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