Mental health assessment Nursing 2 N Ford PSC 11.9.02022

List some things in a patients room that you would want to remove and why...

-Tubing or chords that are not in use as this can be used as a strangulation device -a mirror should be removed as the glass can be broken and used to hurt themselves or someone else ​

Explain the type of posture, positioning, and angle we should have with our patients... (4)

-eye level -not directly in front but on the side -relaxed but showing that you are giving full attention (do not cross arms) -make sure you are not within arms reach for your own safety ​

Explain the difference between a compulsion and an obsession?

A obsession is a thought and compulsion is the action

When being in a patients room what should we make sure we always have?

An exit, the last thing you want is to be trapped in a corner with someone that is manic that is wanting to kill you

What does ataxia mean?

Ataxia means impaired co-ordination

What is thought broadcasting?

Believes everyone can read their thoughts

What is thought insertion?

Believes that thoughts have been implanted into their mind

You ask a patient a simple question and they give you a ton of background information and finally give you the answer (story is filled with unnecessary details) "to make a long story longer" this is considered what type of speech?

Circumstantial speech

Explain the difference between circumstantial and tangentiality...

Circumstantial speech will eventually answer the question tangentiality will never answer the question asked

What is echolalia and echopraxia?

Echolalia is when someone will repeat words of a sentence like a parrot Echopraxia is when someone will copy someones movements

what does euthymic mean when discussing someone's mood?

Euthymic means normal

What does akathisia mean?

Fidget; can't sit still

Explain the differences between full or blunted when discussing affect...

Full affect range= reacting appropriately to a situation blunted affect range= Someone will have the same dull emotion no matter the conversation

If someone believes they are someone like the president or a famous musician this is what type of delusion?

Grandeur delusion (they think that they are very grand)

what does stupor mean when assessing a patient?

Grunts and groans when external stimuli is given to the patient

Occurrences in environment related to patient an example: When the nurses are in the hallway laughing then the patient thinks they are laughing about them...

Ideas of reference

What are loose associations?

Ideas switch subjects, incoherent relating things and ideas that are farfetched

when someone is experiencing euphoria what does this mean? What does dysphoric?

If someone is feeling euphoria then this means they are having a feeling of great well being, dysphoric is the opposite (feeling dissatisfied with ones own self)

Nurse: "Do you think these books will fit in the box?" Patient: "Of course they will, the box is brown" this would represent what type of speech?

Illogical speech

What is the difference between illusions and hallucinations?

Illusions are misperceptions of real stimuli (The vacuum cord is a snake, the shadow that is behind me is someone following me) (Think of an optimal illusion, its there but its not what it perceives to be) Hallucinations are perceptions not associated with real stimuli (they visualize something like a fire on their lap and there is nothing similarly close to something representing a fire)

Echopraxia means what?

Mimicking someone's movement and this typically seen by the patient in a time of distress

Psychological assessment includes what aspects of the patient? (3)

Mood thoughts behaviour

When documenting a fight between two patients is it okay to include the other patients name in the chart?

No it is not okay as this violates HIPPA

What colors should be seen around the mental health unit?

Nothing bright and overwhelming, aim for neutral colors that are not overstimulating

What does obtunded when assessing a patient?

Obtunded= response with few words then goes back to sleep

depersonalization derealization illusions hallucinations these are all examples of different _______

Perceptions (how someone perceives and experiences reality)

If a pt believes that the FBI is out to get them or the teacher hates me... this would be what type of delusion?

Persecution delusion

the patient asks the nurse "when do we eat lunch" in several different ways getting the same answer, this would be known as what?

Perseveration

Special message from environment such as the FBI is communicating to me through this commercial to hide my money... this would be considered what type of delusion...

Reference delusion

Someone believes they are god or the chosen one, what type of delusion is this?

Religious delusion

What is our number one priority with our mental health patients?

Safety safety safety is our number ONE priority

a pt believes their body is diseased or abnormal this would be considered what type of delusion?

Somatic delusion

You ask the patient a question and they ramble about the topic but never end up answering the question the nurse would document this as what type of speech?

Tangentiality

What is affect?

The observable component of emotion

A nurse ask the patient "what brought you to the hospital today?" the patient replies with "a Cab" when the nurse clearly meant like why are they seeking care.... the nurse would document that the patient has ____ thinking...

The patient has concrete thinking and cannot think abstractly

Influence or control delusion

The pt believes they have special powers or are being controlled

What will the patient be doing if they have pseudoparkinsonian symptoms?

They might have a stiff shuffling gait, tremors, and pill rolling

What is a neologism?

This is when the patient will use a MADE UP word

What mental illness do we see thought blocking commonly occur?

Thought blocking is commonly seen with Schizophrenia

If a patient is brought to the hospital and they disagree with being hospitalized because the cause of their illness is the aliens in their brain we would document their insight as what?

WE would document their insight as poor

If we are documenting a sociocultural aspect of someone's life we are documenting what essentially?

We are documenting their environment essentially, where the live

When we are talking about a patients somatic symptoms what are we referring to?

We are referring to their physical symptoms such as -bp -hr -hunger etc....

When we are talking about functional abilities what are we referring to?

We are talking about how much a patient can complete their ADL's for example: -going to the bathroom -sleep -making food for ones self

If we are asking someone if they are hallucinating what word should we avoid when asking this question?

We need to avoid using the word hallucination, we need to ask something like, do you see/hear things that other people don't see sometimes

How scale can we use to rate someone's mood? And what can we use this for?

We should how happy they feel 1-10 this can be used to gauge to see if they are getting more happy or if it is decreasing

If we start to talk to our patient during a mental health assessment and they make an outrageous claim like I am the king or I am the first astronaut on the moon what should we not do?

We should not dent their claims as this will most likely make the patient not trust/not answer questions you have for them

when we are assessing someone's cognitive function what three questions will we ask them?

We will ask questions that will make them identify person, place, and time an example would be, Tell me your first and last name, can you tell me where you're at, and then who is the president of the united states these trail of questions help identify someone's cognitive function

What will we see upon assessment with someone with tardive dyskinesia?

We will see abnormal invol movements of the face

If someone is laughing when explaining that their mother has died how would we document in the affect?

We would document this as inappropriate

What is clang languegue?

When the patient will answer in rhyme

What is a flat affect?

absence of emotional expression

Paranoia

an irrational suspiciousness or distrust of others

What does elevated mean when discussing a patients affect?

appearing to be extremely happy

when someone is fearing the worst we would describe this as someone being...

apprehensive

What does congruent and incongruent mean when discussing affect?

congruent= The mood that they stated matches their affect Incongruent= The mood that the patient stated does not reflect their affect

What is akinesia?

difficulty initiating movement or loss of movement

what does bradykinesia mean?

extremely slow lessness with movement

What does laconic speech look like?

fast and intense with a abrupt/ angry undertone

What are delusions?

fixed false beliefs

when assessing someone's risk of suicide what questions should we ask them...

have you ever had thoughts to hurt yourself or others (if yes) have they made plans to follow out their suicide and or have they attempted their plan

How the patient says they feel describes their what?

how the patient feels describes their mood

If we ask a patient what would you spend $10,000 on if someone gave it to you right now and they respond with 4,000 jars of peanut butter we document their judgment as what?

impaired judgement would be documented poor would be like they would use it to kill someone else or just something really bad essentially

What does anhedonia mean?

inability to feel pleasure

What is dystonia?

involuntary muscle movements

What does labile mean?

mood and affect changing rappidly

How should the lighting be for a mental health patient?

not to bright not to dark (a happy medium should be achieved)

Ruminations

recurrent themes of thoughts -expressing concerns in several different ways but all are centered around one thought -this can also be related to a story being retold over and over again

olfactory

relating to the sense of smell

Explain the differences between religion and spirituality...

someone's religion explains their religious practices while someone's spirituality defines ones purpose to live and what they think life is about and some rules and morals they have developed based on their upbringing (religion and spirituality are closely related but if someone practices their religion souly just due to the rules of religion then those are religious acts not spiritual but if someone truly believes their practice of religion has strong purpose to life then that's when they mix)

gustatory

taste

What is a nihilistic delusion?

the belief that they are dead or between realms

If someone is building a mental health unit what floor should the mental health unit be on and why?

the mental health unit should be located on the first floor so patients do not hop out the window in an attempt to harm themselves

A patient says they feel out of body How would the nurse document this?

the nurse would document this as DEPERSONALIZATION

A patient says that the place or enviorment that they are in feels fake... what would the nurse document this as?

the nurse would document this as DEREALIZATION

A patient is telling a long story then all the sudden they just stop... two minutes passes by and then they continue to tell a DIFFERENT story... the nurse would document this as...

the nurse would document this as Thought blocking

If someone is compulsivley locking the door what does this mean?

this means they will get up over and over again to lock the door even though it is already locked

what kind of questions should we ask our mental health patients and why?

we should ask open ended questions as it will paint a wholistic picture of our patient. YES or NO questions will give you very little data

What a patient thinks and knows would be considered what type of assessment?

what a patient thinks and knows is considered a cognitive assessment

What is magical thinking?

when someone believes that thinking about it will make it happen

What does pressured speech look like?

when someone is nervous so they will talk really fast

What is word salad?

when the patient will talk in a sentence but all the words do not relate a literal word salad