Question

The nurse is assigned to a young adult brought to the clinic by her father for her angry demeanor, agitation and outbursts at home. The nurse notes that the client is dressed in all black, including make-up and hair. No eye contact is made, and appears restless and jittery. (20 points each)

• Identify the key components of the mental status examination.
• Describe the steps to the mental health examination the nurse should perform with rationale.
• Discuss how a client’s decision-making and judgment is evaluated during the mental health examination.
• Identify how a nurse could interpret the client’s agitation, angry demeanor and lack of eye contact.
• During the eye assessment the nurse notes that the client’s eyes are constricted. How does the nurse interpret this finding?

Answer 1

Answer 1. The key components of anger that is shown by the young adult suggests that she might be suffering from the effects of alcoholism or depression. And if it is the depression, it can be any such type like, IED, ODD, etc. Her mental status was observed that she has some differences in her mind with the surroundings and the people around. She was observed to be very agitated and with temper tantrums.

Answer 2. There are proper steps to follow to assess the mental health of a person and they include :-

. Try to get the attention of the patient towards you and try talking in a general way to make her comfortable.

. Physical examinations should be done first to notice any special marks or signs on the body showing any information or any kind of pain felt by the patient.

. Then medical tests should be run including blood tests, urine tests and x ray to get complete results, so that the reason can be judged out.

. Her previous medical records are also checked and the type of medicines she has been taking.

. Her appearance is noted and the way of communication is also considered.

All these steps can help in diagnostic testing and referral to a psychiatrist or other specific mental health professional.

Answer 3. The patients with mental illness can be tested for her judgements like by asking questions in which she has two chose between two or three options. Her choice would decide her behaviour and thoughts. Her decision making ability will be assessed by providing her different but specific conditions and she has to go with only one. Her decision over the question will help in assessing her mind.

Answer 4. The nurse needs to follow proper assessment plan for her. Firstly, she has to make her patient as much comfortable as she can by talking generally and then the behaviour of the patient along with her speech, mood, thoughts, her views about different aspects around them, etc can help the nurse in assessment. The nurse can ask little about her personal life with which she might give an eye contact. Her previous medical records can also help. If she is already under any kind of treatment, she can be given related medications to relax her mind.

Answer 4. The young adult was not making an eye contact and her eyes were constricted. Her unusual eye movements can help to diagnose if she has illness like schizophrenia, or bipolar disorder or any kind of severe depression. Eye test is one step forward towards the decision making for the health.