Exam 3: NR548/ NR 548 (Latest Update 2024/ 2025) Psychiatric Assessment for the Psychiatric-Mental Health Nurse Practitioner Review |Weeks 5-6 Covered| Questions and Verified Answers| 100% Correct- Chamberlain

Exam 3: NR548/ NR 548 (Latest Update 2024/ 2025) Psychiatric Assessment for the Psychiatric-Mental Health Nurse Practitioner Review |Weeks 5-6 Covered| Questions and Verified Answers| 100% Correct- Chamberlain

Exam 3: NR548/ NR 548 (Latest Update
2024/ 2025) Psychiatric Assessment for the
Psychiatric-Mental Health Nurse
Practitioner Review |Weeks 5-6 Covered|
Questions and Verified Answers| 100%
Correct- Chamberlain
Q: individual who presents with an extremely rapid and pressured speech with constant
interruptions may be experiencing _ or _
Answer:
hypomania or mania
Q: An absence of speech is seen with some diagnoses such as
Answer:
dementia
Q: non-sensical speech is often associated with ____
Answer:
psychotic disorders
Q: MSE: Mood and Affect
Answer:
Mood
-client’s state of mind or prevalent emotional state
-subjective

-typically self-reported
-Stable: mood is appropriate to their current situation
-other: bright, happy, angry, agitated, irritable, labile, anxious, depressed, or euphoric
Affect
-physical manifestation of the client’s emotional state as observed by the provider
-normal, blunted, flat, bizarre, dysphoric, or euphoric
-Qualities of affect

• stability (stable or labile)
• appropriateness
• range (does it change with diff. situations)
• intensity
  Q: MSE: Thought Process
  Answer:
  -rate of thoughts and how they flow and are connected
  -coherent vs. incoherent
  -Normal: linear & goal-directed
  -Other: loose, circumstantial, or tangential
  -Clients may experience flight of ideas with little connection between thoughts or words
  -Assessment: questioning client, listening to responses
  Q: MSE: Suicidal and Homicidal Ideation
  Answer:
  -Direct terms should be used to assess suicide preoccupation and planning
  -assess for homicidal ideation, intent, attempts, and plans
  -critical to determine whether a plan exists
• access to the resources needed to execute the plan
• more detailed and thorough the plan, the higher the risk
• assess if plan is composed of fleeting thoughts rather than action steps
• assess whether the client is angry and lashing out or intending to bring actual harm
  -SCREENING FOR SUICIDAL AND HOMICIDAL IDEATIONS IS AN ETHICAL
  OBLIGATION OF THE PMHNP & IS ESSENTIAL FOR PROTECTING ONESELF, THE
  CLIENT, & THE PUBLIC

Q: MSE: Cognitive Assessment
Answer:
-evaluation of a client’s level of awareness, attention, concentration, and memory
-Awareness: observation with emphasis on the client’s eyes and speech
-alertness or wakefulness provides information about cognitive function

• help rule out potential substance use or intoxication
  -levels of awareness: alert and oriented, somnolent, drowsy, or even comatose
  -Attention and concentration: observation of responses during the interview
• can they stay on topic?
• able to focus and respond to Q’s?
• can use standardized tools such as the Mini-Mental State Exam (MMSE), digit span test and the
  SSST
  -Memory assessment: immediate recall, short-term, and long-term memory
• particularly important when ruling out dementia or Alzheimer’s disease
• Stress, anxiety, and depression can also impact memory
• orientation, three-object recall
  -Mini-Cog exam is commonly used to help rule out significant cognitive issues
  Q: Two attention and concentration assessments
  Answer:
  digit span test
  -patient is given 5-7 numbers & asked to repeat them forward and backward
  SSST
  -pt asked to subtract 7 from 100 and to continue counting back by 7s until told to stop
  *research studies have not endorsed them
  -SSST given to 132 normal adults, only 42% with errorless performance
  -325 hospitalized psychiatric pts given SSST, no diff. in performance from 50 healthy control
  subjects
  -Digit span test among 60 elderly pts with memory impairment and 44 elderly who were healthy
  found no difference
  Q: MMSE
  Answer:
  Powered by https://learnexams.com/search/study?query=

Mental Status Exam (MSE)
-best tool for establishing a psychiatric diagnosis
-combination of observations, impressions, & interpretation of client responses
-Eval of patients:

• appearance
• behavior
• speech
• affect
• thought process
• thought content
• cognition

mental health
“a state of well-being in which every individual realizes his or her own potential, can cope with normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community”

mental status
-refers to emotional (feeling) and cognitive (knowing) function
-functioning is inferred through assessment of an individual’s behaviors:

• consciousness
• language
• mood and affect
• orientation
• attention
• memory
• abstract reasoning
• thought process
• thought content
• perceptions

assessment of Individual’s behaviors includes

• consciousness
• language
• mood and affect
• orientation
• attention
• memory
• abstract reasoning
• thought process
• thought content
• perceptions

Factors that affect the interpretation of the MSE
culture
native language
educational level
literacy
social factors

MSE: Appearance
-posture
-dress
-grooming
-physical appearance

• distinguishable markings; scars or tattoos
  -facial expressions
  level of alertness
  -attitudes
  -Self-esteem
  -Personal statement

MSE: Behavior
how the client presents themselves during the examination
-eye contact
-psychomotor activity

• increased or decreased
  -movements
  -mannerisms
  -stereotypies
  -posturing
  -how the client responds to the exam
• responses appropriate to topics?
• sit still through exam?
  -gait
  -movements
• coordinated, slowed, excessive

MSE: Speech
-rate

• fast, rapidly, slowly
  -rhythm
• monotone or slurred
  -latency
  -volume
• soft, normal, or loud
  -content
  -increased or decreased pauses between questions and answers?
  -General quality

individual who presents with an extremely rapid and pressured speech with constant interruptions may be experiencing _ or _
hypomania or mania

An absence of speech is seen with some diagnoses such as _
dementia

non-sensical speech is often associated with ___
psychotic disorders

MSE: Mood and Affect
-subjective
-typically self-reported
-Stable: mood is appropriate to their current situation
-other: bright, happy, angry, agitated, irritable, labile, anxious, depressed, or euphoric
-normal, blunted, flat, bizarre, dysphoric, or euphoric
-Qualities of affect

• stability (stable or labile)
• appropriateness
• range (does it change with diff. situations)
• intensity

Affect
-physical manifestation of the client’s emotional state as observed by the provider
-normal, blunted, flat, bizarre, dysphoric, or euphoric
-Qualities of affect

• stability (stable or labile)
• appropriateness
• range (does it change with diff. situations)
• intensity

Mood
-client’s state of mind or prevalent emotional state
-subjective
-typically self-reported
-Stable: appropriate to their current situation
-other: bright, happy, angry, agitated, irritable, labile, anxious, depressed, or euphoric

MSE: Thought Process
-rate of thoughts and how they flow and are connected
-coherent vs. incoherent
-Normal: linear & goal-directed
-Other: loose, circumstantial, or tangential
-Clients may experience flight of ideas with little connection between thoughts or words
-Assessment: questioning client, listening to responses

MSE: Suicidal and Homicidal Ideation
-Direct terms should be used to assess suicide preoccupation and planning
-assess for homicidal ideation, intent, attempts, and plans
-critical to determine whether a plan exists

• access to the resources needed to execute the plan
• more detailed and thorough the plan, the higher the risk
• assess if plan is composed of fleeting thoughts rather than action steps
• assess whether the client is angry and lashing out or intending to bring actual harm
  -SCREENING FOR SUICIDAL AND HOMICIDAL IDEATIONS IS AN ETHICAL OBLIGATION OF THE PMHNP & IS ESSENTIAL FOR PROTECTING ONESELF, THE CLIENT, & THE PUBLIC

MSE: Cognitive Assessment
-evaluation of a client’s level of awareness, attention, concentration, and memory
-Awareness: observation with emphasis on the client’s eyes and speech
-alertness or wakefulness provides information about cognitive function

• help rule out potential substance use or intoxication
  -levels of awareness: alert and oriented, somnolent, drowsy, or even comatose
  -Attention and concentration: observation of responses during the interview
• can they stay on topic?
• able to focus and respond to Q’s?
• can use standardized tools such as the Mini-Mental State Exam (MMSE), digit span test and the SSST
  -Memory assessment: immediate recall, short-term, and long-term memory
• particularly important when ruling out dementia or Alzheimer’s disease
• Stress, anxiety, and depression can also impact memory
• orientation, three-object recall
  -Mini-Cog exam is commonly used to help rule out significant cognitive issues

Two attention and concentration assessments
digit span test
-patient is given 5-7 numbers & asked to repeat them forward and backward

SSST
-pt asked to subtract 7 from 100 and to continue counting back by 7s until told to stop

*research studies have not endorsed them
-SSST given to 132 normal adults, only 42% with errorless performance
-325 hospitalized psychiatric pts given SSST, no diff. in performance from 50 healthy control subjects
-Digit span test among 60 elderly pts with memory impairment and 44 elderly who were healthy found no difference

MMSE
-Mini-Mental State Exam
-30-point questionnaire
-measures cognitive impairment in the areas of orientation, attention, memory, language, and visual-spatial skills
-method of monitoring deterioration over time
-age, education, and visual or hearing impairment may impact scores

• Most studies have defined poorly educated as 8 or fewer years of education—that is, no high school
  -sensitivity of the test is high, specificity is low

Interpret a mini-cog score
(Total Possible Score: 0-5): Add the 3-item recall and clock drawing scores together.

Recall Score (Total Possible Score: 0-3)
-1 point for each word correctly recalled

Clock Drawing Score (Total Possible Score: 0-2)
-2 points for normal clock (include all numbers, 1-12)
-0 points for abnormal clock
-must be 2 hands present (one pointing to the 11 and one pointing to 2)
-hand length not scored

Mini-Cog exam
-streamlined dementia screen
-score range is from 0-5
-obtained from adding the 3-item recall and clock drawing scores together.
-A total score of 0, 1, or 2 indicates higher likelihood of clinically important cognitive impairment
-A total score of 3, 4, or 5 indicates lower likelihood of dementia

• does not rule out some degree of cognitive impairment.

three object recall
Recall of three objects after at least 2 minutes has been shown to be a useful test in diagnosing cognitive impairments
-Repeat the following three words: ball, chair, purple.
-Once you are satisfied that your patient has registered all three words, say: Now I want you to remember those three words, because I’m going to ask you to repeat them in a couple of minutes.
-In the meantime, ask your patient general knowledge questions bout general cultural and personal information.
-Then ask him to repeat the three words.
-If trouble, use the following hints:

• One of them is something you can play with
• One is a piece of furniture.
• One is a color.

General Cultural Knowledge
Inability to recall at least half of these items is presumptive evidence of long-term memory impairment.
-Last three presidents
-famous figures

• George Washington, first president
• Abraham Lincoln, freed the slaves
• Martin Luther King, Jr., civil rights leader
• Princess Diana, British princess killed in car accident
• William Shakespeare, writer
• Christopher Columbus, discovered America
  -Famous dates
• When did World War II happen? (Any time in the 1930s or 1940s is adequate.)
• When was John F. Kennedy assassinated? (Sometime in the 1960s.)
  -Lists of information
• screening for dementia is the set test: patient to name as many items (up to ten) as he can recall in each of four categories: colors, animals, fruits, and towns; max of 40, score of 25 or above excludes dx of dementia

Personal Knowledge
memory of remote personal events
-Cognitively intact patients should be able to tell you:

• Current address and phone number
• Names and ages of spouse, siblings, and children
• Spouse’s birthday, wedding anniversary, and date and place of marriage (if married)
• Parents’ names and birthdays (primarily for younger patients who are not married)

MSE: Insight and Judgment
-final components of the mental status exam
-determined to be good, limited, or poor depending on the actions the client has taken, awareness of their illness, and the plans they have for the future.

Insight
-client’s awareness of their illness or situation

Judgment
-ability to anticipate the consequences of their behavior and safeguard their well-being
-may be measured with a standard question but should be assessed throughout the entire interview

Q’s to probe for degree of insight
-So, why do you think you’ve been having these problems?
-What do you think needs to happen for your life to improve?

Pt’s with poor insight may respond with:
-I don’t know. You’re the doctor.
-People need to stop hassling me. (A paranoid patient.)

ABSATTC
Mnemonic for Elements of the Mental Status Examination
-All Borderline Subjects Are Tough, Troubled Characters

• Appearance
• Behavior
• Speech
• Affect
• Thought process
• Thought content
• Cognitive examination

closure
-final phase of the psychiatric interview process
-provides the client with a summary and findings of the interview and allows for discussion of future plans
-PMHNP may provide education during this phase

final step of the psychiatric interview
documentation
-Thorough, accurate documentation is necessary for clinical and legal purposes

Closing the Interview
PMHNP explains the diagnosis and treatment options to the client
-offers an opportunity for the client to ask questions and give input
-discussion includes recommendations for any additional psychological assessments and laboratory testing needed
-education regarding recommended medications and therapies
-If a need to collaborate with other providers for information or treatment, the PMHNP should seek permission from the client at this time to do so
-opportunity to address any client concerns about stigma
-discuss need for F/U care

Which of the following should be included when providing client education about medication regimens? Select all that apply.
explain how the medication targets the symptoms, specific benefits, and expected time course.
identify potential side effects, duration of side effects, and adverse effects.
explain the instructions, dosing, and special requirements.
use teach-back methods to ensure client understanding.
explain how the medication targets the symptoms, specific benefits, and expected time course.

identify potential side effects, duration of side effects, and adverse effects.

explain the instructions, dosing, and special requirements.

use teach-back methods to ensure client understanding.

Follow-Up homework
PMHNP may assign homework to the client
-especially when tx plan includes cognitive-behavioral or family therapy
-explain the purpose and goal of the assignment
-explain whether the client will be expected to report on the homework at the next appointment

Follow-Up care
PMHNP should discuss the need for follow-up care with the client during the closure of the interview
-include clients in determining the need for and frequency of follow-up visits

• promote adherence
  -Two-week intervals are common when starting new medications
• assess for tolerability, efficacy, and the need for dose adjustment
  -four-week intervals (or longer) are typical for stable clients
  -Scheduling future visits is important as noncompliance is common in mental health

Documentation
Use the ten minutes following the 50-minute interview to record clinical findings
-facilitates communication with other members of the healthcare team
-provides information to insurance companies and third parties for billing and reimbursement
-required to satisfy legal requirements and mitigate risk

• Careful and thorough record-keeping is imperative in the event of litigation

All components of a clinical encounter should be documented including:

• chief complaint
• referral source
• history of present illness
• current treatments including medications and therapies
• past medical, family, social histories
• review of systems
• mental status examination
• diagnosis
• treatment plan

SOAP note
subjective, objective, assessment, and plan

method of documentation that helps organize the information from a psychiatric interview

three objectives for clinical documentation
-Thoroughness

• thorough yet succinct description of the client
  mindful of presenting an accurate, objective account of the client encounter
• Be aware of personal bias

-Time efficiency

• typically take no more than 10-15 minutes

-Readability

• 2-3 pages maximum to allow for easy review

Identifying Data
fairly long initial sentence that sets the stage for the entire evaluation
-includes demographic descriptors of the client and the context of the referral

• age, sex, marital status, and source of referral at a minimum
• may include other information such as occupation, living situation, and presence of other family.

Chief Complaint
reason client gives for presenting for treatment at this time; typically, a direct quotation or subjective statement

History of Present Illness
-recent psychiatric symptoms, including pertinent positives and negatives
-includes timeframe of recent onset or exacerbation, symptom triggers, or recent treatment and treatment changes providing a snapshot of the onset and progression of the current issue

Past Psychiatric History (PPH)
includes psychiatric hospitalizations, outpatient treatments, current and past medications, types of psychotherapy, and any suicide and/or violence history spanning early childhood to the present
-Can use mnemonic Go CHaMP for write-up

• General statement
• Caregivers
• Hospitalizations
• Medication trials
• past Psychotherapy (include if it was helpful, why/why not)

Substance Use History
-includes drug and alcohol use, when used, consequences of use, the recent pattern of use, last use, and treatment
-also includes nicotine and caffeine usage

Review of Symptoms
-includes screening for present and past symptoms related to the diagnostic category
-section assists in defending and confirming Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5-TR) diagnosis.
-go through the major diagnostic categories, indicating whether the patient met any of the criteria and excluding those that you already mentioned in the HPI and in the substance abuse section, if you have included one

Family History
-includes history of psychiatric disorders, substance abuse, and suicide in the client’s family
-provides an understanding of the client’s home life, their childhood experiences, education, and relationships
-genogram will suffice for family psychiatric hx

Social hx
At a minimum:
-Where your patient was born and raised
-Number of siblings
-Birth order of patient and siblings
-Who was present in the household during the formative years
-Educational level
-Work history
-Marital and parenting history of patient
-Typical daily activities other than work

Medical History
includes significant medical illnesses, hospitalizations, surgeries, seizures, head injuries with loss of consciousness, and prescribed medications and the primary care provider
-may use mnemonic MIDAS
-usually begin with general statement about pt’s general health

Mental Status Exam
includes observational and direct inquiry components and requires vivid description
-Describe your patient so well that a reader would be able to recognize him from your description alone

Assessment
-includes the diagnosis
-concise and informative
-A list of differential diagnoses may be included, but the initial diagnosis listed is the DSM-5 TR diagnosis.

DSM-5 TR vs Diagnosis
includes all diagnoses involving psychiatric, personality, or medical disorders

Treatment Plan
includes any diagnostic testing planned, medications, therapy, client education (dosing instructions, side effects, expected benefits, when to note efficacy), referrals, follow-up care

How to Educate Your Patient
-Briefly state your diagnosis
-Find out what your patient knows about the disorder
-Give a minilecture about the disorder, if indicated
-Ask if there are any questions
-Give your patient written educational materials

Negotiating a Treatment Plan: Essential Concepts
-Elicit the patient’s agenda
-Negotiate a plan that you and your patient can agree on
-Help the patient implement the agreed-on plan

Elicit the Patient’s Agenda
elicit it with a simple question, such as:
How do you hope I can help you?
How were you hoping that I could help you to feel better?
-Sometimes patients have a pretty clear idea of what they’d like; medication, counseling, advice about something, a letter to someone
-don’t have a specific request or agenda; don’t force the issue with these patients

Negotiate a Plan
treatment adherence is enhanced when the patient and practitioner agree on the nature of the problem
-agree at the outset about a plan, go directly to the implementation phase
-must negotiate a mutually agreed-on goal

Common problematic request – patient seeks hospitalization for a problem that can be treated in an outpatient setting: What is important to keep in mind?
possibility that the patient is suffering much more than originally indicated
-their request for hospitalization is their way of obliquely disclosing that.
-may need to reassess for SI at this point, if still satisfied that hospitalization is not indicated, discuss other options:

• Day hospitalization
• Respite care
• Staying with a friend or relative for a while if the home situation is intolerable
• Taking a few days off from work
• Having the patient call you (or another clinician) for daily check-ins during a crisis period
• Setting up more frequent appointments
• A short course of an antianxiety medication

Implementing the Agreed-On Plan
likely fall into one or both of the following categories:

-follow-up therapy appointment with you or someone else

• highest F/U aherence: wait for F/U appt is short, referrals made to specific clinicians rather than to a clinic, specific appt made at time of disposition, pt speaks directly to someone at referral clinic during evaluation session.

-Medication trial

• Determine how your patient will pay for medication: Some patients can’t afford the copays – if so, you may be able to provide samples
• Make sure pt understands the side effect profile of the medication
• Simplification increases recall and compliance
• Having pt repeat what you say increases recall of instructions