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Pertinent Medical History & Assessment
Dr. Glaser Week 1
32
Nursing
Graduate
02/01/2014

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Cards

Term
In documenting nursing diagnoses for mental health patients...
Definition
...one must cite their sources if a reference is used
Term
Of the following questions which is NOT applicable to a primary meeting?
a. Can you tell me why you're in the hospital (in your own words)?
b. What medications are you currently on?
c. When did you stop this particular medication?
d. Would you consider yourself an abuse victim?
Definition
D
Term
True or False: Most MHCs have little to no physical manifestation
Definition
False, most MHCs present physically as well as mentally
Term
Stressor
Definition
Specific/current issues which lead to admission
Term
Purpose of the Mental Status Exam (MSE)
Definition
to provide common language for the documentation of mental health conditions upon admission
Term
Consideration for Recording General Appearance
Definition
be COMPLETELY OBJECTIVE
describe what they're wearing, not how you think they look
Term
This is the question that the Interaction portion of the MSE answers
Definition
What is the patient doing during the assessment?
Term
Three questions to answer when assessing the Speech portion of the MSE
Definition
how FAST are they talking?
how MUCH are they talking?
how CLEAR is their speech?
Term
Affect vs. Mood
Definition
objective vs. subjective
pt's facial expressions/body language vs. how pt says they feel
must compare the two for congruence
Term
labile
Definition
quickly changing (as in affect)
Term
Hallucinations and types
Definition
sensing something which does not exist
visual and auditory hallucinations are common where olfactory and tactile hallucinations are uncommon
Term
Delusions
Definition
false fixed beliefs (paranoia, etc.)
Term
Echolalia
Definition
parroting of others' speech which is inappropriate
Term
circumstantiality
Definition
extremely detailed and lengthy discourse about a topic
Term
loose associations
Definition
absence of normal connectivity between topics
Term
Tangentiality
Definition
pt logically changes the topic from one to the next, but the original point of the conversation is lost as they do so
Term
flight of ideas
Definition
extreme tangentiality where the topic is changed rapidly often after only one sentence or phrase
Term
word salad
Definition
strings of words that aren't connected in any way
Term
neologisms
Definition
made-up words with no understood meaning
Term
paranoia
Definition
unrealistic suspicions and guardedness
Term
referential thinking
Definition
belief that neutral stimuli have special direct meaning to the individual
Term
autistic thinking
Definition
restricts thinking to the literal and immediate so that the individual develops a system of rules and logic that make no sense to anyone but themselves
Term
concrete thinking
Definition
inability to think abstractly: sarcasm, jokes, and hypotheticals are incomprehensible (common in Asperger's)
Term
verbigeration
Definition
senseless repetition of words or phrases
Term
metonymic speech
Definition
use of words interchangeably with similar meanings
Term
clang association
Definition
rapid verbalization of words which are similar in sound, but make no sense together (right, light, might, tight, fight, bite, trite, sight, white...)
Term
stilted language
Definition
overly and inappropriately artificial formal language
Term
pressure speech
Definition
speaking as if the words must be forced out
Term
Judgement
Definition
ability to make decisions
Term
insight
Definition
understanding of the nature of things (like why the pt is in the hospital, their illness, etc)
Term
when assessing whether a client is at risk for harm to themselves or others, what information must be gleaned?
Definition
How..
Specific (do they have a plan?)
Lethal (does it involve killing?)
Accessible (are they capable?), and
Proximal (do they have what they need?)
are their plans?
Term
What is a SMART outcome?
Definition
One that is Specific, Measurable, Applicable, Realistic, and Timely.
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