A nurse is performing a mental status examination for a newly admitted client

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On This Page

    I’m a nurse on an in-patient mental health unit. We often receive orders from physicians asking us to perform checks on patients every 15 minutes due to a high risk of self-harm. These 15-minute checks are difficult for the nurses to perform because of our high workload and nurse-to-client ratios. What are our accountabilities for frequent assessment and monitoring? 

    Performing ongoing client assessments is critical to providing safe client care. Assessment is a professional accountability and an essential part of your nursing practice, as outlined in Professional Standards, Revised 2002. 

    All nurses are expected to regularly assess clients, although certain clients may require more frequent assessments, such as monitoring every 15 minutes. For example, if you work with clients who have acute mental illnesses, frequent checks may be ordered because there are unique safety issues. These include an increased risk of violence, self-harm and suicide. Many of these clients may be isolated, require restraints or have limited capacity for advocating for themselves. Therefore, frequent monitoring is essential in supporting client safety. 

    Professional Standards states that nurses must facilitate, advocate and promote the best possible care for clients. Nurses must also take action if client safety and well-being are compromised. Therefore, if nurses have concerns about their ability to perform ongoing assessments as ordered and part of the client’s care plan, nurses are accountable for sharing those concerns with their team and clinical manager. 

    All members of the health care team have a shared accountability to advocate for quality practice environments and support systems that promote safe care. Nurses are also accountable for providing a complete record of client care including documenting assessment data such as when client assessments are completed. For more information about these accountabilities, see the Documentation, Revised 2008 practice standard. 

    If you have any practice-related questions, visit Practice Support. 

    • Professional Standards, Revised 2002
    • Documentation, Revised 2008
    Page last reviewed June 07, 2022

    Psychiatric-Mental Health Nursing Sample Questions

    These sample questions apply to all exams taken on or after October 25, 2014.

    The following sample questions are similar to those on the examination but do not represent the full range of content or levels of difficulty. The answers to the sample questions are provided after the last question. Please note: Taking these or any sample question(s) is not a requirement to sit for an actual certification examination. Completion of these or any other sample question(s) does not imply eligibility for certification or successful performance on any certification examination.

    To respond to the sample questions, first enter your first and last names in the boxes below (this information will not be recorded; it is strictly for purposes of identifying your results). Then click the button corresponding to the best answer for each question. When you are finished, click the "Evaluate" button at the bottom of the page. A new browser window will open, displaying your results, which you may print, if you wish.

    This practice exam is not timed, and you may take it as many times as you wish. Good luck!

    61. A nurse is performing amental status examination for aclient who has schizophrenia.The nurse should recognizethat which of the followingactions requires the client tothink abstractly?ATI BStudy

    62. A nurse is developing aplan of care for a school agechild who has ADHD. Which ofthe following interventionsshould the nurse include in theplan?

    63. A nurse in a mental healthfacility is making plans for aclient's discharge. Which of thefollowing interdisciplinary teammembers should the nursecontact to assist the client withhousing placement?ATI BStudy

    64. A nurse is providing crisisintervention for a client whowas involved in a violent masscasualty situation in thecommunity. Which of thefollowing actions should thenurse take during the initialsession with the client?a. Encourage the client todisplay anger toward the causeof the crisisb. Tell the client that his life willsoon return to normalc. Identify the client's usualcoping styled. Help the client focus on awide variety of topicsregarding the crisisc

    65. A nurse is planning toconduct a support group foradolescents who have cancer.Which of the following actionsshould the nurse includeduring the orientation phase?

    66. A nurse is assessing a clientwho recently startedantidepressant therapy for thetreatment of major depressivedisorder. Which of thefollowing findings indicates theclient is at an increased risk forsuicide?

    In which step of the nursing process would the nurse conduct a mental status exam?

    The nurse prepared at the basic level performs mental health assessments, establishes relationships, and provides individualized care planning. Note that this question was also offered for Chapter 1.

    How is the mental status examination used quizlet?

    Why do we use an MSE? The MSE provides information for diagnosis and assessment of disorder and response to treatment. MSE is the component of the psychiatric evaluation that includes observing the patient's behavior and describing it in an objective and nonjudgmental manner to reveal SIGNS of an illness.

    Which statement is true regarding the mental status examination by the nurse?

    The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status? Mental status functioning is inferred through the assessment of an individuals behaviors.

    Which items should be assessed during a mental status examination quizlet?

    What are The four main components of the mental status assessment? And the Acronym to help remember? are appearance, behavior, cognition, and thought processes.