- Psychomotor retardation:overall slowed
movements - Waxy flexibility:maintenance of posture or
position over time even when it is awkward
or uncomfortable
The nurse assesses the client’s speech for quan-
tity, quality, and any abnormalities. Does the client
talk nonstop? Does the client perseverate (seem to be
stuck on one topic and be unable to move to another
idea)? Are responses a minimal “yes” or “no” without
elaboration? Is the content of the client’s speech rele-
vant to the question being asked? Is the rate of speech
fast or slow? Is the tone audible or loud? Does the
client speak in a rhyming manner? Does the client use
neologisms(invented words that have meaning only
for the client)? The nurse notes any speech difficulties
such as stuttering or lisping.
Mood and Affect
Moodrefers to the client’s pervasive and enduring
emotional state. Affectis the outward expression of
the client’s emotional state. The client may make
statements about feelings, such as “I’m depressed” or
“I’m elated,” or the nurse may infer the client’s mood
from data such as posture, gestures, tone of voice, and
facial expression. The nurse also assesses for consis-
tency between the client’s mood, affect, and situation.
For instance, the client may have an angry facial ex-
pression but deny feeling angry or upset in any way.
Or the client may be talking about the recent loss of
a family member while laughing and smiling. The
nurse must note such inconsistencies.
Common terms used in assessing affect include
the following:- Blunted affect:showing little or a slow-to-
respond facial expression - Broad affect:displaying a full range of emo-
tional expressions - Flat affect:showing no facial expression
- Inappropriate affect:displaying a facial
expression that is incongruent with mood or
situation; often silly or giddy regardless of
circumstances - Restricted affect:displaying one type of
expression, usually serious or somber
The client’s mood may be described as happy,
sad, depressed, euphoric, anxious, or angry. When the
client exhibits unpredictable and rapid mood swings
from depressed and crying to euphoria with no ap-
parent stimuli, the mood is called labile(rapidly
changing).
The nurse may find it helpful to ask the client to
estimate the intensity of his or her mood. The nurse
can do so by asking the client to rate his or her mood
on a scale of 1 to 10. For example, if the client reports
8 ASSESSMENT 161
problem is the misconception that one should take
medication only when feeling sick. Many mental dis-
orders, like some medical conditions, may require
clients to take medications on a long-term basis per-
haps even for a lifetime. Just like people with diabetes
must take insulin and people with hypertension need
antihypertensive medications, people with recurrent
depression may need to take antidepressants on a
long-term basis.
General Appearance
and Motor Behavior
The nurse assesses the client’s overall appearance
including dress, hygiene, and grooming. Is the client
appropriately dressed for his or her age and the
weather? Is the client unkempt or disheveled? Does
the client appear to be his or her stated age? The nurse
also observes the client’s posture, eye contact, facial
expression, and any unusual tics or tremors. He or
she documents observations and examples of be-
haviors to avoid personal judgment or misinterpre-
tation. Specific terms used in making assessments
of general appearance and motor behavior include
the following:
- Automatisms:repeated, purposeless behav-
iors often indicative of anxiety such as drum-
ming fingers, twisting locks of hair, or tapping
the foot
Building a picture of your client
through psychosocial assessment.