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Mental status is reflected in one’s speech, appearance, and thought patterns. The
ability to think clearly and respond appropriately to daily stressors of life is necessary
to function effectively in the activities of daily living.

The structure and function of the neurological system can affect one’s mental and
psychosocial status. Cerebral abnormalities disturb the client’s intellectual ability,
communication ability, or emotional behaviors.
For example: If the broca’s area is affected, the patient might have what we call
Broca’s Aphasia, which affects their ability to produce speech & language. But if the
Wernicke’s area is affected, the patient might have Wernicke’s Aphasia which affects
their ability to comprehend speech and language

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All general guidelines apply  confidentiality of sensitive data, explain purpose,
adjust to level of comprehension

Before asking questions to determine the client’s mental and psychosocial status,
explain the purpose of this part of the examination. Explain that some questions you
ask may sound silly or irrelevant.

Problems with other body systems may affect mental status. For example, a client
with a low blood sugar may report anxiety and other mental status changes.
Regardless of the source of the problem, the client’s total lifestyle and level of
functioning may be affected.

Clients who are experiencing symptoms such as memory loss or confusion may fear
that they have a serious condition such as a brain tumor or Alzheimer’s disease. They
may also fear a loss of control, independence, and role performance

Mental health problems often affect the client’s self-image and self-concept in a
negative manner

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These answers will provide baseline data about the client’s
level of consciousness, memory, speech patterns, articulation,
or speech defects. Inability to answer these questions may indicate a
cognitive/neurological defect.

This information helps determine a reference point for which

the client’s psychosocial developmental level and appearance
can be compared. Women tend to have a higher incidence of depression and anxiety,
whereas men tend to have a higher incidence of substance abuse and psychosocial
disorders.

Married adults often report less stress than single or divorced

adults.

Psychosocial problems appear more often in those with lower

incomes and lower educational levels. Clients from higher educational and
socioeconomic levels tend to participate in more healthy lifestyles.

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This information will help the examiner determine the client’s perspective and ability
to prioritize the reality of symptoms related to their current health status

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Some clients may have had a negative past experience with mental health care
services.

These conditions can affect the developmental level and the mental status of the
client.

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Tension headaches may be seen in clients experiencing stressful situations.

Posttraumatic syndrome may be seen in veterans who experienced traumatic

conditions in military combat.

Clients with anxiety disorders may hyperventilate or have palpitations.

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Some psychiatric disorders may have a genetic or familial connection such as anxiety,
depression, bipolar disorder and/or schizophrenia, or Alzheimer’s disease.

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Neurological and mental illnesses can alter one’s responses to activities of daily living
(ADLs). Depression may be seen in those with sedentary lifestyles. Anxious clients
may be restless, while depressed clients may feel fatigued. Clients with eating
disorders may exercise excessively.

Poor appetite may be seen with depression, eating disorders, and substance abuse.

Irritable bowel syndrome or peptic ulcer disease may be associated with

psychological disorders.

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This is very common during the Adolescent age – due to development/social
pressure.

(Don't use Altered Body Image because there is no present alteration in body image)

Russel's Sign (Scarring on the back of the hands)

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Use of these substances may alter one’s level of consciousness, decrease response
times, and cause changes in moods and temperament. Inappropriate use of any of
these substances may indicate alcoholism or drug abuse problems.

Cognition may be altered with toxin exposure.  Carbon Monoxide poisoning

Certain religious beliefs can affect the client’s ability to cope in a positive or negative
manner.

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Clients with a low self-concept may be depressed or suffer from eating disorders or
have substance abuse problems.

Clients with psychological problems often have difficulty maintaining effective

meaningful relationships. Mental health problems often interfere with one’s role in
families and relationships. In turn, stressful relationships or roles may interfere with
one’s mental health.  Especially if cluster B personality disorders

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The advantage of assessing mental status at the very beginning of the head-to-toe
examination is that it provides clues regarding the validity of the subjective
information provided by the client throughout the exam. Thus it is best to determine
validity of client responses before completing the entire physical exam only to learn
that the client’s answers to questions may have been inaccurate

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For example, the client will be asked to explain the meaning of a proverb, such as “a
stitch in time saves nine.” They will also be asked to name the day of the week and
explain where they are at the time of the exam

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WHAT YOU DO:
- Ask the client his or her name, address and phone number

- If the client does not respond appropriately, call the client’s name and note the
response. If the client does not respond, call the name louder. If necessary, shake
the client gently. If the client still does not respond, apply a painful stimulus.

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Lethargy: Client opens eyes, answers questions, and falls back asleep.

Obtunded: Client opens eyes to loud voice, responds slowly with confusion, seems
unaware of environment.

Stupor: Client awakens to vigorous shake or painful stimuli but returns to

unresponsive sleep.

Coma: Client remains unresponsive to all stimuli; eyes stay closed.

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The GCS is used to quickly assess a patient’s level of consciousness

8 below – considered coma

Deep Comatose - 3

GCS score of 14 indicates an optimal level of consciousness.

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Decorticate – FLEXOR, usually problems with spinal tract or cerebral hemisphere

Decerebrate – EXTENSOR, usually problems within the midbrain or pons

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Eye - 4*
Verbal - 3*
Motor - 6*

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Eye - 2
Verbal - 5
Motor - 5

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Eye - 2
Verbal - 3
Motor - 4

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NORMAL:
The client appears to be relaxed with shoulders and back erect when standing or
sitting. Gait is rhythmic and coordinated with arms swinging at sides.

Abnormal:
Slumped posture may reflect feelings of powerlessness or hopelessness
characteristic of depression or organic brain disease. Bizarre body movements and
behavior may be noted in schizophrenia or may be a side effect of drug therapy or
other activity. Tense or anxious clients may elevate their shoulders toward their ears
and hold the entire body stiffly.

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Affect refers to the immediate expression of emotion.

NORMAL:
Client is cooperative and purposeful in his or her interactions with others. Mild to
moderate anxiety may be normal in a client who is having a health assessment
performed. Affect is appropriate for the client’s situation

ABNORMAL:
Uncooperative, bizarre behavior may be seen in the angry, mentally ill, or violent
client. Anxious clients are often fidgety and restless. Some degree of anxiety is often
seen in ill clients. Apathy or crying may be seen with depression. Incongruent
behavior may be seen in clients who are in denial of problems or illness. Prolonged,
euphoric laughing is typical of mania.

Affect could be inappropriate

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Observe dressing and grooming:
NORMAL:
Dress is appropriate for occasion and weather. Dress varies considerably from person
to person, depending on individual preference. There may be several normal dress
variations depending on the client’s developmental level, age, socioeconomic level,
and culture or subculture

ABNORMAL:
Unusually meticulous grooming and finicky mannerisms may be seen in obsessive-
compulsive disorder. Poor hygiene and inappropriate dress may be seen in
depression, schizophrenia, dementia, and Alzheimer’s disease. Onesided neglect may
result from lesion in the opposite parietal cortex, usually the nondominant side.
Uncoordinated clothing, extremely light clothing, or extremely warm clothing for
the weather conditions may be seen on mentally ill, grieving, depressed, or poor
clients. This may also be noted in clients with heat or cold intolerances. Extremely
loose clothing held up by pins or a belt may suggest recent weight loss. Clients
wearing long sleeves in warm weather may be protecting themselves from the sun or
covering up needle marks secondary to drug abuse. Soiled clothing may indicate
homelessness, elderly vision deficits, or mental illness.

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NORMAL:
Client maintains good eye contact, smiles, and frowns appropriately.

ABNORMAL:
Poor eye contact is seen in depression or apathy. Extreme facial expressions of
happiness, anger, or fright may be seen in anxious clients. Clients with Parkinson’s
disease may have a masklike, expressionless face.
Staring watchfulness appears in metabolic disorders and anxiety. Inappropriate facial
expressions (e.g., smiling when expressing sad thoughts) may indicate mental illness.
Drooping or gross asymmetry occurs with neurological disorder or injury (e.g., Bell’s
palsy or stroke).

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NORMAL:Speech is in a moderate tone, clear, with moderate pace, and culturally
appropriate.

Abnormal:
Slow, repetitive speech is characteristic of depression or Parkinson’s disease. Loud,
rapid speech may occur in manic phases of bipolar disorder. Disorganized speech,
consistent (nonstop) speech, or long periods of silence may indicate mental illness
or a neurological disorder (e.g., dysarthria, dysphasia, speech defect, garbled speech).
Table 6-1 provides further information about voice and speech problems.

Broca’s Area
Wernicke’s Area

If the client has difficulty with speech, perform additional tests:

• Ask the client to name objects in the room.
• Ask the client to read from printed material appropriate for his or her educational
level.
• Ask the client to write a sentence

NORMAL:
Client names familiar objects without difficulty. Reads age-appropriate written print.
Writes a coherent sentence with correct spelling and grammar.

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Abnormal:
Deficits in this area require further neurologic assessment to identify any dysfunction
of higher cortical levels

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Cerebellar disease - cerebrellum  alcohol intake

Multiple sclerosis  Demyelination of the CNS  Charcot’s Triad  Scanning Speech

otherwise known as your Cerebellar Dysarthria

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Normal:
Cooperative or friendly, expresses feelings appropriate to situation, verbalizes
positive feelings regarding others and the future, expresses positive coping
mechanisms (support groups, exercise, sports, hobbies, counseling).

Abnormal:
Expression of prolonged negative, gloomy, despairing feelings is noted in depression
(see Self-Assessment 6-1). Expression of elation and grandiosity, high energy level,
and engagement in high-risk but pleasurable activities is seen in manic phases.
Excessive worry may be seen in anxiety or obsessivecompulsive disorders. Eccentric
moods not appropriate to the situation are seen in schizophrenia.

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Normal:
Client expresses full, free-flowing thoughts; follows directions accurately; expresses
realistic perceptions; is easy to understand and makes sense; does not voice suicidal
thoughts.

Abnormal:
Abnormal processes include persistent repetition of ideas, illogical thoughts,
interruption of ideas, invention of words, or repetition of phrases as in
schizophrenia; rapid flight of ideas, repetition of ideas, and use of rhymes and
punning as in manic phases of bipolar disorder; continuous, irrational fears, and
avoidance of an object or situation as in phobias; delusion, extreme apprehension;
compulsions; obsessions; and illusions are also abnormal (see the glossary for
definitions).

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NORMAL:
Verbalizes positive, healthy thoughts about the future and self.

Abnormal:
Clients who are suicidal may share past attempts of suicide, give plan for suicide,
verbalize worthlessness about self, joke about death frequently. Clients who are
depressed or feel hopeless are at higher risk for suicide.

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G – Giving away valuables
C – Cancelling appointments
A – Apologetic
S – Satisfied and detached
H – Homicidal and Suicidal Tendencies

C – Confront
C - Confiscate
C – Contract (Safety contract)
C – Constant Supervision (Irregular intervals)

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Normal:
Client is aware of self, others, time, home address, and current location.

Abnormal:
Reduced degree of orientation may be seen with organic brain disorders or
psychiatric illness such as withdrawal from chronic alcohol use or schizophrenia.
(Note: Schizophrenia may be marked by hallucinations—sensory perceptions that
occur without external stimuli—as well as disorientation.)

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Normal:
Client listens and can follow directions without difficulty

Abnormal:
Distraction and inability to focus on task at hand are noted in anxiety, fatigue,
attention deficit disorders, and impaired states due to alcohol or drug intoxication.

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Normal:
Recalls recent events without difficulty.

Abnormal:
Inability to recall recent events is seen in delirium, dementia, depression, and
anxiety.

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NORMAL:
Client correctly recalls past events.

Abnormal:
Inability to recall past events is seen in cerebral cortex disorders.

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Normal:
Client is able to recall words correctly after a 5-, a 10-, and a 30-minute period.

Abnormally:
Inability to recall words after a delayed period is seen in anxiety, depression, or
Alzheimer’s disease.

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Normal:
Client explains similarities and differences between objects and proverbs correctly.
The client with limited education can joke and use puns correctly.

Abnormal:
Inability to compare and contrast objects correctly or interpret proverbs correctly is
seen in schizophrenia, mental retardation, delirium, and dementia.

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Normal:
Answers to questions are based on sound rationale.

Abnormal:
Impaired judgment may be seen in organic brain syndrome, emotional disturbances,
mental retardation, or schizophrenia.

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Normal:
Draws the face of a clock fairly well. Can copy simple figures.

Abnormal:
Inability to draw the face of a clock or copy simple figures correctly is seen with
mental retardation, dementia, or parietal lobe dysfunction of the cerebral cortex.

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