chamberlain College of Nursing)
grammar or word use. Flight of ideas, when severe, may produce
incoherence
-Schizophrenia
6. Blocking: Sudden interruption of speech in mid-sentence
or before the idea is completed “losing the thought”
-Schizophrenia
7. Confabulation: Fabrication of facts or events, to fill in the
gaps from impaired memory
-Korsakoff syndrome from alcoholism
8. Perseveration: persistent repetition of words or ideas
-Schizophrenia or other psychotic disorders
9. Echolalia: Repetition of the words and phrases of others
-Manic episodes or Schizo
10. Clanging: Speech with choice of words based on sound, rather
than meaning, as in rhyming and punning. Example: “look at my
eyes and nose, wise eyes and rosy nose. To to one, the ayes
have it!”
-Schizo and manic episodes
Abnormalities of Perception
1. Illusions: misinterpretations of real external stimuli,
such as mistaking rustling leaves for the sounds of
voices
-Grief, delirium, PTSD, Schizo
2.Hallucinations: Perception-like experiences that seem
real but, unlike illusions, lack actual external stimulation.
The person may or may not recognize the experiences as
false. May be auditory, visual, olfactory, gustatory, tactile,
or somatic.
-PTSD, Schizo, delirium, dementia,
alcoholism Abnormalities of Thought Content
1.Compulsions
-repetitive behaviors feel driven to perform in response to an
obsession (anxiety disorders)
2.Obessions
-Recurrent persistent thoughts,
images, or urges 3.Phobias
-Persistent irrational thoughts, compelling desire to avoid
provoking stimulus
4. Anxieties
5. Feelings of unreality
6.Feelings of
Depersonalization 7.Delusions
Erotomanic: the belief that another person is in love with
the individual
Somatic: involves body functions
Unspecified: includes delusions of reference without a
prominent persecutory or grandiose component
Speech Patterns
NURS 509 Study Guide Test exam-Health Assesment
(Chamberlain College of Nursing)
