Comprehensive Assessment and Screening in Mental Health Care: Identifying Risk Factors

QUESTION

Dry flaky skin on most of her body Last menstrual period = 2 weeks ago Hair dry and brittle – Poor hygiene Vital signs within normal limits 2. Highlight or place a check mark next to the assessment findings that require follow-up by the nurse and the healthcare team. Answer Rationale: The client was referred to a clinical psychologist for psychological evaluation for severe moodiness, irritability, isolation, and a focus on death and darkness in her artwork. She states that she feels depressed most of the time. The client is also underweight and has signs and symptoms of a possible eating disorder. As a result of a comprehensive psychological evaluation, she is diagnosed with major depressive disorder and mild bulimia nervosa. The primary health care provider prescribed fluoxetine 20 mg orally each day and psychological therapy for the client twice a week. On her first visit, the therapist asked questions to determine the client’s suicidal potential. 3. Which of the following screening questions are appropriate for a client to determine the risk for suicide? Select all that apply. a. "What is it like for you when you feel depressed?"open ended- question allow for Expressing feeling b. "When you are feeling sad, what thoughts are going through your mind?" c. "Have you ever thought of taking your own life?" d. "Do you have a way to carry out a plan for taking your own life?"- e. "Have you ever attempted suicide?" f. "Have you been thinking about death recently?" g. "Why does your artwork look dark and focus on death?" Answer Rationale: The therapist also asked questions about her cutting behavior. 4. Which of the following screening questions are appropriate for a client to determine the likelihood for continued cutting or other nonsuicidal self-injury? Select all that apply. a. "Have you recently engaged in cutting behaviors?" b . "How often do you cut yourself?" . "Are you usually with friends with cutting or by yourself?" . "Why do you feel that you need to cut yourself?" ScangneVial do you use tomake the Cuts or yog legs?" f . "Have you ever cut yourself deeper than expected?"

ANSWER

Comprehensive Assessment and Screening in Mental Health Care: Identifying Risk Factors

Introduction

Effective mental health care requires a comprehensive assessment that includes evaluating physical and psychological symptoms, followed by appropriate screening to identify potential risk factors. In the presented scenario, the nurse’s assessment findings and the therapist’s screening questions play a critical role in identifying and addressing the client’s mental health needs.

Follow-Up Assessment Findings

Dry flaky skin on most of her body
Last menstrual period = 2 weeks ago
Hair dry and brittle – Poor hygiene
Vital signs within normal limits

Assessment Findings Requiring Follow-Up

Dry flaky skin on most of her body (Possible indication of neglect or self-neglect)
Hair dry and brittle – Poor hygiene (Possible signs of self-neglect)
Last menstrual period = 2 weeks ago (Relevance to possible eating disorder)

Answer Rationale: Psychological Evaluation

The client’s referral to a clinical psychologist was prompted by severe moodiness, irritability, isolation, and her focus on death and darkness in her artwork. She expresses feeling depressed most of the time, indicating a need for mental health assessment and intervention.

Appropriate Suicide Risk Screening Questions

“Have you ever thought of taking your own life?”
This question assesses the client’s suicidal ideation.

“Do you have a way to carry out a plan for taking your own life?”
This question evaluates the client’s level of risk by assessing whether she has a concrete plan for suicide.

“Have you ever attempted suicide?”
This question identifies any previous suicide attempts.

“Have you been thinking about death recently?”
This question helps gauge the client’s overall mindset and focus.

Appropriate Nonsuicidal Self-Injury Screening Questions

“Have you recently engaged in cutting behaviors?”
This question addresses current self-injury behavior.

“How often do you cut yourself?”
This question assesses the frequency of self-injury.

“Why do you feel that you need to cut yourself?”
This question explores the underlying emotions and triggers for self-injury.

“What do you use to make the cuts on your legs?”
This question provides insight into the methods used for self-injury.

Conclusion

A holistic approach to mental health assessment and care involves addressing both physical and psychological aspects. In the scenario, specific assessment findings highlight potential areas of concern, necessitating further investigation. The screening questions used by the therapist effectively target suicidal ideation and nonsuicidal self-injury behaviors, providing critical information to guide appropriate interventions. By combining comprehensive assessment with targeted screening, healthcare professionals can accurately identify risk factors and tailor interventions to meet the individual needs of clients seeking mental health support.