Psychiatric Mental Health Nursing
Chapter 8: ASSESSMENT Sensorium and Intellectual Processes
General Appearance and Motor Behavior
Specific terms used in making assessments of general appearance and motor
behavior includes the following:
 Automatisms: repeated purposeless behaviors often indicative of
anxiety, such as drumming fingers, twisting locks of hair, or tapping
the foot
 Psychomotor retardation: overall slowed movements
 Waxy flexibility: maintenance of posture or position over time even
when it is awkward or uncomfortable
 Neologisms: invented words that have meaning only for the client
Mood and Affect
Mood refers to the client’s pervasive and enduring emotional state.
Affect is the outward expression of the client’s emotional state.
Common terms used in assessing affect include the following:
 Blunted affect: showing little or a slow-to-respond facial expression
 Broad affect: displaying a full range of emotional expressions
 Flat affect: showing no facial expression
 Inappropriate affect: displaying a facial expression that is incongruent
with mood or situation; often silly or giddy regardless of circumstances
 Restricted affect: displaying one type of expression, usually serious or
somber
When the client exhibits unpredictable and rapid mood swings from depressed and
crying to euphoria with no apparent stimuli, the mood is called labile (rapidly
changing).
Thought Process and Content
Thought process refers to how the client thinks. The nurse can infer a client’s
thought process from speech and speech patterns.
Thought content is what the client actually says. The nurse assesses whether or
not the client’s verbalizations make sense: that is, if ideas are related and flow
logically from one to the next.
Common terms related to the assessment of thought process and content include
the following:
 Circumstantial thinking: a client eventually answers a question but
only after giving excessive unnecessary detail.
 Delusion: a fixed false belief not based in reality.
 Flight of ideas: excessive amount and rate of speech composed of
fragmented or unrelated ideas.
 Ideas of reference: client’s inaccurate interpretation that general
events are personally directed to him or her, such as hearing a speech
on the news and believing the message had personal meaning.
 Loose associations: disorganized thinking that jumps from one idea to
another with little or no evident relation between the thoughts.
 Tangential thinking: wandering off the topic and never providing the
information requested.
 Thought blocking: stopping abruptly in the middle of a sentence or
train of thought; sometimes unable to continue the idea.
 Thought broadcasting: a delusional belief that others can hear or
know what the client is thinking.
 Thought insertion: a delusional belief that others are putting ideas or
thoughts into the client’s head—that is, the ideas are not those of the
client
 Thought withdrawal: a delusional belief that others are taking the
client’s thoughts away and the client is powerless to stop it.
 Word salad: flow of unconnected words that convey no meaning to the
listener.
Assessment of Suicide or Harm Toward Others:
When a client makes specific threats or has a plan to harm another person, health
care providers are legally obligated to warn the person who is the target of the
threats or plan. The legal term for this is duty to warn.
This is one situation in which the nurse must breach the client’s confidentiality to
protect the threatened person.
Orientation refers to the client’s recognition of person, place, and time—that is,
knowing who and where he or she is and the correct day, date, and year. The order
of person, place, and time is significant.
Disorientation is not synonymous with confusion. A confused person cannot
make sense of his or her surroundings or figure things out even though he or she
may be fully oriented.
Memory: The nurse directly assesses memory, both recent and remote, by asking
questions with verifiable answers.
Abstract thinking: to make associations or interpretations about a situation or
comment.
Concrete thinking: when the client continually gives literal translations.
Sensory–Perceptual Alterations
Hallucinations: false sensory perceptions or perceptual experiences that do not
really exist.
Hallucinations can involve the five senses and bodily sensations.
Auditory hallucinations (hearing voices) are the most common.
Visual hallucinations (seeing things that don’t really exist) are the second most
common.
Judgment and Insight
Judgment refers to the ability to interpret one’s environment and situation
correctly and to adapt one’s behavior and decisions accordingly.
Problems with judgment may be evidenced as the client describes recent behavior
and activities that reflect a lack of reasonable care for self or others.
Insight is the ability to understand the true nature of one’s situation and accept
some personal responsibility for that situation.
The nurse frequently can infer insight from the client’s ability to describe
realistically the strengths and weaknesses of his or her behavior.
Self-Concept
Self-concept is the way one views oneself in terms of personal worth and dignity.
To assess a client’s self-concept, the nurse can ask the client to describe himself or
herself and what characteristics he or she likes and what he or she would change.
Roles and Relationships
People function in their community through various roles such as mother, wife,
son, daughter, teacher, secretary, or volunteer.
Family roles include son or daughter, sibling, parent, child, and spouse or partner.
Occupation roles can be related to a career or school or both.
Psychological Tests
Psychological tests are another source of data for the nurse to use in planning care
for the client.
Two basic types of tests:
 Intelligence tests are designed to evaluate the client’s cognitive
abilities and intellectual functioning.
 Personality tests reflect the client’s personality in areas such as self-
concept, impulse control, reality testing, and major defenses.
Personality tests may be objective (constructed of true-and-false or
multiple-choice questions). The nurse compares the client’s answers
with standard answers or criteria and obtains a score or scores.
 Projective tests: are other personality tests. These are unstructured and
are usually conducted by the interview method. The stimuli for these
tests, such as pictures or Rorschach’s inkblots, are standard, but clients
may respond with answers that are very different. The evaluator
analyzes the client’s responses and gives a narrative result of the
testing.