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Case Study: Mental State Assessment

Professional Portfolio
A. Case Study: Mental State Assessment (1000 words)
Due: 4th April 2016
Students are to refer to the case study available below, and answer the THREE
associated questions. Each question has a word limit.
The assignment is to be presented in a question/answer format, and not as an essay
(i.e. no introduction or conclusion). You must use sentences. DO NOT use dot
points. Each answer must be supported by appropriate academic sources. Students
should follow the recommended formatting for academic papers
http://students.acu.edu.au/308971 Students must provide in-text referencing and a
reference list must be provided at the end of the assignment.
A minimum of (6) six academic references and (2) two websites are required
for this assessment task.
Case Study
Dylan Walz has been bought to the mental health unit for assessment. He is
accompanied by a work colleague. Dylan presents as a tall, slim man, who looks his
stated age. His hair is short and it is evident that he has not shaved for several days.
His work clothes are slightly soiled and he is wearing black boots. He mostly gazes
downward towards his feet, making eye contact sporadically with staff.
Documents:
1. The following information is from the letter that was sent to the Mental Health Unit
by the GP.
Dear Doctor,
Thank you for seeing 26 year old Dylan Walz. Dylan has been to see me on several
occasions this past two months requesting a sick certificate for time off work because
he has not been able to sleep. He says that he is not able to sleep because of noises
in the ceiling. He says sometimes the noises are like scratching and other times he
hears muffled voices. He has not wanted to use medication to assist with sleep. I
have noted a slight weight loss but can find no organic cause. He reports that he is
concerned by poisons that might be in the food and prefers to eat canned food. At
his last visit I noted his mood was euthymic and affect blunted.
He denies illegal drug use and reports he doesn’t drink alcohol. He says he likes his
job at Coles and feels they are the only people he can trust.
Regards,
Dr Jean General Practitioner.
2. Registration Form: Dylan firmly refused to complete a Registration form given to
him on presentation to the Assessment Unit today.
Presentation at the Mental Health Assessment Unit
Dylan became agitated after he was approached to complete the Registration form.
He indicated to his friend that he was going to leave but his friend was able to
convince him to stay. He reluctantly agrees to follow staff to the interview room.
Question 1 ( 200 words)
Discuss three (3) essential skills the nurse will use in the mental state examination.
You must include the reasons why these skills are essential and provide an example
of the behaviour, question or statement you would use in the interview with Dylan.
Here is an example:
1. Suitable introduction and explanation of the purpose of the interview.
It is critical that the nurse establish rapport and introducing yourself is one way in
which to begin to establish rapport and also set boundaries related to the nurses’
role. (Elder, Evans & Nizette, 2013).
Example statement
Hello Dylan. Thank you for attending the appointment today. My name is Lilly Deng
and I am one of the nurses who work here in the Mental Health Assessment Unit. I
would like to ask you some questions about
Question 2 (200 words)
Describe the purpose of this mental health assessment for Dylan?
Question 3 (600 words)
For each of the components of the Mental State Examination listed below, write a
question or statement you would use to investigate each component. Include any
evidence from the case study to support your work.
Here is an example
Affect
The GP has noted that Dylan has a blunted affect. Dylan’s external emotional
response would be assessed in regards to its appropriateness and congruence of
mood. There is evidence from the GP that Dylan’s affect has decreased in intensity
and range of his emotional expression.
1. Appearance and behaviour
2. Affect and Mood
3. Speech
4. Cognition
5. Thought form and Content
6. Perception
7. Insight
8. Judgement
9. Risk
Please note any examples that have been used in this case study to support your
understanding can not be re-used within your assessment.

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