NCLEX® QOTD: Mental status assessment

The nurse is conducting a mental status assessment on an adult client with no previous medical or psychiatric history. Which assessment finding(s) should the nurse anticipate? Select all that apply. 

A.Rational thoughts 

B. Glasgow Coma Scale (GCS) score of 15

C. Pressured speech 

D. Smooth body movements

The correct answers to today's NCLEX-RN® Question are...

A. Rational thoughts

Rationale: Rational thoughts are an anticipated finding during a mental status assessment. The presence of perceptual and thought disturbances such as hallucinations, which can be visual, auditory, or tactile; or illusions, are abnormal. 

B. Glasgow Coma Scale (GCS) score of 15

Rationale: A GCS score of 15 is a normal finding, and does not indicate brain injury. A score of 8 or less indicates severe brain injury; 9-12 indicates moderate brain injury; 13-15 indicates mild to no brain injury. Therefore, this is an anticipated finding.

D. Smooth body movements 

Rationale: Smooth body movements are an anticipated finding of a mental status assessment. Abnormal findings include restlessness or fidgeting, which could be a sign of anxiety.

E. Intact short-term memory

Rationale: Intact short-term memory is an anticipated finding during the mental status assessment. 

Major Takeaway

The nurse should recognize normal findings associated with the mental status assessment. The nurse will observe the client’s appearance when they move into the exam room. When evaluating appearance, the nurse should expect their posture to be erect and relaxed; and their movement to be smooth and purposeful. The nurse should assess the client’s behavior, beginning with their level of consciousness. The client should be awake, alert, oriented, and responsive to both internal to environmental stimuli. Also, the nurse should observe the client’s facial expressions which can reveal information about their emotional state. Their expressions should vary throughout the conversation and be appropriate to the context. The nurse should also assess the client’s speech, paying attention to their tone, pace, word choice, and articulation. Their speech should be effortless, with appropriate variations in tone. To assess the client’s orientation to person, the nurse will ask them to state their first and last name or how old they are. For orientation to place, the nurse will ask them where they are or the city or state they are in. For time, the nurse will ask them to tell them the day, month, or year. To assess the client’s memory, immediate recall and recent and long-term memory will be assessed. To evaluate immediate recall, the nurse can ask the client to listen to and then repeat a short sentence or series of numbers. For recent memory, the nurse should ask about the recent past, like what the client ate for breakfast. To assess the client’s thought process,the nurse will evaluate whether their thoughts make sense and are rational. 

Incorrect answer explanations

C. Pressured speech

Rationale: Pressured, or rapid-paced speech, is an abnormal finding and is associated with mania in clients with bipolar disorder. This is not a finding that the nurse should anticipate during the mental status assessment.

F. Client can name the month and date, but not the year

Rationale: A client who cannot remember the year, but can remember the month and date requires follow-up and is not an anticipated finding during the mental status assessment.

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