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As a home health nurse working with, Michael Smith, a newly diagnosed 17-year-

 

old young man with schizophrenia who lives at home with his parents, you stop by to 

 

check on the patient at the request of his parents. The parents share their concerns that the 

 

patient’s medication, haloperidol (Haldol), does not appear to be working as well as it 

 

had when the patient first started taking it. They report that the patient is more irritable, 

 

has an increase in his hallucinations with the patient talking aloud again in response to 

 

auditory hallucinations, frequently laughing at apparently nothing. He has a firmly fixed 

 

delusion that he is inhabited by demons who are slowly eating his internal organs; and 

 

has increased consumption of water with the patient drinking large volumes of water in a 

 

way that his parents describe as, “He seems driven to drink. We’re not sure why. Perhaps 

 

he’s attempting to flush those demons out?” Upon entering the patient’s room, you notice 

 

a strong smell of urine. His parents are obviously embarrassed by this and quickly tell 

 

you they recently took the patient to his medical care provider to rule out a urinary tract 

 

infection. They tell you the urine analysis showed only a low specific gravity, and the 

 

only other abnormal laboratory finding was that his serum sodium level was found to be 

 

low. 

 

Objectives:

 

Complete the Mental Status assessment on the “hypothetical client” using the Mini Mental Status Exam.  

MENTAL STATUS EXAM

I. General Appearance and Motor Behavior: 

   Describe hygiene, grooming, appropriate dress, eye contact, use of personal space, any unusual

  movements or mannerisms, speech.

 

II. Attitude toward interviewer: 

    Cooperative________ Uncooperative___________

    Describe:

 

III. Mood: 

      Happy___ Euphoric___ Sad___ Depressed___   Angry___   Labile___ 

 

IV. Affect: 

      Full range___ Blunted___ Restricted___ Flat___ Inappropriate___ Consistent with stated 

      mood? Yes____ No____

 

V. Thought Process and Content: 

      Is thought process clear to interviewer?  Yes____ No____

 

      Process:  loose associations___ circumstantial___ tangential___   flight of ideas 

      thought blocking___   word salad____ neologisms_____ other_____ (describe)   

      Content:  ideas of reference___   delusion ____ (type)_____    thought insertion___   thought

      withdrawal _____ thought broadcasting_____    ideas of harming self or others_____ 

      other____(describe)

 

VI. Abnormal Sensory-Perceptual Experiences: 

      Presence of hallucinations _____ (describe) or  illusions _____ type______ describe

 

VII. Thinking and Intellectual Abilities:

        Is patient able to identify similarities between pairs of objects? (Apple and orange) 

        Yes___ No___

 

VIII. Sensorium and Intellectual Processes:

        Oriented to person___ place____ time____   and current circumstances_____ if no describe

 

       Memory: Name current president, who was president before that, name country lives in,  

       name capital of this state   Yes_____ No_____

 

IX. Judgment and Insight:

      Impulse control: describe

      Judgment – does patient interpret environment and situation correctly and adapt behavior and 

     decisions accordingly?  Describe.

     Insight- does patient understand true nature of his situation and his own part in it?  Describe.

SCIENCE
HEALTH SCIENCE
NURSING
NURSING 250

 

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