Chapter 9: Mental health assessment skills

Objectives

Upon completion of this chapter, the student will be able to:

1. Identify two purposes of the mental health treatment plan.

2. List and define each step of the nursing process.

3. Describe three methods of data collection.

4. List six parts of a holistic nursing assessment.

5. Identify four guidelines for conducting effective psychiatric interviews.

6. Explain the importance of performing physical assessments of clients with

psychiatric diagnoses.

7. Explain the purpose of the mental status examination.

8. List the five general categories of the mental status examination.

9. Describe the process for conducting a mental status examination.

KEY TERMS

affect (ĀF-ĕkt) (p. 98)

assessment (ă-SĔS-mĕnt) (p. 94)

calculation (KĂL-kyū-LĀ-shŭn) (p. 100)

data collection (DĀ-tă kă-lĕc-shŭn) (p. 94)

depersonalization (p. 99)

insight (p. 100)

interview (ĬN-tәr-vyū) (p. 94)

judgment (JŬDJ-mĕnt) (p. 100)

memory (MĔM-ŏr-ē) (p. 99)

mood (p. 98)

nursing (therapeutic) process (NŬR-sĭng PRŎ-sĕs) (p. 93)

perceptions (pĕr-CĔP-shŭns) (p. 98)

risk factor assessment (p. 95)

sensorium (sĕn-SŌ-rē-ŭm) (p. 99)

thought content (p. 99)

thought processes (p. 99)

[Link]
Good assessment skills are critical to quality health care. The ability to
effectively obtain and use information about clients is a vital part of the
multidisciplinary treatment plan and the foundation of the nursing
(therapeutic) process. Caregivers must first learn about the person before
they can provide personalized care or judge the effectiveness of any
therapeutic action. Uncovering clients’ problems requires critical thinking
abilities and exceptional assessment skills. Therapeutic communications,
interactions, and assessment skills help care providers learn about all
aspects of their clients. This chapter provides the starting point for making
thorough mental health assessments.

Mental health treatment plan

People enter the health care system because they are distressed, disabled,
or suffering. The diagnosis and treatment of people with mental health
problems is challenging because diagnoses of mental illness are not as easily
identified and defined as physical disorders. According to the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5), “no definition adequately
specifies precise boundaries for the concept of mental disorder” (American
Psychiatric Association, 2013). The relationship between the physical and
psychological self is such that the two are difficult to separate. It is important
to remember, however, that every psychological problem has physical
effects, and each physical illness has psychological effects. The wise care
provider is aware of both.

When individuals first enter the mental health care system, ideally they
undergo a comprehensive assessment. Clients are interviewed by several
members of the multidisciplinary health care team. Physical and
psychological diagnostic testing is performed, and data (information) are
gathered from as many sources as possible. The physician provides
information regarding the client’s physical state and need for medications.
The social worker assesses the client’s family, work, and social interactions.
The dietitian learns about the client’s nutritional status. The psychiatrist and
psychologist explore the client’s emotional and cognitive (intellectual)
functioning. The nurse assesses how the illness or disability affects the
client’s activities of daily living. Other care providers contribute information
through their observations and interactions with the client.
Team members then meet to compare data, identify problems, and develop
treatment approaches. When the team and the client agree on the treatment
goals, a course of action is planned. Usually medical treatments
(medications) are combined with psychotherapies, behavioral therapies, and
other therapeutic actions. The overall treatment plan is then developed for
the individual client. Therapeutic actions are implemented, and the client’s
progress toward each goal is evaluated.

The mental health treatment plan serves several purposes. First, it is a guide
for planning and implementing client care. Nurses are guided by the
treatment plan when they develop specific nursing care plans. Psychologists,
social workers, and other therapists use the treatment plan as a framework
for implementing their specialized therapeutic actions.

Second, the plan serves as a vehicle for monitoring the client’s progress and
the effectiveness of therapeutic interventions. Clients meet often with
treatment team members to discuss problems and attempts to meet their
goals. Therapeutic interventions are evaluated, and the treatment plan is
revised to include new information.

Third, the mental health treatment plan serves as a means for

communicating and coordinating client care. The plan prevents costly
duplication of services and provides a focus for all therapeutic activities,
regardless of specialty. This increases the effectiveness of each team
member’s efforts. Developing the mental health treatment plan is not a
complex process, but it is a dynamic, changing as the client progresses.
Using the treatment plan allows clients and care providers the opportunity to
work together to meet client goals.

DSM-5 diagnosis

Therapists who work with mentally or emotionally troubled individuals often

use the fifth edition of the DSM, DSM-5, to aid in diagnosis and help guide
clinical practice. One of the tools used in the DSM-5 is the World Health
Organization’s Disability Assessment Tool (WHODAS 2.0; Table 9.1). The
diagnosis of mental health problems remains the responsibility of the
physician, but nurses and other care providers should be familiar with the
multiaxial system of psychiatric assessment. Several tools are available for
assessing mental status. One example of a mental health assessment tool is
seen in Appendix A.

Table 9.1

World Health Organization Disability Assessment Tool (WHODAS 2.0)

DOMAINS OF FUNCTIONING EXAMPLE

Cognition Communication, understanding

Getting along Interactions, meaningful relationships

Life activities Responsibilities, home, work, school, etc.

Mobility Moving, getting around

Participation Social functioning, community activities

Self-care Hygiene, dressing, eating, living situation

Nursing (therapeutic) process

Each step of the nursing (therapeutic) process is designed to support goal-

directed care for clients (Stuart, 2014). The process is an organizational
framework for effective care and consists of five steps: assessment,
diagnosis, planning, intervention, and evaluation. Using this process
encourages us to focus on the client and develop appropriate and effective
care.

The first step, assessment, is the data collection step. Bits of information
relating to the client are collected from every possible source. Medical
records are reviewed, a history is obtained, and observations are made;
discussions with family members or friends add to the database. Soon a
picture of the client begins to emerge. Using the mass of collected
information as a database, care providers plan care based on the needs,
abilities, preferences, and concerns of the client.
Next, data are organized into related areas, and problems are identified.
Each problem is then examined in detail, and problem statements and
nursing diagnoses are developed. (Medical diagnoses and interventions
relate to the client’s physical or mental dysfunctions; nursing diagnoses and
interventions focus on how the client’s problems affect his or her ability to
carry out the activities of daily living.) Client needs are also considered when
problem statements are being developed.

During the planning phase, specific short-term and long-term goals are
developed. The outcome of each problem is projected by identifying
behaviors that would indicate the problem is solved. These “expected
outcomes” are then used to monitor the client’s progress. Therapeutic
actions (interventions) are planned using goals and expected outcomes.
Then a written care plan is developed.

The intervention phase includes the actual delivery of the planned actions.
Therapeutic interventions, carried out by all mental health care team
members, guide clients toward their goals. Client responses to each
intervention are monitored. Work to keep an open mind when observing the
client’s responses to care, and remember that many reactions are culturally
determined.

Cultural Considerations

It is commonly considered taboo in East Indian Hindu culture for a male to

extend his hand when greeting a female. Initiating direct eye contact with a
woman is seen as a seductive gesture. The proper way to introduce oneself
to a female Hindu client is to first greet the husband or oldest female
companion. Many Hindu individuals are unwilling to give up speaking their
native language, so a bilingual family member commonly accompanies the
client.

• How does this knowledge impact nursing care for this client?
The final phase of the process, evaluation, determines the effectiveness of
care. By comparing expected outcomes with actual results, care providers
are able to note which actions met the goals and which did not. Those
actions that did not meet their goals are reassessed, and the process is
begun again.

Clients are involved as partners in care. Although some individuals are

unable or too discouraged to make decisions, most are capable of
participating in some part of their care. Caregivers help clients problem-solve
by involving them in the care planning process. Evaluation of both clients’
and caregivers’ actions allows for adjustments in the dynamic process known
as “treatment.” Use of the nursing (therapeutic) process requires knowledge,
experience, and the practice of good judgment. Experience grows with each
application of the process, and sound judgment is gained by looking at every
possible side of a problem before arriving at a decision. The nursing
(therapeutic) process serves as a tool for defining and solving client
problems, but the tool is only as effective as the practitioner. The art of
choosing the best course of action must be carefully practiced. Let the “do
no harm” principle guide you as you grow.

About assessment

Assessment includes the “gathering, verifying and communicating of

information relative to the client” (Mosby’s Dictionary, 2016). Clients are
dynamic (changing) individuals affected by more than an illness or disorder.
For this reason, the holistic assessment includes gathering information about
the physical, intellectual, emotional, social, cultural, and spiritual aspects of
each client. The more complete the picture, the more effective the treatment
approaches will be.

The process of assessing clients is ongoing. It begins with the client’s

admission to the facility or service and ends only after his or her relationship
with the health care system is over. To gain an understanding of clients,
become observant and alert for any information that may have an effect on
care.
Data collection

Data (information) relating to clients are grouped into objective and

subjective categories. Objective data are information that can be measured
and shared, and they are gathered through the senses of sight, smell, touch,
and hearing. Blood pressure readings, pulse rates, and laboratory reports
that are compared with “normal” results are examples of objective data.
When working with mental health clients, care providers obtain objective
data through physical examinations, daily assessments, diagnostic testing
results, and repeated observations of behaviors (Potter and Perry, 2017).

Subjective data relate to clients’ perceptions. They include information that

is abstract and difficult to measure or share. For example, the experiences of
pain, nausea, and anxiety cannot be measured by anyone but the individual
experiencing them. Emotions and mental states are all subjective and
difficult to measure. As a result, it is extremely important to document
subjective information as descriptively and accurately as possible. Do not
include interpretive statements (judgments). Document client reactions and
behaviors in exact terms. To say that the client is angry (unless he states
that he is angry) is an interpretive statement or judgment; it is better to
state that the client was pacing about the room while slamming his fist into
the wall and swearing. When documenting subjective data, quote the client
as much as possible. Subjective information is collected during the initial
health history interview and during every interaction with the client. The
simple question “How do you feel?” can elicit much subjective information.

The term data collection refers to a variety of activities designed to gather

information about a certain subject. Data-collecting methods for care
providers include interviews, observational techniques, and rating scales and
inventories. An interview is a meeting of people with the purpose of
obtaining or exchanging information (Keltner and Steele, 2019). Interviews
can be formal and highly structured, or informal and casual. Information
gathered from formal interviews is usually documented on a standardized
form. The interview is an excellent method for obtaining information and it
serves as the starting point for building the therapeutic relationship. Informal
interviews usually occur casually and provide great opportunities to learn
more about clients and their families. Caregivers use informal interview
techniques when they investigate client problems or explore certain topics.
Data-gathering through observational techniques is commonly used.
Observation is the process of purposeful looking. When using observation as
a data-gathering technique, caregivers must take care to be objective;
personal bias or attitudes can alter one’s perceptions and affect the
objectivity of the observations. The use of observation is an excellent
method for gathering information when the caregiver can remain impartial
and does not pass judgment.

Physical assessment skills are important to the data-gathering process. They

are used to gather data, investigate changes in physical conditions, and
evaluate the effectiveness of therapeutic interventions. Physical examination
skills are special methods for obtaining information about the body’s
functioning. The technique of observation is called inspection, which means a
purposeful examination of the body. The skills of auscultation and percussion
use the examiner’s sense of hearing to detect sounds within the body.
Finally, the technique of palpation requires the sense of touch to draw out
information about temperature, texture, and pulsations of the body.

Social workers, psychologists, and other therapists frequently use rating

scales and inventories. These are data-gathering tools specifically designed
to bring out certain kinds of information. The results are then compared with
standardized measurements. Rating scales and inventories can be very
useful for focusing on specific aspects of client problems.

Assessment process

Holistic assessment

The physical, social, cultural, intellectual, emotional, and spiritual areas of an

individual’s life each have an effect on their health. Without knowledge of
these six aspects, health care providers become narrowed and limited in
their effectiveness. The holistic assessment for those who work with mentally
or emotionally troubled clients is the same as that used by caregivers in any
setting. In psychiatric treatment situations, however, the emphasis is on
mental-emotional functioning. The psychiatric assessment tool focuses on
obtaining data about the problems, coping behaviors, and resources of
clients (Table 9.2). Information collected from assessment activities serves as
part of the database from which medical, nursing, and other treatment
decisions are made. An additional risk factor assessment is required for
clients who may pose a risk for violence toward themselves or others.

Table 9.2

Summary Psychiatric Assessment Tool

AREA OF ASSESSMENT EXAMPLE

Appraisal of health/illness Events leading to problem, definition of

problem, client’s goal, regular health care received

Previous psychiatric treatment Diagnosis, type of treatment,

medications, compliance, psychiatric history in family

Coping responses, physical status Review of function in each body system,

physical assessment, diet history, sleep patterns, exposure to toxic
substances, activities of daily living

Coping responses, mental status Appearance, speech, motor activity,

mood, affect, interactions, perceptions, thought content and process,
memory, concentration, calculations, intelligence, insight, judgment

Coping responses, discharge planning, needs Client’s ability to provide for

food, clothing, housing, safety, transportation, supportive relationships, work
needs, financial needs

Coping mechanisms Adaptive mechanisms, maladaptive mechanisms

Psychosocial and environmental problems Educational, occupational,

economic, housing problems; difficulties with support group, culture, access
to health care services

Knowledge deficits Understanding of psychiatric problem, coping skills,

medications, stressors

Modified from Stuart GW: Principles and practice of psychiatric nursing, ed

10, St Louis, 2013, Elsevier.

Risk factor assessment

A risk factor assessment helps “formulate a nursing diagnosis based on the
identification of risk factors that potentially present an immediate threat to
the patient” (Stuart, 2014) or others in the vicinity. With this assessment
tool, five areas of potential risk for harm are identified (Box 9.1). Positive
findings lead to more specific assessments and appropriate safety
precautions. A registered nurse completes the risk factor assessment, but
other health care providers assist by gathering important information and
making objective observations.

Box 9.1

Risk Factor Assessment

Purpose is to identify threats to the client. Remember “SAVES.”

Risk factor

Suicide/self-harm

Current or past suicidal thoughts or actions

History of self-harm or suicide attempts

Alcohol or drug use

Frequency and amount

Interference with daily living activities

Past experiences with withdrawal

Violence

Current feelings of anger and/or aggression

History of assault, destructive behaviors, or striking out

Elopement

History of leaving against medical advice

Does client wish to leave now?

Seizures

History of seizures

History of falls

The health history

Each client is interviewed on admission to the health care service. The

purpose of the history interview is to obtain data about the unique individual
who is the client. It offers care providers an opportunity to introduce
themselves and serves as a starting point for establishing the therapeutic
relationship. During the interview, insight into client concerns, worries, and
expectations is gained and there is the opportunity to obtain clues that may
require further investigation. When used appropriately, the interview is a
powerful method for gathering important information and establishing the
therapeutic relationship.

Effective interviews

The success of any client interview rests on the caregiver’s ability to listen
objectively and respond appropriately. To enhance your interviewing skills,
follow these guidelines:

• Remember that personal values must not cloud professional judgments.

Reacting to a client’s personal appearance or behaviors can stereotype him
or her and have a negative impact on the effectiveness of the therapeutic
relationship.

• Do not make assumptions about how you think the client feels. Discover
what each event means to the client and how he or she views the situation.
The experience of losing a loved one, for example, depends on how an
individual interprets or perceives an event.
• Always consider the client’s cultural and religious values and beliefs. With
mental health clients, this point cannot be emphasized enough. Caregivers
must learn about their clients’ cultures if they are to understand their points
of view. With clients from unfamiliar cultures, it is wise to research
information about the culture and its religious practices before conducting
the interview.

• Pay particular attention to nonverbal communications. Much can be

learned if one is observant. Note which subjects are avoided or quickly
passed over during the interview. These behaviors can be clues that indicate
a need for further investigation. Observing methods of self-expression helps
the caregiver to focus on the client’s unspoken signals and the messages
they communicate.

• Have clearly set goals. Know the purpose of the interview. Is this an initial
assessment interview or an investigation of a specific condition? The
assessment interview is not a random discussion; it is a purposefully planned
interaction with the client.

• Monitor your own reactions during the interview. Use self-awareness to

signal when you are becoming too emotionally involved; a caregiver may
identify with certain clients who have similar interests or situations. Self-
awareness allows one to understand the emotional responses generated by
certain clients. Interviewing skills are used throughout the nursing
(therapeutic) process. Work to develop and refine your interviewing skills
because they are important tools.

Sociocultural assessment

The health history includes information about both the physical and
psychological functions of an individual. The sociocultural assessment
focuses on the cultural, social, and spiritual aspects of an individual. During
the history interview, the care provider obtains information about a client’s
background and observes his or her appearance, behaviors, and attitudes
(these are also included in the mental status examination).

The sociocultural assessment focuses on six areas; clients are asked

questions about their age, ethnicity (culture), gender, education, income,
and belief system. Risk factors and stressors are also defined during the
sociocultural assessment (National Depressive and Manic-Depressive
Association, 2014). This information helps care providers develop accurate
and appropriate plans of care.

Review of systems

The holistic assessment also includes a review of each body system and its
functioning. Clients are first questioned about their general health care, past
illnesses and hospitalizations, and family health history. Questions then focus
on the function of each body system. Last, the lifestyle and activities of daily
living are assessed. Box 9.2 lists the topics covered by the health history for
clients with mental health problems. Data obtained from the health history,
physical assessments, and various diagnostic examinations all help complete
the picture of each individual client.

Box 9.2

Health History for Mental Health Clients

Health care history

General health care

• Regular health care provider

• Frequency of health care visits

• Last medical examination and test results

• Any unusual circumstances of pregnancy or births

• Hospitalizations and surgeries: when, why indicated, treatments, outcome

• Family history

• Diagnosed brain problem

• Head trauma: Details of accidents or periods of unconsciousness for any

reason—blows to the head, electrical shocks, high fevers, seizures, fainting,
dizziness, headaches, falls
• Endocrine disturbances: Thyroid and adrenal function particularly,
diabetes, stability of glucose levels

Lifestyle

• Eating: Details of unusual or unsupervised diets, appetite, weight changes,

cravings, caffeine intake

• Medications: Full history of current and past psychiatric medications in self

and first-degree relatives

• Substance use: Alcohol and drug use

• Toxins: Overcome by automobile exhaust or natural gas; exposure to lead,

mercury, insecticides, herbicides, solvents, cleaning agents, lawn chemicals

• Occupation (current and past): Chemicals in workplace (farming, painting)

• Cancer: Full history, particularly consider metastases (lung, breast,

gastrointestinal tract, and kidney tumors and melanoma are most likely to be
affected); results of treatment (chemotherapy and surgeries)

• Lung problems: Details of anything that restricts flow of air to lungs for
more than 2 minutes or adversely affects oxygen absorption (brain uses 20%
of oxygen in body), such as with chronic obstructive pulmonary disease, near
drowning, near strangulation, high-altitude oxygen deprivation, resuscitation

• Cardiac problems: Childhood illnesses such as scarlet or rheumatic fever;

history of heart attacks, strokes, or hypertension

• Blood diseases: Anemia, arteriosclerotic conditions, HIV, work-related

accidents, military experiences

• Injury: Safe sex practices, contact sports and sports-related injuries,

exposure to violence or abuse

• Presenting symptoms and coping responses: Description—nature,

frequency, and intensity; threats to safety of self or others; functional status;
quality of life

HIV, Human immunodeficiency virus.

From Townsend M, Morgan K: Pocket guide to psychiatric nursing, ed 10,

Philadelphia, 2018, FA Davis.
Physical assessment

Clients receive a physical examination on admission to a psychiatric service.

The purpose of the examination is to discover physical problems that can be
treated medically. Many alterations in behavior are often traced to a physical
cause. For example, low blood sugar levels can result in confused and
uncooperative behavior. Hormone imbalances, exposure to toxic substances,
and severe pain can also affect behavior.

A complete physical examination is performed by a physician or nurse

practitioner. The client’s current health status is explored, and then each
system is examined. Nurses have an obligation to assess each client’s health
status on a routine basis. A complete physical assessment is not needed
every day, but nurses must be alert to changes in their clients’ conditions.
Most nurses use a systems approach or head-to-toe assessment. Both take
less than 5 minutes and can be performed whenever information about
physical functions is needed.

Diagnostic studies for clients with mental-emotional problems include

standard blood and urine tests, evaluation of electrolytes, and hormone
function examinations. Many clients are screened for tuberculosis, HIV, and
sexually transmitted diseases. Studies such as x-ray examinations,
electrocardiograms (ECGs), electroencephalograms (EEGs), and brain
imaging studies (computed tomography [CT], magnetic resonance imaging
[MRI], positron emission tomography [PET] scans) may be ordered. To
complete the picture, the client’s current mental and emotional state is
assessed via a mental status examination.

Mental status assessment

The mental status examination allows care providers to observe and describe
a client’s behavior in an objective, nonjudgmental way. It is a tool for
assessing mental health dysfunctions and identifying the causes of clients’
problems. Understanding each part of the examination enables care
providers to plan and deliver the most appropriate care for each client.
The mental status examination explores five areas: general description,
emotional state, experiences, thinking, and sensorium and cognition (Table
9.3).

Table 9.3

The Mental Status Examination

General description Appearance, speech, motor activity, interaction

during interview

Emotional state Mood, affect

Experiences Perceptions

Thinking Thought content, thought processes

Sensorium (ability to sort information) and cognition Level of consciousness,

memory, level of concentration and calculation, information and intelligence,
judgment

From Stuart GW: Handbook of psychiatric nursing, ed 7, St Louis, 2012,

Elsevier.

General description

Under the category of general description, the client’s general appearance,

speech, motor activity, and behavior during the interaction are assessed.
This category includes everything that can be readily observed about a
client, such as physical characteristics, dress, facial expressions, motor
activity, speech, and reactions. To assess a client’s physical characteristics,
observe each part of the client’s body, noting anything unusual. Describe the
person’s build, skin coloring, cleanliness, and manner of dress. Does the
person appear neat and tidy or careless and unkempt? Note any body odors.
If cosmetics are used, are they appropriately applied? Does the client’s
appearance match his or her gender, age, and situation? People with
depression, for example, may look unkempt and neglected and it is not
uncommon for manic clients to dress in colorful but bizarre clothing and wear
a lot of cosmetics and jewelry. Document all findings. Note the client’s facial
expressions and use of eye contact; do the facial expressions match his or
her emotions and actions? Is eye contact avoided or held for long periods?
Also note the size of the client’s pupils; large, dilated pupils are seen in
people with certain drug intoxications, whereas small pupils are associated
with narcotic use.

Describe the rate, volume, and characteristics of the client’s speech. Note
any abnormal speech patterns (see Chapter 10).

Next, turn your attention to the client’s motor activity, gestures, and posture.
Observe the client’s physical movements for the level and type of activity,
and note any unusual movements or mannerisms. Is the client agitated,
tense, restless, lethargic, or relaxed? Are there any tics, grimaces, repeated
facial expressions, or tremors? Excessive body movements are seen in
individuals with anxiety or mania; they can also result from the use of
stimulants or other drugs. Repeated movements or behaviors are seen in
clients with obsessive-compulsive disorders, and picking at one’s clothing is
often seen in clients with delirium or toxic reactions.

To complete the general description, assess the client’s behavior during the
interaction. How did the client relate to you? Was he or she cooperative,
hostile, or overly friendly? Did the client appear to trust you? Note whether
the verbal messages matched the behaviors. Clients who use unconnected
gestures, for example, may be hallucinating.

Critical Thinking

Cybil is being admitted to the clinic’s day treatment program. She insists that
she feels fine, but she will not speak, except to answer “yes” or “no,” and
she refuses to give her caregiver eye contact.

• What messages is Cybil’s behavior sending?

• How do her verbal and nonverbal messages agree or disagree?

Emotional state
To assess the client’s emotional state, the care provider considers the client’s
mood and affect. Mood is defined as an individual’s overall feelings; it is a
subjective factor that can be explained only by the person experiencing it.
Usually, people will have a basic mood, although it may change during the
day. To illustrate: a basically relaxed and happy person may feel disappointed
by an incident during the day but soon forgets and returns to his or her usual
happy mood. A person’s mood can range from overwhelming sadness to
great elation and joy. These variations are referred to as one’s range of
emotion. Affect is the client’s emotional display of the mood being
experienced. Table 9.4 explains several kinds of affect. Affect can be
categorized as appropriate, inappropriate, pleasurable, or unpleasurable. To
assess a client’s affect, ask what he or she is feeling and then observe the
reactions. Do the responses to your questions match the subjects being
discussed? Is the client overreacting, not reacting at all, or responding
inappropriately? Document objective descriptions of the client’s behaviors.
Descriptions communicate much more information than does a single
medical term.

Table 9.4

Common Emotional Responses (Affects)

NAME OF AFFECT DESCRIPTION

Inappropriate Response

LabileRapid, dramatic changes in emotions

Inconsistent Affect and mood do not agree

Flat Unresponsive emotions

Pleasurable Response

Euphoria Excessive feelings of well-being (feeling too good)

Exaltation Intense happiness, often with feelings of grandeur

Unpleasurable (Dysphoric) Response

Aggression Anger, hostility, or rage that is out of keeping with situation

Agitation Motor restlessness, often seen with anxiety

Ambivalence Having both positive and negative feelings about the same
subject

Anxiety Vague, uneasy feeling, often from unknown cause

Depression Sadness, hopelessness, loss that is present over time

Fear Reaction to recognized danger

Experiences

The category of experiences explores the client’s perceptions, the ways in

which he or she experiences the world. An individual’s perceptions are often
called one’s frame of reference. In short, a person’s perceptions help
determine his or her sense of reality.

People who are having mental health problems may have difficulty in
perceiving the same reality as the rest of society. Hallucinations are
perceptions that have no external stimulus. The client may hear voices or
see things that are not perceived by other people. Hallucinations involving
taste, touch, or smell may indicate a physical problem. Visual and auditory
hallucinations are associated with schizophrenia, the acute stage of alcohol
or drug withdrawal, and organic brain disorders. Alterations in perceptions
that have a basis in reality are called illusions. External stimuli are present,
but the client perceives them differently, for example, a client who perceives
the person walking down the hall as a wolf. If a client is having illusions or
hallucinations, ask him or her to describe the experience. Box 9.3 lists
several questions that can help explain the client’s experience.

Box 9.3

Assessing Illusions or Hallucinations

Ask the client if he or she hears voices or sees things when other people are
not present. If the answer is yes, ask the client to describe the experience.
Questions can include the following:

• How many different voices (images) do you hear (see)?

• What do the voices say (images do)?

• Do you recognize any of the voices (images)?

• When did the voices (images) first begin? What was happening in your life
at the time?

• How do you feel about the voices (images)?

Remember that hallucinations or illusions are very real to the person

experiencing them. Caregivers cannot “talk them out of it” or tell them to
ignore what they perceive. However, because they are so real, clients usually
are willing to describe them when asked.

Thinking

The “thinking” section of the mental status examination focuses on thought

content and processes. Thought content relates to what an individual is
thinking. Clients may be experiencing delusions, obsessions, phobias,
preoccupations, amnesia, or confabulations.

Disturbances in thought processes relate to how a person thinks—how he or

she analyzes the world, connects and organizes information. Disorders of
thought processes include blocking, flight of ideas, loose associations, and
perseveration. Several disorders of thought processes are listed in Table 9.5.

Table 9.5

Disorders of Thinking

DISORDER DESCRIPTION

Thought Processes (How One Thinks)

Blocking Thoughts stop suddenly for no apparent reason

Flight of ideas Rapid changes from one thought to another related

thought

Loose associations Poorly organized or connected thoughts

Perseveration Repeating same word in response to different questions

Thought Content (What One Thinks)

Delusions False beliefs that cannot be corrected by reasoning or

explanation

Obsession Thought, action, or emotion that is unwelcome and difficult to

resist

Phobias Strong fears of certain things, places, or situations

Preoccupations All experiences and actions are connected to central

thought that is usually emotional in nature

Others

Amnesia Inability to remember past events

Confabulation Using untrue statements to fill in gaps of memory loss

Another problem of thinking is depersonalization, a feeling of unreality or

detachment from oneself or one’s environment. The unreal feelings produce
a dreamlike atmosphere that overtakes the individual’s consciousness. One’s
body does not feel like one’s own. Events that are dramatic or important are
seen with a detached calmness, as if the person were watching instead of
participating in reality. Feelings of depersonalization can normally occur
when one is anxious, stressed, or very tired. Depersonalization disorders are
often seen in clients with severe depression and in some forms of
schizophrenia.

Assessment of the client’s thought content and process occurs throughout

the entire mental status examination. Are the client’s thoughts based in
reality? Are his or her ideas communicated clearly? Do the client’s thoughts
follow a logical order? Are any unusual thoughts, preoccupations, or beliefs
present? Does the client have any suicidal, violent, or destructive thoughts
(American Psychiatric Association, 2018)? Are there any persistent dreams?
Does the client believe that someone is intent on harming him or her
(feelings of persecution)? Observe the client closely, and listen intently. Much
information will be revealed during the course of the interaction.

Sensorium and cognition

The sensorium is that part of consciousness that perceives, sorts, and
combines information. People with a clear sensorium are oriented to time,
place, and person. They are able to use their memories to recall recent and
remote information. Levels of consciousness and memory recall help assess
a person’s sensorium.

Level of consciousness can be determined by observing the amount of

stimuli needed to arouse the client (Table 9.6). If the client cannot be
awakened by verbal stimuli, notify your supervisor immediately. If the client
is awake, note his or her responses to your questions, the degree of
interaction, and the amount of eye contact that is being made.

Table 9.6

Levels of Consciousness

Comatose/unconscious Unresponsive to verbal or painful stimuli, may

respond to deep painful stimuli

Stuporous Responds only to strong physical stimuli; falls asleep if not

stimulated

Drowsy/somnolent Wakens with strong verbal stimuli; falls asleep if left

undisturbed

Lethargic Can be verbally aroused; shows decreased wakefulness; may

have periods of excitability alternating with periods of drowsiness

Alert Awake and responsive; oriented to time, place, and person

Hyperalertness Increased state of alertness or watchfulness

(hypervigilance)

Mania State of extreme excitement, elation, and activity

Memory is the ability to recall past events, experiences, and perceptions. For
the purpose of testing, memory is divided into three categories: immediate,
recent, and remote memory. Immediate memory is also referred to as recall.
To assess it, ask the client to remember three things (e.g., a color, an
address, an object). Later in the conversation (after at least 15 minutes have
elapsed), ask the client to repeat the three items. Recall can also be tested
by having the client repeat a series of numbers within a 10-second period.

Recent memory includes events within the past 2 weeks. Caregivers test
recent memory by asking the client to recall the events of the past 24 hours.
Loss of recent memory is seen in people with Alzheimer’s disease, anxiety,
and depression.

Assessing remote memory involves asking the client questions about his or
her place of birth, background, schools attended, and ages of family
members. This part of the mental status examination can easily be done
during the nursing health history interview. It is sometimes difficult to tell
whether the client has accurate memories. Long-term memory loss is seen in
clients with organic (physical) problems, conversion disorders, and
dissociative disorders.

The level of concentration focuses on the client’s ability to pay attention

during the conversation. Calculation tests the ability to do simple math
problems. Have the person count rapidly from 1 to 20; perform simple
addition, multiplication, and division problems; and subtract 7 from 100, then
7 from 93, and so on. Then ask practical questions such as the number of
dimes in $1.90. Note how easily the client becomes distracted during these
tasks. People with mental-emotional problems commonly have difficulty with
concentration and calculations. These difficulties also occur in people with
physical disorders, such as brain tumors, so it is important to assess the
client’s ability to concentrate and do simple calculations.

During this phase of the mental status examination, the client’s education
level, general knowledge, ability to read, use of vocabulary, and ability to
think abstractly are also assessed. General knowledge can be tested by
asking the person to name the past five presidents or five large cities. Ask
the client about the last grade completed in school.
To determine reading ability, print a command, such as “Close your eyes,” on
a piece of paper. Ask the client to read it and follow the directions. During the
conversation, also note the client’s choice of words and their use.

Assess the client’s ability to think abstractly by having him or her explain the
meaning of several well-known proverbs, such as “a stitch in time saves
nine”; “a rolling stone gathers no moss”; “when it rains, it pours”; or “people
in glass houses shouldn’t throw stones.” Many people with mental health
problems give concrete answers such as, “Moss only grows on the north
sides of stones,” or “People who live in glass houses shouldn’t throw stones
because it breaks the glass.”

Judgment refers to the ability to evaluate choices and make appropriate

decisions. During the health history interview, observe how the client
explains personal relationships, his or her job, and economic responsibilities.
Assess the client’s judgment by asking questions such as, “What would you
do if you...

• found an addressed envelope on the ground?”

• ran out of medication before your next appointment?”

• won $25,000?”

Judgment is often impaired in people with chemical dependence,

intoxication, schizophrenia, intellectual disability, and organic mental
disorders. Document the client’s responses using the client’s own words
whenever possible.

Insight refers to the client’s understanding of the situation. What is the

client’s understanding of the disorder? Questions that help the caregiver
assess insight include, “Have you noticed a change in yourself recently?”
and, “What do you think is the cause of your anxiety (discomfort)?” Expect
clients to have different degrees of insight. For example, a person with an
alcohol problem may realize that he or she drinks too much but does not
think that it is interfering with family life. Again, be sure to document the
client’s statements rather than your opinions.
Although the mental status examination may appear to be a lengthy process,
much of it can be performed during the history interview. Checklists that
address each area of the examination are available (see Box 9.4 and
Appendix A for a copy of the Mental Status Assessment at a Glance).

Box 9.4

Mental Status Assessment at a Glance

1. Appearance

_____ Manner of dress

_____ Personal grooming

_____ Facial expressions

_____ Posture and gait

2. Speech

_____ Manner of response (frank, evading)

_____ Choice of words (to assess general intelligence, education, levels of

function, thought)

_____ Speech disorder

3. Level of consciousness

_____ Level of alertness

_____ Orientation (time, place, person)

4. Attention span

_____ Ability to keep thoughts focused on one topic

_____ Repeat a series of numbers

_____ Serial sevens (ask client to subtract 7 from 100, 7 from 93, etc.)

5. Memory

_____ Immediate memory (ask client to repeat words after 15 minutes)

_____ Recent memory (ask client about yesterday’s activities)

_____ Remote memory (ask client about dates of birth, marriage, schooling)

6. Understanding abstract relationships

_____ Understanding of proverbs (concrete or abstract)

_____ Ability to understand similarities (e.g., “How are a bicycle and an

automobile alike?”)

7. Arithmetic and reading ability

_____ Simple addition, subtraction, multiplication, and division (ask client to

make change)

_____ Ability to read newspaper, magazine

8. General information knowledge

_____ Discuss newspaper or magazine article

_____ General information questions (e.g., “How many days in a year?”

“Where does the sun set?”)

9. Judgment

_____ Responses to family, work, financial problems

_____ Responses to “What would you do if... ” questions

10. Emotional status

_____ Ask “How do you feel today?” or “How do you feel about... ” questions

_____ Affect

_____ Current situation and coping behaviors

Care providers often use parts of the mental status examination to assess
clients whose mental state changes frequently. For example, the caregiver
assesses the hallucinating client for thought content and process at intervals
throughout the day.

Work to develop your powers of observation. Do not pass judgment or let

your opinions interfere with data-gathering. Remember, the results of the
mental status examination can be affected by attitudes and beliefs. Learn to
use assessment tools. Develop your observation and assessment skills
because they will serve you well in all practice settings.

Get ready for the NCLEX® examination!

Key points

• The ability to effectively obtain and use information about clients is a vital
part of the multidisciplinary treatment plan.

• The mental health treatment plan is used as a guide for client care, to
monitor progress and assess the effectiveness of therapeutic interventions,
communicate and coordinate clients’ care, provide a focus for all therapeutic
activities, and prevent duplication.

• Every psychological illness has physical effects, and psychological effects

accompany every physical illness.

• Therapists who work with mentally and emotionally troubled individuals

use the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to aid
in diagnosis and help guide clinical practice.

• The nursing (therapeutic) process is a purposeful and organized approach

to solving client problems that requires knowledge, experience, and the use
of sound judgment.

• Data-collecting methods for care providers include interviews,

observational techniques, and rating scales and inventories.

• The process of assessing a client is ongoing and begins with the client’s
admission.

• Individuals’ physical, social, cultural, intellectual, emotional, and spiritual

areas of functioning are included in a holistic assessment.

• The psychiatric assessment tool includes an appraisal of the client’s health,

previous psychiatric treatment, physical and mental coping responses,
discharge planning needs, psychosocial and environmental problems, and
needs for knowledge.

• The purpose of a risk factor assessment is to identify risk factors that may
present an immediate threat to the client or others.
• The history interview is an organized conversation with a client that has
the purpose of bringing out certain information about his or her health
status.

• Guidelines for conducting effective interviews relate to being

nonjudgmental, considering cultural factors, having clear goals, and
assessing communications.

• The sociocultural assessment focuses on cultural, social, and spiritual

aspects.

• The mental status examination is a tool for assessing mental health

dysfunctions and identifying the causes of clients’ problems.

• The mental status examination explores appearance, consciousness,

behavior, speech, mood, affect, thought content, intellectual performance,
insight, judgment, and perception.

• Much of the mental status examination can be performed during the

history interview using checklists. Caregivers often use various parts of the
mental status examination to assess clients whose mental state changes
frequently.

Additional learning resources

Go to your Study Guide at the back of this text for additional learning
activities to help you master this chapter content.

Go to your Evolve website ([Link] for

additional online resources.

Review questions for the NCLEX® examination

1. During an admission assessment, a male client states that he has been

having auditory hallucinations and difficulty concentrating at work. This type
of data is referred to as:

1. Objective

2. Subjective

3. Measured

4. Shared
2. The nurse observes the client as he paces the floor and talks to himself.
The nurse documents this as “Client confused and agitated.” This is an
example of:

1. Objective data

2. A judgment

3. Subjective data

4. An observation

3. The care provider is completing the general description portion of the

mental status examination tool. One of the primary focuses of this portion of
the tool is the client’s:

1. Level of consciousness

2. Motor activity, gestures, and posture

3. Level of concentration and judgment

4. Perceptions

4. When assessing the recent memory of a client, the nurse may ask
questions regarding events that occurred within the past __________

1. 2 weeks

2. 3 weeks

3. 4 weeks

4. 5 weeks

5. The nurse documents in a male client’s records that he displayed a “flat

affect.” The client’s behavior most likely would consist of:

1. Rapid, dramatic changes in emotion

2. Sadness and hopelessness

3. Lack of agreement of affect and mood

4. Unresponsive emotions