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Med Surg I Chapt 8
Mental Health
| Term | Definition |
|---|---|
| Which is an example of an open-ended question? | What concerns you most about your health? |
| Which is an example of a closed-ended (focused) question? direct questions | Where are you employed? |
| Assessment data about the client’s speech patterns are categorized in which areas | General appearance and motor behavior |
| When the nurse is assessing whether the client’s ideas are logical and make sense, the nurse is examining which areas? | Thought process |
| The client’s belief that a news broadcast has a special meaning for them is an example of | ideas of reference |
| The client who believes everyone is out to get them is experiencing a(n) | delusion. |
| To assess the client’s ability to concentrate, the nurse would instruct the client to do which? | Repeat the days of the week backward. |
| The client tells the nurse, “I never do anything right. I make a mess of everything. Ask anyone; they’ll tell you the same thing.” The nurse recognizes these statements as examples of | negative thinking. |
| Assessment of sensorium and intellectual processes includes which? | Concentration Memory Orientation |
| Assessment of suicidal risk includes which? | Intent to die Method Plan Reason |
| Abstract thinking ability What does the saying “A rolling stone gathers no moss” mean to you? | which is to make associations or interpretations about a situation or comment |
| Insight the ability to understand the true nature of one’s situation and accept some personal responsibility for that situation. | The nurse can frequently infer insight from the client’s ability to realistically describe the strengths and weaknesses of their behavior. |
| Self-concept is the way one views oneself in terms of personal worth and dignity. | the nurse can ask the client to describe themself, what personal characteristics they like, and what they would change. |
| Judgment If you were lost downtown, what would you do? | this refers to the ability to interpret one’s environment and situation correctly and to adapt one’s behavior and decisions accordingly |
| Mood In general, how are you feeling? It is what the patient says they feel | example I feel depressed |
| Orientation Can you tell me your name? (person) Can you tell me where you are? (place) Can you tell me today’s date? (time) | |
| Circumstantial thinking: a client eventually answers a question but only after giving excessive, unnecessary detail. eventually gets to the answer | |
| Delusion: a fixed false belief not based in reality | |
| Flight of ideas: excessive amount and rate of speech composed of fragmented or unrelated ideas. rapidly jumps from topic to topic | |
| Ideas of reference: client’s inaccurate interpretation that general events are personally directed to them, such as hearing a speech on the news and believing the message had personal meaning | thinks they are talking about them |
| Loose associations: disorganized thinking that jumps from one idea to another with little or no evident relation between the thoughts | talking about diff things |
| Tangential thinking: wandering off the topic and never providing the information requested. Never gets back to the answer!! | off subject talking |
| Thought blocking: stopping abruptly in the middle of a sentence or train of thought; sometimes unable to continue the idea | mind goes blank |
| Thought broadcasting: a delusional belief that others can hear or know what the client is thinking | |
| Thought insertion: a delusional belief that others are putting ideas or thoughts into the client’s head—that is, the ideas are not those of the client | |
| Thought withdrawal: a delusional belief that others are taking the client’s thoughts away and the client is powerless to stop it | |
| Word salad: flow of unconnected words that convey no meaning to the listener | |
| Orientation refers to the client’s recognition of person, place, and time—that is, knowing who and where they are and the correct day, date, and year | This is often documented as “oriented × 3.” |
| Absence of correct information about person, place, and time is referred to as disorientation or “oriented × 1” (person only) or “oriented × 2” (person and place). | |
| The order of person, place, and time is significant. | |
| When a person is disoriented, they first lose track of time, then place, and, finally, person. | |
| Orientation returns in the reverse order; first, the person knows who they are, then realizes place, and, finally, time. | |
| Disorientation is not synonymous with confusion. | |
| A confused person cannot make sense of their surroundings or figure things out even though they may be fully oriented. | |
| What is the name of the current president? Who was the president before that? In which county do you live? | What is the capital of this state? What is your social security number? questions to assess memory |
| The nurse assesses the client’s ability to concentrate by asking the client to perform certain tasks | Spell the word “world” backward. Begin with the number 100, subtract 7, subtract 7 again, and so on. This is called “serial sevens.” |
| Repeat the days of the week backward. Perform a three-part task, such as “Take a piece of paper in your right hand, fold it in half, and put it on the floor.” (The nurse should give the instructions at one time.) | client’s ability to concentrate by asking the client to perform certain tasks: |
| Proverb: A stitch in time saves nine. Abstract meaning: If you take the time to fix something now, you’ll avoid bigger problems in the future. | Literal translation: Don’t forget to sew up holes in your clothes (concrete thinking). |
| Proverb: People who live in glass houses shouldn’t throw stones. Abstract meaning: Don’t criticize others for things you also may be guilty of doing. | |
| . If the client provides a literal explanation of the proverb and cannot interpret its meaning, abstract thinking abilities are lacking. | When the client continually gives literal translations, this is evidence of concrete thinking |
| Assessment is an ongoing, dynamic process, not a one-time activity | |
| The nurse will assess and reassess throughout the care of the client | |
| Reassessment is the basis for changing the plan of care, evaluation of treatment effectiveness, discharge planning, and follow-up care in the community. | |
| Psychological tests are another source of data for the nurse to use in planning care for the client | |
| Intelligence tests are designed to evaluate the client’s cognitive abilities and intellectual functioning. | |
| Personality tests reflect the client’s personality in areas such as self-concept, impulse control, reality testing, and major defenses. | |
| Other personality tests, called projective tests, are unstructured and are usually conducted using the interview method. | |
| The stimuli for these tests, such as pictures or Rorschach’s inkblots, are standard, but clients may respond with answers that vary widely. | |
| Medical diagnoses of psychiatric illness are found in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). | |
| this taxonomy is universally used by psychiatrists and some therapists in the diagnosis of psychiatric illnesses. | |
| It describes each disorder and provides diagnostic criteria to distinguish one from another. The descriptions of disorders and related behaviors can be a valuable resource for the nurse to use as a guide. | |
| . The Mini-Mental State Exam (MMSE) is available on many website | |
| Mental Status Examination include items such as orientation to person, time, place, date, season, and day of the week; ability to interpret proverbs; ability to perform math calculations; | memorization and short-term recall; naming common objects in the environment; ability to follow multistep commands; and ability to write or copy a simple drawing. |
| mental status examination assesses cognitive ability, it is often used to screen for dementia. | |
| cognition may also be impaired (usually temporarily) when clients are depressed or psychotic. | |
| Intensive care unit (ICU) survivors often have long-term complications, such as post intensive care syndrome (PICS) and posttraumatic stress disorder (PTSD), following critical illness and a stay in the ICU | |
| Two areas that may be uncomfortable or difficult for the nurse to assess are sexuality and self-harm behaviors. | |
| The burden of PICS and PTSD on clients, their families, and health care providers can be overwhelming. | |
| Self-awareness is crucial when a nurse is trying to obtain accurate and complete information from the client during the psychosocial assessment process. | |
| The nurse must be aware of any feelings, biases, and values that could interfere with the psychosocial assessment of a client with different beliefs, values, and behaviors. | |
| the nurse cannot let personal feelings and beliefs influence the client’s treatment. | |
| Self-awareness does not mean the nurse’s beliefs are wrong or must change, but it does help the nurse to be open and accepting of others’ beliefs and behaviors even when the nurse does not agree with them. | |
| Insight What led you to come to the clinic? | |
| Self-concept How would you describe yourself as a person? | body image personal characteristics |
| Abstract thinking ability What does the saying “A rolling stone gathers no moss” mean to you? | |
| emotions coping strategies | what do you do when u have problems? |
| role assessment types are | family occupation hobbies fulfillment of roles |
| relationship assessment | do you feel close to your family have you been involved in an abusive relationship |
| Physiological functioning importance emotional problems can affect eating | bipolar disorder and major depression |
| data analysis invovle reviewing overall assessment and leads to care plans | look for patterns, consider congruence, identify low self -esteem or inefficient coping |
| A role NOT typically assessed in a role assessment is Client Satisfaction- Client satisfaction is NOT a role itself | |
| Hallucinations are false sensory perceptions or experiences that do not exist i hear someone talking to me when no one is there | |
| Auditory Hallucination are MOST common- client hears voices | |
| Visual Hallucinations are SECOND common- client sees things NOT actually there | |
| Example of POOR INSIGHT is blaming others for personal behavior and expecting problems to be solved without effort | |
| Labile Mood- Rapid mood swings | |
| Intensity rating- scale of 0-10 | |
| Blunt Affect- Slow to respond facial expressions | |
| Broad Affect- Full emotional facial expression | |
| Flat Affect- No facial expression | |
| Inappropriate Affect- Incongruent facial esxpression | |
| Restricted Affect- Serious/Somber facial expression | |
| Automatisms- purposeless behaviors insicating anxiety | |
| Psychomotor retardation- slow movements | |
| Waxy flexibility- Awkard posture | |
| Do not give nonverbal cues this causes defensiveness | |
| Ask sensitive questions matter of fact such as "What type of discipline do you use?" | |
| The first step in client care according to definition is collecting data and information | |
| Nurse relies on observations, medical records, and family input for accurate assessment | |
| Psychosocial assessment includes metal status examination | |
| Psychosocial assessment is to gain a picture of the client's mental status- a baseline | looking to assess mental capacity and behavioral function |
| Nurse wants to identify cues requiring action to establish baseline to evaluate treatment effectiveness | |
| Illusion= a real stimulus is misinterpreted patient sees a coat hanging on a chair and thinks it's a person | perception |
| Affect=what a nurse observes patient appears tearful with little facial affects | |
| Neologism is a made-up word only meaningful to patient | thought process |
| Grandiose delusion- exceptional power, wealthy, ability, or identity | thought content |
| persecutory delusion belief someone is targeting or harming them | thought content |
| Orientation *4= person place time situation | |
| tactile hallucination= feeling something touching them not there olfactory hallucination=smelling something not there gustatory hallucination= tasting something not there | perception |
| obsession=recurrent unwanted thought compulsion= repeat behaviors to reduce anxiety | OCD thought content |
| poor insight= limited awareness of illness/behavior good insight=understands illness/behavior | insight |
| REFERNTIAL DELUSION=DELUSIONAL THINKING Believing unrelated events/messages are specifically about them!! ON THE TEST | Thought Content |
| somatic delusion=false belief involving the body/health | thought content |
| euphoric=abnormal elevated happiness dysphoric=unpleasant, sadness/irritability euthymic=normal/stable | mood |
| Pressured=rapid, difficult to interrupt | speech |
| intense=prolonged/staring | eye contact |
| psychomotor agitation= excessive, purposeless movements psychomotor retardation=slowed movement and responses | behavior |
| bizarre dress=clothing inappropriate or unusual for situation disheveled= mess, unkempt appearance | appearance |
| guarded=reluctant to share information | behavior |
| constricted=reduced range of emotions labile=rapidly changing emotions | affect |
Created by:
Daarina Jones