In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of mental health concepts in order to:

  • Identify signs and symptoms of impaired cognition (e.g., memory loss, poor hygiene)
  • Recognize signs and symptoms of acute and chronic mental illness (e.g., schizophrenia, depression, bipolar disorder)
  • Recognize the client use of defense mechanisms
  • Explore why client is refusing/not following treatment plan (e.g., non-adherence)
  • Assess client for alterations in mood, judgment, cognition and reasoning
  • Apply knowledge of client psychopathology to mental health concepts applied in individual/ group/family therapy
  • Provide care and education for acute and chronic behavioral health issues (e.g., anxiety, depression, dementia, eating disorders)
  • Evaluate the client ability to adhere to treatment plan
  • Evaluate a client's abnormal response to the aging process (e.g., depression)

Identifying the Signs and Symptoms of Impaired Cognition

Impaired cognition, also referred to as a disturbed thought process, is defined as a disturbance and disruption in terms of the client's cognitive and thinking abilities, operations and activities.

Cognitive impairments can lead to behavioral and cognitive impairments which can present as difficulty reading, difficulty writing or understanding speech, disorientation, the inability to recognize people, places or things, rambling in nonsensical speech, problems speaking or understanding words, and poor short-term memory.

Behavioral changes, such as extreme emotions like fear, anxiety, depression or anger, changes in sleep habits, restlessness, agitation, irritability, combative behavior, and hallucinations can also occur.

Some of the defining characteristics, signs and symptoms of impaired cognition include egocentricity, poor hygiene and grooming, hypervigilance, short and/or long term memory loss, cognitive dissonance, an inability to understand and comprehend the written and spoken word, confusion, the lack of orientation, the client's failure to recognize familiar faces and things, a lack of good judgment and insight, and the failure to perform the basic and instrumental activities of daily living.

Disturbed and impaired thought processes can occur as the result of many factors and forces. Some of these factors and forces include delirium, dementia, a closed head injury and other neurological events such as a cerebral tumor or a cerebrovascular accident.

Dementia, not considered a disease entity in itself, is instead a cluster of syndrome of related signs and symptoms that impair the client's ability to think and that impede the client's ability to perform the normal activities of daily living and to interact with others in the environment. Dementia interferes with the patient's everyday life and functioning. Organic brain syndrome and Alzheimer's disease are the leading causes of dementia.

Although preventive measures to prevent dementia are not fully understood, some believe that dementia can be prevented by treating and controlling hypertension, with consistent daily physical exercise, with good nutrition and maintaining a sharp and active mind with things like brain games and memory exercises.

Although the characteristics, signs and symptoms of dementia are similar to those of delirium, dementia differs from delirium in that dementia is not reversible and correctable and delirium is sometimes reversible and correctable when the underlying disorder that is causing the delirium is corrected.

Delirium, in contrast to dementia, is of shorter duration, it has a more abrupt and sudden onset, it is not always permanent, it can include intermittent periods of time vacillating between periods of impaired cognition with periods of mental clarity, and it is often treatable and correctable. The possible etiology of delirium can include some medications, substance related abuse, infections, and the presence of a chronic mental illness.

Some of the treatments for delirium, in addition to the elimination and/or correction of an assessed underlying cause, include supportive care to prevent any complications and adverse events, which, similar to the treatment of dementia, can include, among others:

  • Nutritional support
  • The maintenance of safety
  • Emotional support for the affected client and significant others
  • Pain assessment and pain management
  • The prevention of aggressive and dangerous behaviors
  • Symptomatic relief of things like agitation and hallucinations
  • Maintaining hydration
  • Assistance with the client's activities of daily living
  • Maintaining and facilitating the client's highest possible level of independence

Some nursing diagnoses for client's affected with impaired cognition include:

  • At risk for danger to self and/or others related to impaired and disturbed levels of cognition
  • At risk for falls related to impaired cognition
  • Disturbed thought processes related to impaired cognition
  • Loss of self esteem related to impaired cognition
  • Memory loss related to impaired cognition

Recognizing the Signs and Symptoms of Acute and Chronic Mental Illnesses

As previously stated, the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) contains four major categories of mental illness. These four broad categories include thought disorders, mood disorders, behavioral disorders and mixed mental health disorders.

Mental health disorders can also be categorized and described as mild, moderate and severe, chronic and acute and in a number of different ways. For the purpose of this NCLEX-RN review, you will learn about acute and chronic mental health disorders classified as:

  • Depressive mental health disorders
  • Anxiety disorders
  • Bipolar illness
  • Cognitive mental health disorders
  • Personality mental health disorders
  • Substance use and addictive disorders
  • Eating disorders
  • Psychotic disorders

Depressive Mental Health Disorders

Examples: Situational and developmental/maturational depression, major depressive disorder, postpartum depression, and seasonal affective disorder. Depressive disorders often occur concurrently as a comorbidity with other psychological disorders such as schizophrenic psychosis, substance related disorders, and anxiety disorders. Some standardized assessment tools for depression include the Geriatric Depression Scale, the Zung Self Rating Depression Scale, the Beck Depression Scale and the Hamilton Depression Scale.

Sign and symptoms: Depression leads to physical, emotional and cognitive signs and symptoms. Some of these signs and symptoms are sadness, feelings of dejection, feelings of hopelessness, feelings of helplessness, despair, sleep loss, poor problem solving skills, diminished performance, listlessness, headache, weight loss, anorexia, social withdrawal, a loss of libido, crying, poor concentration, poor decision making, personality changes, a lack of self-worth, and poor self-esteem. It can also be associated with psychotic symptoms such as hallucinations, delusions, suicidal ideation and suicide.

Treatments: Milieu therapy, individual and group counseling and therapy, alternative, complementary interventions such as progressive relaxation techniques and St. John's wart, light therapy for seasonal affective disorder, electroconvulsive therapy and medications such as antidepressant medications like as the selective serotonin reuptake inhibitors, the monoamine oxidase inhibitors, serotonin norepinephrine reuptake inhibitors, and tricyclic antidepressants.

Anxiety Disorders

Examples: Acute stress disorder, post-traumatic stress disorder, obsessive compulsive disorders, separation anxiety disorder, phobias including specific phobias, social phobia, agoraphobia, and other phobias, panic disorder, and generalized anxiety disorder. Some standardized assessment tools for anxiety disorders include the Modified Speilberger State Anxiety Scale, the National Stressful Events Survey, the Hoarding Scale of Self Reports, the Hamilton Rating Scale for Anxiety and the Yale Brown Obsessive Compulsive Scale.

Sign and symptoms:

  • Acute stress disorder: Anxiety, detachment, and a numbness and indifference which typically lasts no longer than one month
  • Post-traumatic stress disorder (PTSD): Mild to severe symptoms, nightmares, fear, terrors, horror, avoidance and social isolation, distress and physical responses as well as intrusive memories of the traumatic event which are often referred to as flashbacks and which can persist for years in an unrelenting manner long after the traumatic event.

The signs and symptoms of obsessive compulsive disorders include pathological hoarding, a preoccupation with persistent thoughts and urges that the client has to suppress with behaviors in order to prevent a complete disruption of one's life and high levels of anxiety.

Separation anxiety disorder occurs when a client experiences high anxiety when one is separated from a person with whom they have an intense emotional attachment. Many young children have separation anxiety when they are separated from the parent as is the case when the child is hospitalized or goes to a preschool. Some of the signs and symptoms of separation anxiety disorder stress, anxiety, and tearfulness.

Phobias including specific phobias to a specific object, animal or person, social phobia which leads to anxiety and stress when the client is in a situation with others, agoraphobia which is a phobia to being outdoors from the home, and other phobias including a fear of spiders, airline travel, heights, or clowns. Clients experiencing a phobia will avoid the source of the phobia, have alterations of their daily living as a result of the avoidance and fear of the phobia, and they will also experience mild to severe anxiety when the person or object is inadvertently confronted.

Panic disorders and panic attacks are characterized with temporary but severe anxiety, chest pain, palpitations, shortness of breath, fears of death, and an inability to swallow and breathe normally.

Generalized anxiety disorder is characterized with persistent and ongoing excessive worries that continue for duration of more than three months.

Treatments: The treatments for anxiety disorders can vary among individuals, among the different anxiety disorders and according to the severity of the particular disorder. These treatments may include the provision of a therapeutic milieu, individual and group counseling and therapy, the provision of a safe and supportive environment, the prevention of complications such as suicide ideation and suicide, and other disorder specific interventions such as desensitization therapy for the client who is adversely affected with a phobia.

Bipolar illness

Description: Bipolar disorder, referred to as manic depressive disorder in the past, is characterized with periodic episodes of recurring mania and depression.

Examples: Bipolar disorders can be characterized and classified as Type I Bipolar disorder which is experienced by the client with one episode of mania and depression, Type II Bipolar disorder which is characterized by two or more major episodes of depression and one episode of hypomania, or depression, and, lastly, cyclothymia bipolar disorder which consists of a persistent minimum of two years within which the client has hypomania and mania.

Signs and symptoms: The signs and symptoms associated with bipolar illness include rapid cycling with four or more episodes of acute mania in less than 12 months, mania and an elevated mood as well as irritability, and hypomania which is a less severe form of mania. Manic episodes can be marked with a wild flight of ideas, restlessness, agitation, euphoria, a lack of good judgment, sleep deprivation, impulsivity, delusions of grandeur, and potential hallucination and other delusions.

Treatments: The provision of a therapeutic milieu, individual and group therapy and counseling, the maintenance of an environment with low levels of stimulation and the protection of the client's safety during the manic phase of bipolar disorder, electroconvulsive therapy, and medications such as an antidepressant, anticonvulsant and/or a mood stabilizer.

Cognitive Mental Health Disorders

Examples: Dementia, organic brain syndrome and delirium.

Signs and symptoms: The signs and symptoms of cognitive mental health disorders were discussed immediately above under the section entitled "Identifying the Signs and Symptoms of Impaired Cognition".

Treatments: The treatments for clients affected with a cognitive mental health disorders were also discussed immediately above under the section entitled "Identifying the Signs and Symptoms of Impaired Cognition".

Personality Mental Health Disorders

Examples: Personality mental health disorders can be classified according to common characteristics and also in terms of a cluster. Cluster A personality mental health disorders include the schizoid, paranoid and schizotypal personality mental health disorders; Cluster B personality mental health disorders include the narcissistic, antisocial, histrionic and borderline personality mental health disorders; and Cluster C personality mental health disorders include the dependent and the avoidant personality mental health disorders.

Sign and symptoms:

  • The schizoid personality mental health disorder: Indifference, detachment, a lack of close interpersonal relationships.
  • The paranoid personality mental health disorder: An intense distrust of others and suspicions.
  • The schizotypal personality mental health disorder: Eccentric thinking and behaviors, hallucinations and delusions.
  • The narcissistic personality mental health disorder: Delusions of grandeur, a pronounced lack of sensitivity and empathy to others and their feelings, arrogance, and the continuous need for praise and esteem by others.
  • The antisocial personality mental health disorder: A failure of the client to accept personal responsibility and accountability for their own actions, indifference for others and their needs, the possible exploitation of others including loved ones, and possible illegal actions.
  • The histrionic personality mental health disorder: Flirtation, seductiveness and other attention seeking behaviors.
  • The borderline personality mental health disorder: Impulsiveness, ego weaknesses, the exploitation of others, indifference and a lack of empathy to others, a loss of identity, and an unstable and fluctuating affect. This disorder can also be associated with violent behaviors towards self and/or others including suicide, homicide and suicide-homicide.
  • The dependent personality mental health disorder: Aggression, apathy, despair, depression, fears of criticism and rejection by others, antisocial behaviors, the need to control others, a lack of sensitivity and empathy towards others, helplessness, a lack of confidence, the forgoing of decision making, and egocentricity.
  • The avoidant personality mental health disorder: The avoidance of social situations and interpersonal relationships, fears of criticism and rejection by others, and anxiety.

Treatments: Again, the treatments can vary according to the specific disorder, the intensity of the disorder, the client's responses to the disorder and the client's coping with the disorder. Some intervention and treatments, again include, the provision of a therapeutic milieu, individual and group counseling and therapy, a safe environment, and medications as indicated for the symptoms that the client is experiencing. Some of these medications can include mood stabilizers, antidepressants, anti-anxiety medications, and antipsychotic psychotropic medications, as indicated.

Substance Use and Addictive Disorders

Examples: Alcoholism, illicit drug abuse, and impulse control disorders, such as sexual addiction, compulsive gambling, internet addiction, exercise addiction, pyromania, shopping addictions, an addiction to pornography, kleptomania, food addiction, trichotillomania and addictions to work.

Signs and symptoms: The signs and symptoms of these substance related abuse and addictive disorders were previously detailed in the previous section of this review which is titled "Assessing the Client for Drug and Alcohol Dependencies, Withdrawal or Toxicities and Intervening Appropriately".

Treatments: The treatments of these substance use and other addictive disorders were also previously discussed with the topics entitled "Providing Information on the Substance Abuse Diagnosis and the Treatment Plan to the Client' and "Providing Care and/or Support for a Client with a Non Substance Related Dependency".

Eating Disorders

Examples: Anorexia nervosa, including the binge eating-purging type and the restriction type of anorexia nervosa, bulimia nervosa, including the nonpurging and purging types, and binge eating disorder

Sign and symptoms:

  • Anorexia nervosa: Excessive food restriction and the lack of purging (the restrictive type of anorexia nervosa), food binging or purging (the binge eating-purging type of anorexia vervosa), a fear of weight gain, the loss of muscular mass, fluid and electrolyte disorders, irritability, bradycardia, amenorrhea, anemia, a low bodily weight, obsessions with food, and esophageal erosion from vomiting.
  • Bulimia nervosa: Binge eating that may be followed by purging with vomiting or other methods such as laxatives, enemas or diuretics in addition to impulsivity, a normal body weight or slight overweightness, extroversion, and sensitivity to the feelings of others.
  • Binge eating disorder: The repeated consumption of large amounts of food without any purging behaviors. This disorder leads to obesity and its related health risks.

Treatments: Eating disorders are treated with medical interventions when the client is adversely affected with physiological changes and risks such as heart disease, impaired renal and hepatic functioning, dehydration, electrolyte imbalances like hyponatremia, hypokalemia and hypochloremia. Some of these physiological changes and their associated health risks can be very severe and even life threatening. Psychological interventions can include the provision of a therapeutic milieu, individual, family and group counseling and therapy, measures to increase the client's levels of self-esteem and self-worth, the regular monitoring of the client's weight gains or losses, and the monitoring of client during meals.

Psychotic Disorders

Examples: Schizophrenia, schizotypal personality disorder, delusional disorder, schizophreniform disorder, brief psychotic disorder, schizoaffective disorder and substance induced psychotic disorder.

Sign and symptoms: The signs and symptoms of psychotic disorders are classified and categorized as cognitive symptoms, affective symptoms, positive symptoms which is defined as those signs and symptoms that ARE present, and the negative signs and symptoms which is defined as those signs and symptoms that are NOT present.

Cognitive symptoms associated with psychotic mental health disorders include things like deficits in terms of the client's memory, a poor attention span, a decreased level of concentration, disorganized thinking, poor problem solving skills, and poor decision making.

Some of the affective symptoms of psychotic mental health disorders include those associated with the client's thoughts of suicide and hopelessness.

Positive signs and symptoms associated with psychotic disorders include hallucinations, delusions, bizarre behavior, and others that result because the client is out of touch with reality.

The negative signs and symptoms associated with psychotic disorders include those associated with the client's flat and emotionless affect, a lack of energy, a lack of motivation, an inability to verbally communicate with others and a lack of pleasure in life and all it has to offer.

Some of the standardized tools that can be used to assess the client with a psychotic disorder include the Abnormal Involuntary Movement Scale, the Scale for the Assessment of Negative Symptoms, the Global Assessment Scale of Functioning and the Brief Psychiatric Rating Scale.

Treatments: In addition to the provision of a therapeutic milieu, individual and group therapy and counseling, other treatments for clients affected with a psychotic disorder include medications, using appropriate therapeutic interventions and communication when the client is experiencing hallucinations and/or delusions, and the protection of the client and their safety, as indicated.

Age Specific Considerations for the Child and Adolescent

Although children throughout the life span, including infants, toddlers, young children and adolescents, experience some of the same psychiatric mental health disorders as adults do, there are some discrete differences between adults and children and adolescents that the nurse must be knowledgeable about as they care for these pediatric clients.

These age specific considerations should be applied to all phases of the nursing process including assessments, planning, implementation and evaluation as well as the teaching and learning process.

The pediatric population differs from the adult population in terms of the psychosocial assessment of the client. Depending on the child's age, developmental level, and level of cognition, they may not be able to communicate their feelings and symptoms in the manner that is clear to the nurse; and the parents may not be able to separate the signs and symptoms of a psychiatric mental health disorder from a normal behavior.

"Normal behavior" can be separated from, and differentiated from, abnormal psychiatric mental health signs and symptoms when the child does NOT:

  • Behave in a manner that is consistent with social norms, the appropriate level of growth and development, and in a manner that is coping adaptively
  • Act in response to stressors in an age appropriate way
  • Exude a positive self image
  • Able to interact with others in an appropriate manner
  • Able to develop and maintain healthy and satisfying relationships with others including friends, siblings and other family members

Some of the most commonly occurring psychiatric mental health disorders that affect the pediatric population up to the age of adulthood and beyond are impulse control disorders like a deviance disorder, bipolar disorder, eating disorders, a substance related disorders, depression, anxiety disorders such as those relating to separation anxiety, attention deficit hyperactivity disorders, disorders included in the autism spectrum, mutilation and self harm disorders, trauma disorders and learning disorders.

Recognizing the Client's Use of Defense Mechanisms

As fully discussed and described under the previous section entitled "Evaluating the Constructive Use of Defense Mechanisms by a Client", clients use protective ego defense mechanisms such as:

  • Displacement
  • Regression
  • Projection
  • Acting Out
  • Reaction formation
  • Suppression
  • Repression
  • Isolation of Affect
  • Rationalization
  • Sublimation
  • Undoing
  • Dissociation
  • Compensation
  • Identification
  • Minimization
  • Intellectualization
  • Introjection

Exploring Why the Client is Refusing/Not Following the Treatment Plan

The fact that a client has an understanding of their treatment plan does not insure their compliance and adherence with it. There are factors that impact on the client's compliance. Broadly categorized, these factors are therapy related factors, patient centered factors, health care system factors, social factors, economic factors, and disease factors.

Some of the factors and forces that may impact on the client's refusal and not following their treatment plan include:

Lack of the Client's Participation in the Treatment Plan

Preventive measures and interventions: Involve the client in all aspects of the treatment plan and, to the greatest extent possible, also involve the family and significant others in the treatment plan and treatment options and choices.

Client's Locus of Control

A client with an internal locus of control will be motivated to learn about their disorder and follow their treatment plan because they believe that they have control over their future, their health and their wellness. On the other hand, clients with an external locus of control are not likely to be motivated to learn about and follow their treatment plan because they believe that they have NO control over their future and their level of health and wellness. This client believes that they can do nothing to change their fate in terms of their personal health and wellness as well as other aspects of their life.

Preventive Measures and Interventions: Provide the client with support, positive reinforcement and access to others who share the same disorder and similar treatment plans in a peer support group.

Client's Level of Self Efficacy

A client with a high degree of self efficacy, according to Albert Bandura's Theory of Self Efficacy, will more likely adhere and comply with their treatment plan when compared to others who have low levels of self efficacy. Albert Bandura states that self efficacy "refers to beliefs in one's capabilities to organize and execute the courses of action required to manage prospective situations. More simply stated, self-efficacy is what an individual believes he or she can accomplish using his or her skills under certain circumstances". People with high levels of self efficacy believe that they can succeed because they have a can do attitude. People with a low level of self efficacy have the belief that they cannot succeed; they have an "I cannot do it" attitude.

Preventive Measures and Interventions: Provide the client with support, positive reinforcement and access to others who share the same disorder and similar treatment plans in a peer support group.


The client denies the illness and its severity. Denial is often facilitated with the client's belief that they feel better and are "cured" when their medications, for example, have been effective. For example, a client may stop taking their antibiotic when they no longer have a sore throat and another client may stop taking their ordered antidepressant when they start feeling better because they think that they are "cured".

Preventive measures and interventions: Educate the client about the importance to continue their treatment plan, including taking their medications, even when they are feeling better.

Prohibitive Costs Associated with the Treatments

Some treatments are covered with the client's health insurance and others are not. Additionally, many, if not the majority of treatments, require some client out of pocket payments with co pays.

Preventive measures and interventions: Refer the client to a resource that can help with the payments of some medical treatments. For example, some pharmaceutical companies provide high cost ordered medications to clients for little or no cost when the client is able to demonstrate and substantiate financial need for this assistance.

Nature of Treatment Plan

Some treatment plans are simple to follow and others are far more difficult. For example, clients with HIV/AIDS have long term medication regimens consisting of many medications. These and other treatments are often too cumbersome for the client to follow.

Preventive measures and interventions: Whenever possible, the treatment plan should be generated in collaboration with the client so that it can be as simple as possible according to the specific client's needs and preferences.

Side Effects of the Treatment

Client will be noncompliant when the side effects of the treatment, including medications, are negative and unpleasant to them. These complaints can range from an unpleasant texture, to an unpleasant taste, to an actual troublesome side effect, such as nausea, that is associated with the medication that they are taking.

Preventive measures and interventions: An alternative to the ordered treatment and/or medication should be explored with the client, whenever possible, and any treatable side effects for the treatment or medication should also be explored.


Some clients, even when they understand the necessity of following their treatment plan, may just not care enough to comply with it.

Preventive measures and interventions: Apathy is indeed a challenging barrier to compliance in terms of the client's treatment plan. The cause of the apathy should be assessed and then overcome.

Previous Negative Experiences

Clients who have, in the past, had a treatment plan that was unpleasant, unaffordable and/or perceived as unsuccessful will be less likely to follow their current treatment plan.

Preventive measures and interventions: Nurses and other health care providers should allow the client to ventilate their concerns and feelings about their previous experiences and attempt to overcome these perceptions as much as possible.

Cultural, Religious and Spiritual Conflicts

Some treatment plans may be contrary to the client's own cultural, religious and/or spiritual beliefs, values and practices.

Preventive measures and interventions: After these conflicts are identified, the client in collaboration with the nurse and other health care providers should generate a plan of care and treatment that is consistent and congruent with the client's cultural, religious and/or spiritual beliefs, values and practices so that any conflicts and dissonance are resolved.

Substance Related Disorders and Psychiatric Mental Health Issues

For a number of reasons, clients who are affected with a substance related disorders and/or other psychiatric mental health issue are less likely to seek and adhere to treatments and treatment plans when compared to those who are not affected by these same disorders, but instead, a physiological disorder.

Preventive measures and interventions: The client should be supported and encouraged to accept treatment for the substance related and mental health disorder as fully discussed and described above.

Other general interventions to promote compliance and adherence to the treatment plan include collaborative problem solving with the client in an open, trusting and nonjudgmental environment and eliciting the support of other health care providers and the client's significant others to promote adherence to the treatment plan and to prevent a relapse.

Nurses should continuously monitor clients during treatment and, when nonadherence is assessed, the nurse then explores the reasons why this is happening and then they intervene to overcome these barriers. If, after these interventions, the client continues to refuse the treatment plan, or parts of it, the nurse must insure that the client is fully knowledgeable about any possible alternatives and the risks associated with noncompliance and non adherence to it.

Some of the related nursing diagnoses associated with non adherence to the treatment plan can include:

  • Noncompliance/non-adherence to the treatment plan related to the side effects of medications
  • Noncompliance/non-adherence to the treatment plan related to a substance related or psychiatric mental health disorder
  • Noncompliance/non-adherence to the treatment plan related to the lack of self efficacy
  • Noncompliance/non-adherence to the treatment plan related to cultural, religious or spiritual conflict with the treatment plan
  • Noncompliance/non-adherence to the treatment plan related to an external locus of control
  • Noncompliance/non-adherence to the treatment plan related to apathy
  • Noncompliance/non-adherence to the treatment plan related to the lack of support systems
  • Noncompliance/non-adherence to the treatment plan related to a lack of knowledge about the treatment plan
  • Noncompliance/non-adherence to the treatment plan related to economic disadvantage and/or the lack of health insurance
  • At risk for a relapse related to noncompliance/non-adherence to the treatment plan
  • At risk for disease progression related to noncompliance/non-adherence to the treatment plan

The client's adherence to the treatment plan is evaluated by determining whether or not the client is demonstrating compliance with it.

The expected outcomes related to the client's adherence and compliance with the treatment plan can include:

  • The client will verbalize an understanding of the treatment plan and the consequences associated with non-adherence
  • The client will overcome barriers to adhering to the treatment plan
  • The client will overcome apathy in terms of their treatments and their treatment plan

Assessing the Client for Alterations in Mood, Judgment, Cognition and Reasoning

The patient's mood and affect, judgment, level of cognition and reasoning abilities are assessed by the nurse in addition to any changes in these same characteristics, states or traits. Changes are often more indicative of client changes and health problems than the client's baseline in terms of these variables. For example, a client's traits like their extroversion or introversion traits are baseline characteristics; and the client's state in terms of these variables indicate a change in the client in terms of some response to a stressor or event. For example, a child who is typically extroverted and happy in terms of their traits may become introverted and despondent in terms of their state when they are adversely affected with a stressor or event such as being bullied or failing in school.


The clients' mood can be assessed in a number of different ways including the collection and analysis of data relating to verbal and nonverbal cues, standardized tests, self tests, and level of activity in terms of the client's performance of psychomotor skills.

For example, the nurse will want to assess subjective statements from the client in respect to their perception of their mood, objective data relating to the nurse's observation of the client's body language and nonverbal communication skills, and objective as well as subjective data relating to the client's self perceived and demonstrated ability to perform tasks including the basic activities of daily living.

Some of the questions that the nurse will explore include:

  • Is the client demonstrating a mood that is happy, elated, euphoric, somber, sad, depressed or flat and absent of all emotion?
  • Has the client related to the nurse that they feel is happy, elated, euphoric, somber, sad, depressed or flat and without any emotion?
  • Is the client making or not making eye contact with the nurse?
  • Is the client demonstrating nonverbal communication and body language cues such as pacing, restlessness, hostility, withdrawal and/or detachment?


Simply stated, judgment is an individual's ability to reach a sound decision or opinion after understanding all of the aspects of the situation. Judgment is closely aligned with other concepts and constructs such as logic, reasoning and insight.

Like mood, the clients' judgment can be assessed in a number of different ways including the collection and analysis of data relating to verbal, nonverbal and behavioral cues.

Some of the questions that the nurse will explore include:

  • Is the client stating that they can magically, for example, change and transform an unsafe condition or situation into one that is safe?
  • Is the client stating that they can magically, for example, avoid all unsafe conditions and situation?
  • Is the client using poor judgement and demonstrating poor insight into their disease process and/or their treatment plan?
  • Is the client demonstrating behaviors that are not based on good judgment, such as drinking poisonous cleaning chemicals that were left unsecured in the client care area?


Nurses also assess the client's level of cognition and awareness which are often related to the client's level of consciousness.

Level of cognition should be differentiated from the client's level of intelligence and the client's aptitude. Levels of cognition can change as the result of physical and psychological situational forces but a client's innate level of intelligence remains consistent even when it appears that it has decreased as the result of changes in terms of the client's level of consciousness, level of awareness and level of cognition.

The Rancho Level of Cognitive Functioning Scale, a standardized test tool that assesses the cognitive levels of clients after a coma, grades the client's cognitive level as follows in the correct sequential order from the lowest to the highest level of cognition as:

  • No response
  • A generalized response
  • A localized response
  • Confused and agitated
  • Confused, inappropriate, but not agitated
  • Confused but appropriate, automatic and appropriate responses
  • Purposeful and appropriate responses

Levels of consciousness, as previously detailed in the section entitled "Assessing the Client's Appearance, Mood and Psychomotor Behavior and Identifying and Responding to Inappropriate and Abnormal Behavior" in correct descending order from the highest level to the lowest level of consciousness are:

  1. Alert
  2. Confused
  3. Lethargic
  4. Obtunded
  5. Stuporous
  6. Comatose


Reasoning, which is closely aligned with critical thinking and decision making, is simply defined as the individual's ability to collect data and information and then come to a sound conclusion after considering the situation, circumstances and the alternatives. The two types of reasoning are inductive reasoning and deductive reasoning. Inductive reasoning is coming to a generalization as based on the data and information that is provided; and deductive reasoning is defined as the kind of reasoning that leads to a decision as based on some assumption or principle.

When clients, who were previously able to make decisions by using critical thinking and logic, are no longer able to do so, the nurse will plan interventions to accommodate for these changes.

Applying a Knowledge of Client Psychopathology to Mental Health Concepts Applied in Individual, Group and Family Therapy

There are numerous interventions, including individual, group and family treatments and therapies that are used for clients affected with a psychiatric mental health disorder and which are based on the client's psychopathology and their unique needs.

Some of these treatments include psychotherapy, psychoanalysis, behavioral therapies, brain stimulation therapies, pharmacological therapies and non pharmacological interventions.


Psychotherapy entails the initiation establishment of a therapeutic client - therapist after which this treatment is characterized with verbal communication and discussions between the client(s) and the therapist which can be the nurse. In contrast with psychoanalysis, psychotherapy focuses more on the present and less on the past.

Some examples of psychotherapy for individuals, groups, and families can include the following:

Cognitive Psychotherapy

This form of therapy aims to focus on the client's problem solving in terms of the client's thoughts and behaviors. This type of psychotherapy is most often used among clients, groups, and families who are adversely affected with depression, eating disorders, anxiety, and anxiety disorders. Cognitive psychotherapy is used to facilitate the altering of the clients' attitudes and perspectives relating to stressors.

Some of the techniques that are used with cognitive therapy include facilitating the client's recognition of negative thoughts, cognitive reframing, priority setting, assertiveness skills development, flooding, stopping negative thoughts by replacing them with positive thoughts, and the prevention of maladaptive responses to anxiety such as occurs among clients affected with an obsessive compulsive disorder.

Behavioral Psychotherapy

This form of psychotherapy, in alignment with the theories of Skinner's conditioning theory and Freud's theory of psychoanalysis, is based on the premises that behavior is learned, that our behaviors have consequences, and that clients can change their behaviors. This type of psychotherapy is often used to decrease anxiety and it is particularly useful among clients who are adversely affected with substance related disorders, other addictive disorders, and phobias.

Some of the techniques that are used with behavioral therapy include operant conditioning as put forth by Skinner, aversion therapy, desensitization therapy, modeling and complementary and alternative stress management techniques.

Cognitive Behavioral Psychotherapy

This psychotherapy technique is a combination of cognitive psychotherapy and behavioral psychotherapy. Cognitive behavioral psychotherapy, also referred to as dialectical behavior therapy, aims to gradually change the client's behavior over time within a supportive and therapeutic environment and relationships. This type of therapy is often used for clients affected with a personality disorder and those at risk for injury and harm to self and/or others.


Psychoanalysis, in contrast to cognitive behavioral therapy and other individual and group therapies, dives into the client's subconscious and it often focuses on the past as well as the client's current issues. This strategy, as put forward by Sigmund Freud, is based on the premise that mental illness and internal conflicts occur as the result of relationships, events and situations that occurred in the past. Experienced psychotherapists employ transference, free association, and dream interpretation and analysis in addition to other techniques with this form of psychotherapy.

Brain Stimulation Therapies

The three different types of brain stimulation therapies are transcranial magnetic stimulation, vagus nerve stimulation, and electroconvulsive therapy. Brain stimulation therapy is used among clients who are affected with schizophrenia, major depression and mania.

Electroconvulsive Therapy

also referred to as ECT, is most frequently used for severely depressed mental health patients. Electroconvulsive therapy delivers an electrical shock to the brain via electrodes that are externally placed on the patient's head. Electroconvulsive therapy is typically given to the client three times a week for a total of about six to twelve treatments as based on the client's mental status, their level and duration of their depression, and the efficacy of this treatment for the client.

Prior to the procedure, the nurse maintains the client at NPO status for a minimum of 6 hours prior to the electroconvulsive therapy; they complete and document all of the elements contained in the facility's pre procedure checklist which contains things like the client's informed consent; they insure that the client has no items in or on the body that must be removed prior to the procedure such as jewelry and dentures; they initiate and maintain an intravenous line that will remain in place until the client has recovered fully; they assess the client's mental status, and they administer pre electroconvulsive therapy medications, such as glycopyrrolate or atropine sulfate which decrease secretions and are ordered by the client's physician.

The nurse in attendance during the electroconvulsive therapy session will closely monitor the patient's physical status, their therapeutic seizure activity and also insure the patient's safety throughout the procedure.

After the procedure, the nurse will continue to monitor the client, their mental status, and their vital signs; the nurse will also reorient the client because confusion and amnesia may occur as the result of this treatment. Patient safety is a major nursing consideration during and after electroconvulsive therapy.

Some of the commonly occurring complications of electroconvulsive therapy, when they do occur, include hypertension, memory loss, confusion, a headache, changes in terms of the client's cardiac rhythms, and muscular soreness that can occur as the result of the induced seizure activity.

Transcranial Magnetic Stimulation

Also used for clients affected with a major depressive disorder, consists of the transmission of magnetic pulses to the brain in order to stimulate different areas of the brain. In contrast to electroconvulsive therapy, transcranial magnetic stimulation is given on a daily basis for a duration of four to six weeks; it is also most often done on an outpatient basis. Unlike electroconvulsive therapy, the client remains alert and awake during the transcranial magnetic stimulation procedure and it does not produce seizure like those that are produced for electroconvulsive therapy.

Some of the complications associated with transcranial magnetic stimulation include discomfort and a tingling sensation where the magnet was placed and a feeling of being lightheaded and dizzy after the procedure.

Vagus Nerve Stimulation

like transcranial magnetic stimulation and electroconvulsive therapy, is also used as a treatment for clients with depression, in addition to anxiety. This noninvasive procedure entails the placement of a subcutaneous device in the client's chest which will be then used to electrically stimulate the vagus nerve of the brain on an intermittent and automatic basis around the clock.

This procedure, like transcranial magnetic stimulation, is also given on an outpatient basis and some of the complications of this treatment can include dysphagia, hoarseness of the voice and dyspnea as the result of the device in the proximity of the client's larynx and pharynx.

Pharmacological Therapies

The major classifications of medications that are used for the treatment of psychiatric mental health disorders are:

  • Antianxiety or anxiolytic medications
  • Antidepressant medications
  • Mood stabilizing drugs
  • Anti-psychotic medications
  • Medications used for substance abuse disorders

Antianxiety or Anxiolytic Medications

The primary subcategories of antianxiety or anxiolytic drugs are the benzodiazepines, the selective serotonin reuptake inhibitors, and the anxiolytic/nonbarbiturate anxiolytics.

Examples of benzodiazepines are diazepam, chlordiazepoxide, lorazepam, oxazepam and clorazepate; examples of some of the selective serotonin reuptake inhibitors are sertraline, fluoxetine, fluvoxamine and escitalopram; and an example of an antianxiety anxiolytic/nonbarbiturate anxiolytics is buspirone.

Antidepressant Medications

The major subcategories of the antidepressant medications are the tricyclic antidepressants, the monoamine oxidase inhibitors, the selective serotonin reuptake inhibitors and the atypical antidepressant drugs.

Examples of tricyclic antidepressants are doxepin, amoxapine, imipramine and nortriptyline; examples of some of the monoamine oxidase inhibitors are isocarboxazid, tranylcypromine and selegiline; examples of selective serotonin reuptake inhibitors are fluvoxamine, sertraline, fluoxetine, and escitalopram; and an example of an atypical antidepressant drug is bupropopion.

Tricyclic antidepressants act by blocking the uptake of serotonin and norepinephrine in the brain; selective serotonin reuptake inhibitors block the reuptake of the brain's serotonin, and monoamine oxidase inhibitors act by inactivating epinephrine, norepinephrine, serotonin and dopamine.

Mood Stabilizing Medications

The subcategories of mood stabilizing medications that are used for the treatment of mood disorders, such as bipolar disorders, are mood stabilizing medications like lithium, antiepileptic drugs such as valproic acid, carbamazepine and lamotrigine, anxiolytics such as diazepam, chlordiazepoxide, lorazepam, oxazepam, clorazepate, sertraline, fluoxetine, fluvoxamine, escitalopram and buspirone.

Medications for Psychotic Disorders

The classifications of antipsychotic drugs are the first generation antipsychotic drugs and the second generation antipsychotic drugs. Loxapine, thioridazine, haloperidol, perphenazine and trifluoperazine are examples of the first generation, traditional antipsychotic medications. Examples of second generation antipsychotic medications are clozapine, asenapine, olanzapine, iloperidone and quetiapine, among others.

The first generation antipsychotic drugs block dopamine, thus decreasing psychotic symptoms and symptomatology. These drugs also block histamine, and acetylcholine. They are most often used among clients who are affected with schizophrenia, bipolar disorder clients when they are in the manic phase, Tourette's syndrome, and acute and chronic psychotic disorders.

The second generation antipsychotic drugs block dopamine receptors, serotonin, histamine, acetylcholine and norepinephrine. They are used for the treatment of the symptoms of schizophrenia, including both the positive and the negative ones, the reduction of bipolar disorder psychotic symptoms, and for the treatment of psychosis that results from a treatment regimen of levodopa.

The complications of the first generation antipsychotic drugs include Parkinsonian type symptoms like drooling, muscular rigidity and tremors which can be controlled with medications such as diphenhydramine, amantadine or benztropine. Other complications of the first generation antipsychotic drugs are akathisia which is characterized with pacing and agitation and which can be treated and controlled with beta blockers, anticholinergic medications or benzodiazapines, dystonia which can manifest with spasms of the tongue and neck which can be treated with diphenhydramine or an anticholinergic medication, tardive dyskinesia which is signaled with the smacking of the client's facial and tongue, and, also, neuroleptic malignant syndrome which can include cardiac arrhythmias, altered levels of consciousness a high temperature, neuroendocrine complications such as irregularities of the menstrual cycle and gynecomastia, sedation, orthostatic hypotension, and seizures.

The complications of the second generation antipsychotic drugs include tremors, the onset of diabetes or the poor control of glucose levels among clients already diagnosed with diabetes, agitation, sedation, dry mouth, orthostatic hypotension, hypercholesterolemia, and weight gain.

Medications Used for Substance Abuse Disorders

Medications used for substance related abuse disorders can be broadly categorized as medications used for detoxification, medications used for maintaining drug cessation after detoxification, medications used for the support of withdrawal and abstinence from opioids, and medications used for the support of withdrawal and abstinence from nicotine.

Examples of medications used for detoxification are the benzodiazepines, clonidine, propranolol and carbamazepine; examples of medications that are frequently used for maintaining drug cessation after detoxification has been completed are disulfiram for alcohol cessation and abstinence maintenance, naltrexone for the maintenance of abstinence from opioids and alcohol, and acamprosate for the abstinence from alcohol. Examples of medications that are used for the support of withdrawal and abstinence from opioids include buprenorphine, methadone and clonidine; and examples of medications that are used for the support of withdrawal and abstinence from nicotine are bupropion and nicotine replacement medications using a patch, gum or a lozenge.

Providing Care and Education for Acute and Chronic Behavioral Health Issues

Nurse provide care and education to clients affected with acute and chronic behavioral health issues including those affected with anxiety, depression, dementia, eating disorders and other behavioral health issues.

Generally speaking, the plan of care for these clients are establishing trust with the client, allowing the client to ventilate their feelings, establishing and maintaining a therapeutic milieu, providing other interventions such as individual and group counseling, administering ordered medications, monitoring and assessing the client for their safety needs and changes in terms of their mental status and behaviors, and other treatments such electroconvulsant therapy.

The education of clients, significant others and families, affected with acute and chronic behavioral health issues, including those affected with anxiety, depression, dementia, eating disorders and other behavioral health issues, should be based on the assessed learning needs and, it most often includes information about:

  • The etiology of the acute or chronic behavioral health issues
  • Things that increase and decrease the symptoms
  • All elements of the plan of care including therapies and medications
  • Follow up care in the community
  • When to contact one's primary care provider
  • Community resources such as peer support groups

Evaluating the Client's Ability to Adhere to Their Treatment Plan

Some of the risk factors associated with clients' nonadherence to their treatment plan include:

  • The lack of the client's participation in the treatment plan
  • A client internal locus of control
  • The client's low level of self efficacy
  • Denial
  • The prohibitive costs associated with the treatments
  • The cumbersome and troublesome nature of the treatment plan
  • The troublesome side effects of the treatment
  • A lack of good judgment and decision making
  • A lack of insight into one's disorder
  • Client apathy
  • Previous negative experiences with the same or similar treatment plan
  • Personal cultural conflicts with the treatment plan
  • Religious and spiritual conflicts with the treatment plan
  • Substance related disorders
  • Severe psychotic illness

Evaluating the Client's Abnormal Responses to the Aging Process

Aging and the aging process are maturational and developmental crises that occur predictably along the life span. Despite the fact that aging is a predictable, gradual process, the client responds to these changes with physiological, psychological, social and spiritual responses, some of which are normal and adaptive and some of which are abnormal and maladaptive.

The physical changes associated with the aging process including changes in terms of the client's sensory and neurological changes, cardiovascular changes, musculoskeletal changes, joints and bone changes, renal system changes, hepatic functioning changes, skin and hair changes, respiratory system changes, and fluid and electrolyte changes. Some of these physiological changes are responded to with normal and expected physiological responses and others are responded to with abnormal and maladaptive physiological responses. For example, visual deficits can be adapted to with the use of eyeglasses and calcium losses in the bones can be adapted to with a pathological fracture related to osteoporosis.

All of these normal changes of the aging process were fully discussed previously with the sections entitled "Providing Care That Meets the Needs of the Adult Client Ages 65 through 85 years and Over" and "The Changes Associated With the Aging Process".

Psychological and emotional responses to the normal changes of the aging process can also include normal and adaptive responses as well as abnormal, maladaptive and pathological responses. For example, a client can successfully adapt and cope with the normal changes of aging, their declines and their deteriorations associated with aging by accepting these changes and establishing realistic goals and self expectations in terms of these changes; and they can also have abnormal and maladaptive responses such as depression, anxiety, complicated grief, distress, anger, denial, and a loss of loss of hope and meaning.

Social responses to the normal changes of the aging process can also include normal and adaptive responses as well as abnormal, maladaptive responses such as social isolation, withdrawal from others and alienation from family members and other significant others.

Some of the spiritual maladaptive responses to the normal changes of the aging process can include spiritual distress, guilt and remorse.


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