Student Laboratory Guide
Chapter 7
Mental Health and Mental Status Assessment
For this lab activity, take a history on your lab partner, focusing on a mental health problem or a change
in mental status. Become familiar with the various screening tools by conducting these on your lab
partner.
History
Name: Gender: Race:
Age: LMP:
Occupation: Source of Data:
Immunizations: Allergies/Reactions:
Presenting Problem (check all that apply): Depression Anxiety Anger Stress
Substance abuse Change in mental status Other:
Symptom Analysis of Presenting Problem (onset, location, duration, characteristics, aggravating and
alleviating factors, related symptoms, treatment, severity)
Current Health Status (include medications, dose, and frequency)
Past Medical and Surgical History
Family History
Mental Health Status
How have you been feeling about yourself? Do you consider your present feelings to be a problem in
your daily life (at home or at work/school)?
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Chapter 7 Mental Health and Mental Status Assessment Page 2
Describe your interpersonal relationships. Do you have a significant other or partner? Do you have
friends you socialize with? Do you prefer to be alone or with other people?
Mental Health Screening
Complete the following screening examinations on your lab partner and record the scores in the space
provided. The screening examinations are found in Chapter 7 of your textbook. Below each, describe
what the results of your points mean, and indicate in what situation you might use the form.
Beck Depression Inventory, Short Form points
Interpretation of the score:
When might you use this?
Holmes Social Readjustment Rating Scale points
Interpretation of the score:
When might you use this?
CAGE points
Interpretation of the score:
When might you use this?
AUDIT points
Interpretation of the score:
When might you use this?
Examination
Data collected about clients with mental health concerns include vital signs, height and weight, and
observations of clients to determine if physiologic changes are associated with the mental health
problems.
Examination Technique Findings (document findings below)
General Observations General Observations
1. OBSERVE the client’s posture and body 1.
movements.
2. OBSERVE the client for appropriate dress
2.
and hygiene.
3. OBSERVE the client for voice tone, rate of
speech, perspiration, muscle tension, or 3.
tremors.
Mosby items and derived items © 2005, 2002 by Mosby, Inc.
Chapter 7 Mental Health and Mental Status Assessment Page 3
Vital Signs Vital Signs
1. MEASURE the client’s pulse, noting rate, 1. Heart rate:
rhythm, and amplitude.
2. Blood pressure:
2. MEASURE the client’s blood pressure.
3. Respiratory rate:
3. MEASURE the client’s respiratory rate;
Temperature:
note effort and rhythm.
Height: Weight:
Nursing Diagnoses and Collaborative Problems
Based on the subjective and objective data collected above, identify applicable nursing diagnoses and
collaborative problems.
Nursing Diagnoses Collaborative Problems
1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
Mosby items and derived items © 2005, 2002 by Mosby, Inc.