ATI - RN Mental Health Nursing Latest update 2024
What do you assess for during a Mental Status Exam (MSE)? - Answer--1. level of consciousness
2. physical appearance
3. behavior
4. cognitive and intellectual abilities
alert - Answer--able to fully respond by opening eyes, attend to normal ton...
What do you assess for during a Mental Status Exam (MSE)? - Answer--1. level of consciousness
2. physical appearance
3. behavior
4. cognitive and intellectual abilities
alert - Answer--able to fully respond by opening eyes, attend to normal tone of voice and speech, and
answer questions spontaneously and appropriately
lethargy - Answer--able to open eyes and respond, but is drowsy and falls asleep readily
obtundation - Answer--needs to be lightly shaken to elicit a response; may be confused and slow to
respond
What do you assess for during a Mini-Mental State Exam? - Answer--1. orientation
2. attention span and ability to calculate
3. registration and recall of objects
4. language (e.g. naming objects, following commands, and writing ability)
stupor - Answer--requires painful stimuli (e.g. pinch a tendon, rub sternum) to elicit a brief response;
may not be able to respond verbally
, coma - Answer--no response from repeated painful stimuli
decorticate rigidity - Answer--flexion and internal rotation of upper extremity joints and legs (arms
toward midline)
decerebrate rigidity - Answer--neck and elbow extension, wrist and finger flexion (arms away from
midline)
mood - Answer--subjective data about emotions that are felt
How do you assess recent memory? - Answer--Have patient recall a series of number or list of objects.
How do you assess remote memory? - Answer--Have patient state a verifiable fact (e.g. birthdate).
How do you assess level of knowledge? - Answer--Ask patient what they know about their illness or
hospitalization.
How do you assess ability to calculate? - Answer--Ask patient to count backward from 100 in serials of 7.
How do you assess ability to think abstractly? - Answer--See if patient can interpret an idiom/saying.
How do you assess judgment? - Answer--Ask patient a hypothetical question to see how they would
answer (i.e. is it logical).
affect - Answer--objective data about expression of mood
What is evaluated in the Glasgow Coma Scale? - Answer--eye, verbal, and motor response
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