Mental Health Nursing Assessment

During a mental health assessment, which action demonstrates respecting a client's personal space?

A client is drowsy and falls asleep easily during an assessment. Which level of consciousness is the client most likely exhibiting?

Which of the following best describes 'affect' as it is assessed during a Mental Status Examination (MSE)?

During an assessment, a nurse asks a client to explain the meaning of a common proverb. Which cognitive ability is the nurse primarily evaluating?

A client consistently displays flexed arms and legs. This physical presentation is best described as:

When using the HEADSS assessment tool with an adolescent, which area is being explored when asking about 'activities'?

In the context of mental health nursing, what is the primary goal of trauma-informed care?

A nurse is using the Mini-Mental State Examination (MMSE). Which of the following cognitive functions is assessed by this tool?

A client experiencing significant life changes, such as job loss and subsequent depression, would benefit MOST from an initial nursing intervention focused on:

Which intervention exemplifies the ethical principle of autonomy in mental health nursing?

A patient is admitted to a psychiatric unit due to expressing intent to harm themselves and exhibiting severe self-neglect. Following an initial evaluation, what type of admission is most appropriate, and what is the next legal step after 60 days?

A client is pacing the halls and yelling. The nurse decides to put the client in restraints without trying other options because of the unit is short-staffed. Which client right was violated?

A nurse observes a colleague regularly divulging patient information to unauthorized personnel. Which ethical principle is the colleague violating?

A 16-year-old patient in acute mania requires physical restraint due to aggressive behavior towards staff. According to established guidelines, what is the maximum duration for a single episode of restraint, and how often should the patient be monitored?

A patient with a history of violence toward others is admitted to an inpatient psychiatric unit. Which intervention demonstrates the ethical principle of beneficence?

A nurse overhears a colleague discussing a patient's diagnosis and treatment plan in the hospital cafeteria. Which legal and ethical principles are being violated?

A patient with a history of violence makes a credible threat against a specific individual. According to the Tarasoff Law, what is the mental health professional's responsibility?

Which scenario best illustrates the application of the ethical principle of veracity in mental health nursing?

A client who was admitted voluntarily to a mental health facility demands to be released immediately, despite the treatment team's concerns. Which of the following is the MOST appropriate initial nursing action?

A psychiatric nurse administers an injection to a patient against their will, even though there was no emergency situation. This action could be considered:

Which of the following is an example of a client exercising their right to a psychiatric advance directive?

A patient who is suicidal is placed in restraints because the team does not have time to provide appropriate verbal de-escalation. What tort could charges be pressed for?

Which documentation example demonstrates clear, factual, and objective reporting, while meeting documentation guidelines?

A patient has been prescribed a PRN restraint, what is the appropriate action?

During a complex psychiatric evaluation, which assessment strategy would BEST enable a nurse to differentiate between a client's genuine perception of reality and potential delusional beliefs?

A client is admitted with decerebrate rigidity. What does the nurse expect to see?

When initiating care for a newly admitted client with a complex psychiatric history, which nursing action demonstrates the MOST comprehensive approach to gathering a psychosocial history?

In assessing abstract thinking, the nurse asks the client what brought them to the hospital. The client responds, "The ambulance". Which response by the nurse would BEST assess abstract thinking?

A nurse is preparing to conduct a mental status examination (MSE) on a client who is culturally diverse and speaks limited English. Which strategy would be MOST effective in ensuring the validity and reliability of the MSE findings?

When applying the HEADSS assessment tool to an adolescent client, the nurse asks, 'Tell me about your relationships with your family members.' Which domain of the HEADSS assessment is the nurse primarily exploring with this question?

Considering the principles of trauma-informed care, which approach demonstrates the HIGHEST priority when interacting with a client who has a known history of severe childhood trauma?

What BEST describes the distinction between religion and spirituality when assessing a client's cultural and spiritual considerations?

A client recently lost their job and is experiencing increased anxiety. Which initial nursing intervention would MOST effectively address their immediate needs, while promoting long-term coping?

Which scenario poses the most significant ethical challenge regarding a client's right to autonomy in a mental health setting?

In a mental health facility, a newly implemented policy mandates that all clients participate in group therapy sessions, regardless of their individual preferences or treatment plans. Which ethical principle is MOST clearly violated by this policy?

A client with bipolar disorder, currently in a manic phase, is admitted voluntarily to a psychiatric unit. Two days later, the client demands to be discharged, despite the treatment team's assessment that they are a danger to themselves due to impaired judgment and impulsivity. What is the MOST appropriate immediate nursing action?

A nurse discovers that a colleague has been consistently documenting client vital signs without actually taking them. Which ethical principle is the colleague violating?

A nurse is caring for a client with a history of aggression who becomes increasingly agitated. To ensure the safety of the client and others, the nurse initiates a series of interventions. Which intervention would be considered LEAST restrictive?

A client with paranoid schizophrenia is reluctant to take prescribed antipsychotic medication due to concerns about potential side effects, despite multiple attempts at therapeutic communication and education. Which approach best balances the client's right to refuse treatment with the nurse's responsibility to promote well-being?

A mental health nurse is working with a client who has a history of trauma. Which intervention demonstrates the MOST effective application of trauma-informed care principles?

A patient on a long-term involuntary admission is approaching the end of their initial court-ordered period. What is the most appropriate next step regarding their admission status?

A patient in seclusion is observed to be increasingly agitated, demonstrating signs of escalating distress. Which intervention should the nurse prioritize while adhering to both legal and ethical guidelines?

A nurse observes a colleague repeatedly accessing patient records for individuals not under their direct care, without a legitimate reason. What is the most appropriate initial action for the nurse to take?

A newly admitted patient with a history of aggressive behavior refuses medication and becomes increasingly agitated, pacing and yelling. What is the most appropriate and ethical sequence of interventions?

A patient discloses to a nurse that they are planning to harm a specific individual upon discharge. What is the nurse's legal and ethical responsibility in this situation?

A nurse makes a medication error that results in a client experiencing a severe adverse reaction. Which of the following actions constitutes professional negligence (malpractice)?

Which documentation entry demonstrates clear, factual, and objective reporting, while adhering to documentation guidelines for a patient exhibiting aggressive behavior?

A patient expresses a desire to create a psychiatric advance directive. What is the nurse's most appropriate response?

Mental Health Assessment

Psychosocial History

Mental Status Examination (MSE)

Levels of Consciousness

Spirituality (vs. Religion)

HEADSS (for Adolescents)

Trauma-Informed Care

DSM-5-TR (2022)

Life Changes Impact

Milieu Therapy

Legal Rights

Autonomy

Justice

Veracity

Voluntary Admission

Beneficence

Temporary Emergency Admission

Long-Term Involuntary Admission

Seclusion/Restraint Use

Torts

False Imprisonment

Negligence

Malpractice

Mental Health Nursing Assessment

Psychosocial History Components

Key Areas of MSE

Lethargic (Consciousness)

Stuporous (Consciousness)

Comatose (Consciousness)

Importance of Cultural Awareness

Characteristics of Spirituality

Role & Life Changes

Counseling

Client Legal Rights

Right to Humane Care

Confidentiality (HIPAA)

Fidelity

Informal Admission

Restraint Time (Adults)

Restraint Time (9-17)

Restraint Time (≤8)

PRN Restraint Orders

Tarasoff Law

Assault (Tort)

Battery (Tort)