Jarvis: Physical Examination and Health Assessment, 5th edition

Instructor’s Manual

Chapter 06: Mental Status Assessment

ANNOTATED LEARNING OBJECTIVES

At the completion of this chapter, the student will:
Define the behaviors that are considered in an assessment of a person’s mental
status.
Consciousness, language, mood and affect, orientation, attention, memory,
abstract reasoning, thought process, thought content, and perceptions all need to be
considered when one is assessing mental status. For some aspects of the assessment,
direct questions, such as “Where are you?” may need to be asked, whereas for others the
examiner can gather the data indirectly through the way in which the patient responds to
questions asked during the health assessment.
Describe relevant developmental care related to the mental status examination.
Consciousness, the use of language, attention span, and the ability to use abstract
thinking all develop over time and must be considered from a developmental perspective
when one is examining infants and children. Although the process of aging leaves the
parameters of mental status mostly intact, a slower response time may affect new
learning. The examiner must also be cognizant of the impact of age-related physical
changes, such as alterations in vision or hearing that may affect the mental status of the
older adult.
State the purpose of a mental status examination.
The full mental status examination is a systematic check of emotional and
cognitive functioning. The purpose is to determine mental health strengths and coping
skills and to screen for any dysfunction. Usually, mental status can be assessed through
the context of the health history interview. A full mental status examination would be
conducted if family members express concern about a person’s behavior, if the presence
of a cerebral pathological condition or aphasia is observed, or if the symptoms of
psychiatric mental illness are noted. The examiner must be aware of factors that might
affect findings, such as preexisting illnesses and medications. These factors are included
in the health history.
List the four components of mental status assessment.
Appearance, behavior, cognition, and thought processes are the four main
components addressed during the mental status assessment. The initials A, B, C, and T
may help the practitioner to remember these categories.

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Complete a MiniMental State examination.
The MiniMental State is a quick and easy means of assessing cognitive function,
not mood or thought processes. It can be used for both initial measurement and serial
measurement to follow a patient over time. The examination is used to detect dementia
and delirium. In addition, the examination is used to differentiate organic disorders from
psychiatric illnesses. As with other skills, practice increases both competence and self-
confidence. Using the form under the guidance of an instructor will assist in this
development.
Discuss developmental care for infants, children, and aging adults.
The focus of the mental status assessment of infants and children addresses the
behavioral, cognitive, and psychosocial development of the child in coping with his or
her environment. The Denver II screening test can be used to assess the mental status of
young children. The Behavioral Checklist provided in the text can be used as an
assessment tool for school-age children. The A, B, C, and T guidelines may be used for
the adolescent. For the aging adult, the A, B, C, and T guidelines are used, with
additional attention to certain aspects of behavior and cognitive function. The Set Test
(FACT) is useful for assessing mental status. In this test, the person is asked to name 10
items in each of four categories or sets: fruits, animals, colors, and towns. Before mental
status is assessed in older adults, sensory status must be checked and deficits corrected, if
possible.

KEY TERMS
abstract reasoning
affect
attention
consciousness
language
memory (recent and remote)
mental disorder
mental status
mood
organic disorder
orientation
perception
psychiatric mental illness
thought content
thought process

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TEACHING STRATEGIES
• Have the students search the Internet for available mental status assessment
instruments. For each instrument, have the students assess the instrument for
completeness.
• Working in trios, have students role play various types of patients that may be
encountered (shy, angry, fearful, disoriented, etc.). One student is the interviewer, one
is interviewee, and the third uses the Performance Checklist to follow the interview. At
the conclusion of the interview, have each student describe the strengths and
weaknesses of the interview.
• Using the form provided in the text, assign students to work in pairs and have each
complete a MiniMental State Examination on the assigned partner. At the completion
of the exercise, discuss interviewing techniques that facilitated the completion of the
examination.
• Have students play the part of a patient and take the Set Test.
• Use segments of movies or other visual materials and ask students to describe the
mental status of the personality portrayed, using A, B, C, and T for the segment viewed.
Some suggestions for movies might include The Over the Hill Gang with George Burns
for viewing older adults, Forrest Gump for the educationally challenged, Rain Man for
a psychiatric disorder, Terms of Endearment for anger, and A Beautiful Mind for a
psychiatric disorder (schizophrenia).
• Write brief descriptions of various alterations in mental status that students might
encounter in the patients of various clinical agencies. Ask one or two students to
provide a role-play based on the supplied description and have the rest of the group
complete a mental status assessment on the “patient.”
• At the end of the assigned class or laboratory period, have each student briefly
(providing half a piece of paper will limit length of response) answer the question, “The
area in which I would like additional clarification is …”
• Assign students to complete a mental status assessment of an assigned patient in a
clinical setting, using responses to health history questions as the basis for the
examination.
• Assign students to complete a Denver II test on a pediatric patient in an outpatient
clinical setting.
• Have students document the results of the above assessments and the associated nursing
diagnoses.

CRITICAL THINKING EXERCISES

Application to Clinical Practice

For each person described in the situations below, have students discuss the
developmental, age, socioeconomic, and cross-cultural considerations that should be
addressed during the gathering of subjective and objective data and the implications for
the provision of health care. Ask students to determine whether information is provided

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regarding appearance, behavior, cognition, and thought processes (A, B, C, and T).
Because patients with alterations in mental status may be unable to meet their own
physical needs, have students also discuss the implications for the family member
providing care or community social services that may be required. Have students describe
any additional data that might be needed before a judgment or diagnosis can be made and
cite at least one relevant nursing diagnosis for any actual or potential problem identified.
• H. M. visits the social center, where congregate meals are provided at lunch time. He is
known to the health care provider and has been alert and oriented ×3 in the past. Today,
the provider notes that, although it is 30° F outside, he has come without a coat or
jacket, is unshaven, and has difficulty in obtaining food in the cafeteria line.
• D. J. has Parkinson’s disease and is therefore seen every 6 months for follow-up
evaluation. In the past, her husband has accompanied her and been present during the
examination. Because he was unable to accompany her today, a neighbor has brought
her for the visit, and D. J. is therefore in the examining room alone. When the health
care practitioner comes into the room, D. J. is still in her street clothes, and when asked
to put on the examining gown she seems confused about how to proceed with the task.
She is unable to recall what she had for breakfast and cannot state her phone number.
• T. R. comes 5 days a week to an outpatient clinic for physical therapy and occupational
therapy for strengthening and gait training after an auto accident that resulted in a head
injury. She has been prescribed chlorpromazine (Thorazine) by a psychiatrist. Today
she is angry and unwilling to follow the directions of the therapist, and her tremors
seem to be more pronounced. She evades orientation questions by responding, “Why do
you need to know that?”
• C. C., a college student, is in her advisor’s office because she has been issued an
academic warning for her clinical performance. The advisor is aware that C. C. has a
history of bipolar disorder and is under the care of a psychiatrist. C. C. is crying
uncontrollably, looks unkempt in appearance, and her speech is not completely
coherent. The advisor asks C. C. whether she is considering suicide and C. C. answers
“yes” and reveals that she has been saving her medications.
• T. C. is recovering from abdominal surgery and is receiving narcotics for pain. When
the nurse comes to complete an assessment at the beginning of the day, T. C. tells the
nurse about the moving pictures he is seeing on the wall. Interview reveals that T. C. is
oriented to place and person, and review of admission data does not indicate a history
of mental illness.
• D. S. is admitted to the unit through the emergency department, where a diagnosis of
cerebrovascular accident (CVA, or stroke) was made. The nurse performing the health
history notes the inability of the patient to answer questions, but D. S. responds
correctly when given simple commands. Because of right-sided paralysis, D. S. is
unable to write.
• A. H. has come for a follow-up visit for pneumonia. The practitioner is aware that her
daughter was recently killed in a motor vehicle accident that involved alcohol. During
the examination, the practitioner notes the smell of mints on A. H.’s breath, slurred
speech, and a disheveled appearance.

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• During an annual GYN checkup, 35-year-old Z. C. expresses a fear of cancer of the
cervix, of which her mother died last year. As you assist her to the table for the physical
examination, Z. C. starts to tremble and sweat and complains of feeling cold and of
having a “choking” feeling and nausea. Her respirations are shallow and rapid, and you
note that her pulse is bounding.
• During morning rounds, the nurse finds that P. R., a 48-year-old man who is recovering
from vascular surgery, wakes up when his name is called but looks drowsy and answers
in a slow voice when asked questions. He tries to tell the nurse about his leg pain but
loses his train of thought and appears to be falling asleep after a few minutes.

WEB SITES OF INTEREST

• Alzheimer’s Disease Education and Referral Center,
http://www.nia.nih.gov/alzheimers
• American Federation for Aging Research, http://www.afar.org
• American Psychiatric Nurses Association, http://www.apna.org
• American Psychological Association, http://www.apa.org
• Association of Child and Adolescent Psychiatric Nurses, http://www.ispn-
psych.org/html/acapn.html
• Centers for Disease Control and Prevention, http://www.cdc.gov
• National Institute of Mental Health, http://gopher.nimh.nih.gov/
• National Mental Health Association, http://www.nmha.org
• American Psychiatric Organization, http://www.psych.org
• Bipolar.com, http://www.bipolar.com
• Mini-Mental State Examination (MMSE), http://www.minimental.com

PERFORMANCE CHECKLIST
Mental Status
Yes No Comments
Appearance
Posture
Body movements
Dress
Grooming and hygiene
Behavior

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Instructor’s Manual 6-
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Level of consciousness
Facial expression
Speech
Mood and affect
Cognitive functions
Orientation
Time
Place
Person
Attention span
Recent memory
Remote memory
New learning—four unrelated words test
Aphasia assessment
Word comprehension
Reading
Writing
Higher intellectual functioning
Judgment
Thought processes and perceptions
Thought processes
Thought content
Perceptions
Suicidal thoughts
Supplemental Mini Mental State Examination
Developmental care
Document findings

OPEN-BOOK QUIZ

Chapter 6: Mental Status Assessment

Provide the missing words or phrases for each of the following statements.
1. When one is doing a mental status assessment, the mnemonic A-B-C-T stands for:

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Instructor’s Manual 6-
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__________, __________, __________, __________.
2. __________ is a disorder of articulation in which the speech sounds distorted or
unintelligible, but the basic language, such as word choice and grammar, is intact.
3. __________ is defined as the awareness of the objective world in relation to the
self.
4. _____ _____ is the ability to ponder deeper meanings that are beyond the
concrete and literal level.
5. __________ is an awareness of objects through any of the five senses.
6. __________ memory is tested by asking the person verifiable past events, such as
“what war did you fight in when you were in your 20s?”
7. __________ memory is tested by asking the person about his activities for the
past 24 hours.
8. __________ is defined as a rapid shift of emotions. The person may be tearful one
minute, very happy the next minute, and then suddenly very angry.
9. A person who can only respond when shaken vigorously and can only groan,
mumble, or move restlessly is in a(n) __________.
10. A person who is __________ is not fully alert, drifts off to sleep when not
stimulated, but can be aroused when his or her name is called in a normal voice.
11. A person who is completely unconscious, with no response to pain or to any
external or internal stimuli, is in a(n) __________.
12. The most common and severe form of aphasia is __________ aphasia.
13. Also known as acute confusional state is __________.
14. A person with a(n) __________ affect would laugh when told about a serious
prognosis.
15. A person with a(n) __________ affect has no expression of feelings, a
monotonous voice, and lack of emotional response.

Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.