Posture, Body Movement, Facial Affect: Observe the client's overall look.
Dress, Hygiene, and Grooming: Inappropriate appearance or poor hygiene may indicate conditions like depression, manic disorder, dementia, brain disease, or other behavioral disorders.
Behavior
Calmness and Eye Contact: Note if the client is calm and making appropriate eye contact.
Answering Questions: Assess whether the client is responding correctly to questions about their situation and content.
Example questions: Name, date of birth, location, current president.
Determine if the client is alert and oriented (times three or four).
Orientation
Person, Place, and Time: Evaluate the client’s awareness of themselves, their location, and the current time.
Attention Span
Concentration Ability: Test using Serial Sevens (counting backward from 30 by sevens).
This assesses attention to the task and calculation abilities.
Distractions during this task can indicate ADHD or dementia.
Mental Status Exam (MSE)
Memory
Recent Memory: Use tests like the three-word or forward recall test.
Example words: "dog, train, blue."
Ask the client to recall these words immediately, and then after some time (5, 10, or 30 minutes).
Monitor changes in the ability to recall as an indicator of dementia.
Dementia Indicators
Confabulation: A sign of dementia where clients may fabricate or recall incorrect memories as true.
Important to test with verifiable information.
Judgment
Decision-Making: Assess if the client's actions and decisions during discussions are realistic.
Clients with dementia may show impaired judgment due to brain damage.
Additional Information
SimpleNursing.com Resources: Over 900 videos, 500 visual study guides, and a quiz bank available for further learning and assessment preparation.