Reference no: EM133798050

Question

Basic Mental Health Nursing Concepts Mental Status Examination (MSE) Level of consciousness The level of consciousness is described using the following terms. Observed behaviors are included in the documentation. Alert: The client is responsive and able to fully respond by opening their eyes and responding to a normal tone of voice and speech. The client answers questions spontaneously and appropriately. Lethargic: The client is able to open their eyes and respond but is drowsy and falls asleep readily. Stuporous: The client requires vigorous or painful stimuli (pinching a tendon or rubbing the sternum) to elicit a brief response. The client might not be able to respond verbally. Comatose: The client is unconscious and does not respond to painful stimuli. Abnormal posturing in the client who is comatose Decorticate rigidity: Flexion and internal rotation of upper-extremity joints and legs Decerebrate rigidity: Neck and elbow extension, wrist and finger flexion Physical appearance Examination includes assessment of personal hygiene, grooming, nutritional status, clothing choice, and whether the client looks older than their stated age. Expected findings with regard to this assessment are that the client is well-kempt, clean, and dressed appropriately for the given environment. Behavior Examination includes assessment of voluntary and involuntary.