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Exam Elaboration | Nursing
Focused Exam Alcohol Use Disorder In Progress Attempt Shadow Health Mental Status Notes
SKU: BSN Psychiatric | Pages: 1 | Year: 2020
Document Brief Description
Reflections
Activity Description: Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician and gives your in...
Reflections
Activity Description: Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician and gives your instructor insight into your learning proces
This reflection activity will help you think more deeply about your performance in the assignment. Use your documentation as you respond to the prompts at the bottom of the p
Documentation Review
Mental Status Note
Student Response Model Documentation
Appearance Indirect eye contact, tension and rigidity, clean clothing, and
appropriate level of grooming
Ms. Adler is a 20-year-old White woman of average heigh
average weight. She exhibits indirect eye contact during th
examination, and a worried expression. Her posture was
tense. When she arrived, Ms. Adler’s clothing was approp
to her age and worn appropriately. Appropriate hygiene an
grooming.
Attitude Generally suspicious, guarded, or evasive Ms. Adler displays no excessive liveliness or intense
mannerisms. She has a blunt affect. She is cooperative w
the medical staff and forthcoming with information about h
current mental state.
Speech Expected rate of speech, loud speech volume, and no
appreciable issues with articulation
Ms. Adler’s speech characteristics display the expected
complexity for her age, education level, and general ability
Presents no observable articulation problems. Her speech
slow, hesitant, and spoken at a low volume.
Mood and Affect Stable mood and a balanced affect Ms. Adler expresses a moderate level of anxiety over her
current circumstances, stating that the last six months of h
life have been stressful, and that she has been increasing
anxious. She states that she was overwhelmed. Her
responses seem appropriate to the situation, and although
is upset, her emotions are within a stable range.
Nursing Admitting...
Mental Status Note
SBAR
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Student Response Model Documentation
Thought Process No presence of thought disturbances Ms. Adler’s pattern of thinking is coherent and logical. She
offers relevant information about her circumstances and
exhibits a normal continuity of thought. Observed no poten
disordered behaviors. Observed no rhyming, clang
association, or puns.
Thought Content Suicidal ideation Ms. Adler displays passive suicidal ideation and expresse
that she does not care if she lives or dies. Ms. Adler does
express any active suicidal ideation or plans for ending he
life. She says she has never attempted suicide or planned
suicide attempt. Ms. Adler seems to be under stress from
school and her relationship with her mother. She is deeply
distraught over her DUI and the circumstances that broug
her to the ER.
Perceptual
Disturbances
No perceptual disturbances Ms. Adler displays no evidence of delusions or observable
abnormal tendencies during the exam. There is no eviden
hallucinations or false sensory perceptions.
Orientation and Level
of Consciousness
Oriented to person, place, time, and situation A&O x4
Cognition Able to complete the serial sevens series, demonstates
abstract thinking with similarity test, remote and immediate
memory intact,
Normal attention and serial 7s. Normal ability for abstract
reasoning. Ms. Adler seems to have a logical train of thou
and is capable of understanding why she is here. Her gen
intellect appears to be above average. Working memory a
episodic memory seem normal.
Insight Demonstrates limited or no awareness of illness and/or is
unwilling to seek treatment
Ms. Adler appears to be unclear in her awareness of her
alcohol use. She says she drinks because of stressors like
school and her relationship with her family. She describes
drinking up to five drinks at a time three or four nights a w
and expres
- 1-pages detailed model answer (PDF + online view)
- Clinical reasoning & medication selection justified
- NP-level explanation with key teaching points
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Keywords
alchohol,disorder
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