DELAWARE TECHNICAL & COMMUNITY COLLEGE

TERRY CAMPUS, NURSING DEPARTMENT

NUR 174 Mental Health Nursing

Mental Status Examination Guide

Name____________________________ Client initials__________

Date_____________________________

1. Categories of Data/Background information (Psychiatric history)

1.1 Complaint
1.2 Present Symptoms
1.3 Previous hospitalizations and mental health treatment
1.4 Family history
1.5 Personal history
1.6 Personality

2. Mental Status Examination: There is to be a narrative write-up of the following categories of

the mental status exam. Support your statements with descriptions of behavior and direct
quotes from the client where applicable.

2.1 General behavior, appearance, attitude

2.2 Characteristics of speech
2.3 Emotional State
2.4 Content of thought
2.5 Sensorium or orientation
2.6 Memory
2.7 General intellectual level
2.8 Abstract thinking
2.9 Insight evaluation
2.10 Summary

3. List all nursing diagnoses (prioritized) related to the data collected during the mental status
examination.

Adapted from Kneisl and Trigoboff (2009). Contemporary Psychiatric-Mental Health Nursing.
(2nd ed.). Upper Saddle River, New Jersey: Pearson Prentice-Hall.
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The Psychiatric history generally includes the following categories of data:

1. Complaint – the main reason the client is having a psychiatric examination. The client may
have personally initiated the psychiatric examination, or others (such as courts, hospital staff,
family, referral from school or employer) may have initiated it. The “chief complaint” should be
recorded verbatim and indicated as such with quotation marks, (“I just don’t want to live
anymore” or “I know these are crazy thoughts but I can’t stop them”).
2. Present symptoms – the nature of the onset and the development of symptoms. These data
are usually traced from the present back to the last period of adaptive functioning
3. Previous hospitalizations and mental health treatment
4. Family history – generally, whether any family members have ever sought or received mental
health treatment
5. Personal history – the client’s birth and development; past and recent illnesses; schooling and
educational problems; occupation; sexual development, interests and practices; marital history;
the use of alcohol, drugs caffeine and tobacco; trauma history; and religious, spiritual or
cultural practices
6. Personality – the client’s relationships with others, moods, feelings, interests, and leisure
activities

Mental Status Examination (MSE): usually a standardized procedure in agencies that use it.

Primary purpose is to help examiner gather objective data to be used in determining etiology,
diagnosis, prognosis, and treatment, and to deal immediately with any risk of violence or harm. The
sections of the MSE that deal with sensorium and intellect are particularly important in establishing
the existence of delirium, dementia, amnestic, and other cognitive disorders. The purpose of this
examination differs from that of the psychiatric history in that it identifies the person’s present mental
status.

The mental status examiner generally seeks the following categories of information (not necessarily in
the sequence presented here):

1. General behavior, appearance, and attitude – a complete and accurate description of the
client’s physical characteristics, apparent age, manner of dress, use of cosmetics, personal
hygiene, and responses to the examiner. Posture, gait, gestures, facial expression, and
mannerisms are included in the description. The examiner also notes the client’s general
activity level.

Example: A 35 year-old white male, appears stated age, dressed in torn, disheveled jeans. Presents
a blank facial expression, slouched posture, shuffling gait, generally low activity level, and sullen
behavior.

2. Characteristics of Speech – the form, rather than the content, of the client’s speech. Speech
is described in terms of loudness, flow, speed, quantity, level of coherence, and logic. A
sample of the client’s conversation with the examiner may be included in quotation marks. The
goal is to describe the quantity and quality of speech to identify difficulties in thought
processes. The following patterns, if present, should be particularly noted.
a. Mutism – no verbal response despite indications that the client is aware of
examiner’s questions.
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b. Circumstantiality – cumbersome, convoluted, and unnecessary detail in response to

the interviewer’s questions
c. Perseveration – a pattern of repeating the same words or movements despite
apparent efforts to make a new response
d. Flight of ideas – rapid, overly productive responses to questions that seem related
only by chance associations between one sentence fragment and another
e. Blocking – pattern of sudden silence in the stream of conversation for no obvious
reason but thought to be associated with intrusion of delusional thoughts or
hallucinations

3. Emotional State – the person’s pervasive or dominant mood or affective reaction. Both
subjective and objective data are included. Subjective data are obtained through use of
nonleading questions, for instance, “How are you feeling?” If the client answers with general
terms, such as nervous, the interviewer should ask the client to describe how the nervousness
shows itself and its effect, since such words may have different meanings to different
individuals. Examiner should observe objective signs such as facial expression, motor
behavior, presence of tears, flushing, sweating, tachycardia, tremors.

Note whether intense emotional responses accompany discussion of specific topics.

Shallowness or flat affect is indicated by an insufficiently intense emotional display in
association with ideas or situations that ordinarily would call for a stronger response.

4. Content of thought: special preoccupations and experiences – delusions, illusions, or

hallucinations, depersonalizations, obsessions or compulsions, phobias, fantasies, and
daydreams.
Delusions are false beliefs. Beliefs are held even in the face of contradicting or no evidence.
If the client has delusions of someone or something in the environment paying extra attention
to him or her, some of the following questions might reveal them: “Do people like you?” “Have
you ever been watched or spied on or singled out for special attention?” “Do others have it in
for you?” Delusions of alien control are feelings of being controlled or guided by external
forces. If you suspect these delusions, ask the client such questions as “Do you ever feel your
thoughts or actions are under any outside influences or control?” or “Are you able to influence
others, to read their minds, or to put thoughts in their minds?”
A client with nihilistic delusions completely denies reality and existence. The client states that
nothing exists or that everything is lost. Statements such as “I have no head, no stomach,” “I
cannot die,” or “I will live to eternity” suggest nihilistic delusions.
Delusions of self-deprecation are often seen in connection with severe depression. The client
describes feeling unworthy, sinful, ugly or foul smelling. Delusions of grandeur are associated
with elated states such as great wealth, strength, power, intellect, sexual potency, or
identification with a famous person or a god. Somatic delusions are focused on having
physical problems such as cancer, obstructed bowels, leprosy or some horrible disease.
Hallucinations are false sensory impressions with no external basis in fact. Hallucinations
occur with the five senses of hearing, seeing, smelling, tasting, or touching. Try to elicit details
of the experience – for example, the source of sounds or voices (from outside or inside the
head), the clarity and distinctness of the perception, and the intensity. Be subtle when
approaching the client for evidence of hallucinatory phenomena, unless the client is obviously
hallucinating. In the case of obvious hallucinations, it is appropriate to ask direct questions.
Obsessions are insistent thoughts recognized as arising from the self. The client usually
regards them as absurd and relatively meaningless, yet they persist despite endeavors to get
rid of them.
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Compulsions are repetitive acts performed through some inner need or drive but supposedly
against the client’s wishes; yet not performing them results in tension and anxiety.
Fantasies and daydreams are preoccupations that are often difficult to elicit from the client.
The difficulty may be that the client is not sure what you want in terms of detail or is ashamed
to discuss fantasies and daydreams because of their content.

5. Orientation – in terms of time, place, person, and self or purpose; helps determine the
presence of confusion or clouding of consciousness. You may introduce such questions by
asking, “Have you kept track of the time?” If so, “What is today’s date?” Clients who say they
don’t know should be asked to estimate approximately or to guess at an answer.

Note: Many examiners begin the MSE with these questions because disorientation should
cause the examiner to question the validity and reliability of data obtained subsequently.

6. Memory – attention span and ability to retain or recall past experiences in both the recent and
remote past. If memory loss exists, determine whether it is constant or variable and whether
the loss is limited to a certain time period. Be alert to confabulations – memories invented to
take the place of those the client cannot recall. It is useful to introduce questions relating to
memory with some general question such as “How has your memory been?” Then you can
move on to more specific questions such as “Have you had difficulty remembering telephone
numbers or appointments?”
a. Recall of remote past experiences. Ask for a review of the important events in the client’s
life. Then compare the response with information obtained from other sources during the
history taking.
b. Recall of recent past experiences. These are events leading to the present seeking of
treatment.
c. Retention and recall of immediate impressions. The examiner might ask the client to
repeat a name, address, or a set of objects – for example, rose, teacup, battleship –
immediately and again after 3-5 minutes.
d. General grasp and recall. You might ask the client to read a story and then repeat the gist
of the story to you with as many details as possible.

7. General Intellectual level – A nonstandardized evaluation of intelligence. The examiner

explores the person’s ability to use factual knowledge in a comprehensive way.
a. General grasp of information. The client may be asked to name the five largest cities of
the USA, the last four presidents, or the governor of the state.
b. Ability to calculate. Tests of simple multiplication and addition are useful for this purpose.
Another test consists of subtracting from one hundred by sevens until the person can go no
further (serial sevens test).
c. Reasoning and judgment. A common test of reasoning is to ask what the client might do
with a gift of $10,000.

8. Abstract thinking – Making distinctions between such abstractions as poverty and misery or
idleness and laziness. It is common to ask the client to interpret simple fables or proverbs
such as “Don’t cry over spilled milk” or “ A rolling stone gathers no moss”.

9. Insight evaluation – whether clients recognize the significance of the present situation,
whether they feel the need for treatment, and how they explain the symptoms. Often it is
helpful to ask the client for suggestions for their own treatment.
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10. Summary – Summarize the important findings. Any pertinent facts from the medical history
and/or physical examination should be added to the summary.

Nursing Diagnoses: List all nursing diagnoses that flow from the data collected in priority order.

Example

This is the 7th inpatient psychiatric hospitalization for this 45 year-old woman, who is readmitted at this
time for recurrence of paranoia, auditory hallucinations, and suicidal ideation.

“The voices are telling me to kill myself and I can’t get away from them.”

The client was discharged from the hospital 1 month ago. She attended day treatment but took her
medication inconsistently. Over the past 3 days she has become preoccupied with suicide. She
states she has recently discovered that her husband is having an affair, and she thinks he wants to
leave her. She blames herself for difficulties in her marriage. There are no known medical
conditions.

The client was the middle child in a family of three children. Her parents had an intact marriage,
although there was a great deal of hostility between them. She has flashbacks of her mother and
father yelling at each other in the night. She is currently married (9 years), with no children. She has
completed college, with a liberal arts degree. She is employed part time in a local decorating
business.

The client is dressed appropriately for the weather in a turtleneck sweater and jeans. She is well
groomed. The client is cooperative with the interviewer. Her mood and affect are depressed and
anxious. She became tearful and remained so throughout the interview. Her flow of thought is
coherent, and her thought content reveals feelings of low self esteem, ie. “I really am a nobody”. She
reports hearing voices that demean her. She admits to suicidal ideation but denies having a plan or
intent. Her orientation is good, with accurate knowledge of the current date, place and person.
Recent memory as well as remote memory are good, as she was able to recall what the clients all
had for breakfast and knew that she was born in Lancaster, PA (verified in the chart). The client
shows insight and judgment regarding her illness and need for help.
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