Nursing Process - Mental Status Examination (MSE) and Risk Screening Tool - Report Writing Assessment Answer

Assessment Task:

Rationale: A nursing process is a tool that ensures nurses critically think and document the assessment, diagnosis, planning, implementation and evaluation of competent care provided to a person under the registered nurses care (Lemone et al., 2014, p.7). Nursing assessments performed in the mental health setting include the mental status examination as well as several risk assessments, which may be client-centred or health service centred (Edward et al. 2014, p. 341). It is essential that the nurse includes a lifestyle assessment and an assessment of the client’s physical health. Some lifestyle choices, such as substance use or inadequate dietary intake, can produce a disease that may manifest as disorders of mental status. This origin of the disease needs to be exposed through questioning so that other causes and influencing factors of mental health can be investigated and eliminated.

Learning outcomes: It is expected that a student will develop an ability to observe client behaviour and accurately document those observations as findings on the Mental Status Examination (MSE) and risk screening tool in the correct assessment categories using the correct terminology. Students will also develop patient-focused documentation skills in reporting the identified MSE and risk assessment findings concisely and accurately within the nursing report. From your findings, it is also expected that students will be able to identify symptoms about the client and consequently be able to develop mental health nursing-specific interventions to assist the client. 

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