Mental Health: Assessment, Risk Factors, and Care Plan

Running head: MENTAL HEALTH
MENTAL HEALTH
Name of the Student
Name of the university
Author’s note

1MENTAL HEALTH
Mental state examination
APPEARANCE: Young Asian black haired man. He is wearing glasses. His clothing is
appropriate for his age. Has a slim figure. He was dressed in cargo pants with red and
black flannel shirt along with glasses. Appeared disengage as his head was hung down,
arms crossed and restrictive posture. His Grooming is adequate and he was
cooperative about the examination.
BEHAVIOUR: The patient is avoiding eye contact, probably due to the sense of
insecurity or fear. He was Looking different direction, fidgeting with his fingers and
appeared uncomfortable while answering the questions, but became comfortable after
sometimes. He had a poor concentration. His eyes sometimes become fixated in the
opposite wall.
AFFECT: His affect was labile, response was stable and within the context.
MOOD: He reports that it is scary to hear the voices sometimes and he feels extremely
uncomfortable. He sometimes became distracted by the voices, while conversing with
the nurse. The curtains distracted him.
SPEECH: clients pitch was very low and not within a normal pace throughout the
conversation. Client sometimes becomes distracted with the voices and doesn’t answer
the nurse.
THOUGHT FORM: He was talking abstract in the beginning, but as the conversation
went on, his response seems logical.

2MENTAL HEALTH
THOUGHT CONTENT: He has friends but goes out on movies by himself, he has
expressed interest on calling her mom.
PERCEPTION: The boy was having auditory hallucinations and can hear voices. He
reported that the voices in the background often make fun of him for being weak in math
and criticize him. He sometimes gets distracted by the voices. He has reported he was
also suffering from sleeping disorders due to the voices as they often wake him up from
sleep.
COGNITION & INTELLECTUAL FUNCTIONING: He is alert and orientated. He knows
he is in a clinical mental health unit and knows the date, year and knows why he is in
that particular unit. Client appeared unfocused as he said that he is getting distracted by
the voices. The client confesses that he might have poor cognitive skills as he feels that
he cannot do math.
INSIGHT & JUDGEMENT (Insight- He was aware he has a problem and needs
medication as he knows that his symptoms remain in control as long as he is under
medications, But becomes anxious with the thought of going to the hospital, insight to a
degree – denial; judgment = on the self-defense question he wouldn’t harm anyone
understanding of consequences of their behaviors, hence he says that the voice does
not tell him to cause harm to others). He likes writing. He is worried about his mother.
He remembers that he in under medications.

3MENTAL HEALTH
Risk factors
 The risk factors are the cognitive, affective and the psychomotor factors.
 The voices wake him up sometimes from his sleeps that can also lead to
sleeping disorders.
 Another risk factor is that the hearing voices may arise suicidal tendencies on
him as he had already told that he cannot concentrate on his studies as the
voices constantly distracts him (Hepworth et al., 2012).
 Another risk factor is that the patient is weak in math and hence has developed a
sense of frustration. He has also stated that the voices do not let him to do math.
Hence the boy may also get into depression for not being able to do his studies
and he feared that he might be humiliated by his classmates. Furthermore he is
also concerned that his mother will become anxious if he comes to know
regarding his problems.
