Mental Status Examination

A full mental status examination should be completed if the patient:

• develops dysphagia.

• has a new diagnosis of type 2 diabetes mellitus.

• complains of insomnia.

• has a change in behavior

  and the family is concerned.

Mental status assessment documents:

• schizophrenia and other mental health disorders.

• artistic or writing ability in the mentally ill person.

• emotional and cognitive functioning.

• intelligence and educational level.

Although a full mental status examination may not be required for every patient, the health care provider must address the four main components during a health history and physical examination. The four components are:

• language, orientation, attention, and abstract reasoning.

• mood, affect, consciousness, and orientation.

• appearance, behavior, cognition, and thought processes.

• memory, attention, thought content, and perceptions.

Which of the following best illustrates an abnormality of thought process?

• Lability

• Compulsion

• Aphasia

• Thought blocking

The mental status examination:

• should be completed at the end of the physical examination.

• assesses mental health strengths and coping skills and screens for any dysfunction.

• is usually not assessed in children younger than 2 years of age.

• will not be affected if the patient has a language impairment.

To assess affect, the nurse should ask the patient:

• “How do you feel today?”

• “Would you please repeat the following words?”

• “Have these medications had any effect on your pain?”

• “Has this pain affected your ability to dress yourself?”

The nurse is planning to assess new memory with a patient. The best way to do this would be to:

• administer the FACT Test.

• ask him to describe his first job to you.

• give him the Four Unrelated Words Test.

• ask him to describe the last TV show he watched before coming to the clinic.

Nurse Hazel is caring for a male client who experiences false sensory perceptions with no basis in reality. This perception is known as:

• Hallucinations

• Delusions

• Loose associations

• Neologisms

Nurse Benjie is communicating with a male client with substance-induced persisting dementia; the client cannot remember facts and fills in the gaps with imaginary information. Nurse Benjie is aware that this is typical of?

• Flight of ideas

• Associative looseness

• Confabulation

• Concretism

A 23-year-old client who has been admitted with a diagnosis of schizophrenia says to the nurse “Yes, it’s march, March is a little woman”. That’s literal you know”. These statements illustrate:

• Neologisms

• Echolalia

• Flight of ideas

• Loosening of association