ATI - RN Mental Health Nursing
What do you assess for during a Mental Status Exam (MSE)? - Answers -1. level of
consciousness
2. physical appearance
3. behavior
4. cognitive and intellectual abilities
alert - Answers -able to fully respond by opening eyes, attend to normal tone of voice
and speech, and answer questions spontaneously and appropriately
lethargy - Answers -able to open eyes and respond, but is drowsy and falls asleep
readily
obtundation - Answers -needs to be lightly shaken to elicit a response; may be confused
and slow to respond
stupor - Answers -requires painful stimuli (e.g. pinch a tendon, rub sternum) to elicit a
brief response; may not be able to respond verbally
coma - Answers -no response from repeated painful stimuli
decorticate rigidity - Answers -flexion and internal rotation of upper extremity joints and
legs (arms toward midline)
decerebrate rigidity - Answers -neck and elbow extension, wrist and finger flexion (arms
away from midline)
mood - Answers -subjective data about emotions that are felt
affect - Answers -objective data about expression of mood
How do you assess recent memory? - Answers -Have patient recall a series of number
or list of objects.
How do you assess remote memory? - Answers -Have patient state a verifiable fact
(e.g. birthdate).
How do you assess level of knowledge? - Answers -Ask patient what they know about
their illness or hospitalization.
How do you assess ability to calculate? - Answers -Ask patient to count backward from
100 in serials of 7.
, How do you assess ability to think abstractly? - Answers -See if patient can interpret an
idiom/saying.
How do you assess judgment? - Answers -Ask 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? - Answers -1. 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? - Answers -eye, verbal, and motor
response
Glasgow Coma Scale - what is the lowest to highest value? - Answers -3 (coma) to 15
(awake and responding appropriately)
Axis I of the DSM-IV - Answers -all mental health dx except those found in Axis II
Axis II of the DSM-IV - Answers -personality disorder dx, mental retardation
Axis III of the DSM-IV - Answers -any general medical dx (e.g. asthma)
Axis IV of the DSM-IV - Answers -psychosocial problems, problems that may affect
dx/treatment/prognosis of mental disorders
Axis V of the DSM-V - Answers -global assessment of functioning (GAF)
What are some mental health nursing interventions? - Answers -1. 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
What do you assess for during a Mental Status Exam (MSE)? - Answers -1. level of
consciousness
2. physical appearance
3. behavior
4. cognitive and intellectual abilities
alert - Answers -able to fully respond by opening eyes, attend to normal tone of voice
and speech, and answer questions spontaneously and appropriately
lethargy - Answers -able to open eyes and respond, but is drowsy and falls asleep
readily
obtundation - Answers -needs to be lightly shaken to elicit a response; may be confused
and slow to respond
stupor - Answers -requires painful stimuli (e.g. pinch a tendon, rub sternum) to elicit a
brief response; may not be able to respond verbally
coma - Answers -no response from repeated painful stimuli
decorticate rigidity - Answers -flexion and internal rotation of upper extremity joints and
legs (arms toward midline)
decerebrate rigidity - Answers -neck and elbow extension, wrist and finger flexion (arms
away from midline)
mood - Answers -subjective data about emotions that are felt
affect - Answers -objective data about expression of mood
How do you assess recent memory? - Answers -Have patient recall a series of number
or list of objects.
How do you assess remote memory? - Answers -Have patient state a verifiable fact
(e.g. birthdate).
How do you assess level of knowledge? - Answers -Ask patient what they know about
their illness or hospitalization.
How do you assess ability to calculate? - Answers -Ask patient to count backward from
100 in serials of 7.
, How do you assess ability to think abstractly? - Answers -See if patient can interpret an
idiom/saying.
How do you assess judgment? - Answers -Ask 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? - Answers -1. 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? - Answers -eye, verbal, and motor
response
Glasgow Coma Scale - what is the lowest to highest value? - Answers -3 (coma) to 15
(awake and responding appropriately)
Axis I of the DSM-IV - Answers -all mental health dx except those found in Axis II
Axis II of the DSM-IV - Answers -personality disorder dx, mental retardation
Axis III of the DSM-IV - Answers -any general medical dx (e.g. asthma)
Axis IV of the DSM-IV - Answers -psychosocial problems, problems that may affect
dx/treatment/prognosis of mental disorders
Axis V of the DSM-V - Answers -global assessment of functioning (GAF)
What are some mental health nursing interventions? - Answers -1. 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
