| Course | NU 671 Clinical Decision-Making in Psychiatric Mental Health |
|---|---|
| Unit | Unit 2 |
| Paper type | Mental status examination record |
| Length | About 760 words, 5 pages |
| Format | APA 7 student paper |
| School | Herzing University |
| Program | MSN Psychiatric Mental Health Nurse Practitioner |
| Updated | October 2026 |
Free sample paper for NU 671 Unit 2
Mental Status Examination Record in Observational Language: Mr. K., 56, at Intake
Student Name
Department of Nursing, Herzing University
NU 671: Clinical Decision-Making in Psychiatric Mental Health
Instructor Name
January 29, 2026
Mental Status Examination Record in Observational Language: Mr. K., 56, at Intake
Context
This examination was recorded during the 55-minute intake of Mr. K., the composite patient whose primary care clinician sent him after four months of sertraline without improvement. Each domain is written as what was seen and heard. Where a term that implies interpretation is used, the observation supporting it appears beside it. The domains follow the conventional order of the mental status examination (Trzepacz & Baker, 1993).
Appearance
Man who appears his stated age, heavy build, wearing a work jacket with a company logo, jeans, and work boots. Clothes clean. Face unshaven for what looked like two or three days. Hair uncombed at the back. Dark discoloration under both eyes. He yawned six times during the interview.
Behavior and Psychomotor Activity
Sat still in the chair for most of the interview, hands resting on his thighs. Few gestures. Eye contact intermittent; he looked at the floor while answering questions about mood and at me when talking about work. No tremor, tics, or abnormal movements observed. He closed his eyes for several seconds twice while his wife's concerns were being discussed and opened them when addressed. Walked to and from the room at a normal pace with a normal gait.
Attitude Toward the Examiner
Cooperative, answered every question, and volunteered some information, such as his fear of dementia. He apologized twice for "not making sense."
Speech
Normal volume. Rate slower than average. Pauses of three to four seconds before answering many questions, longer for questions about dates and events. Articulation clear. No word-finding pauses in which he searched for a specific word, except once, when he could not name the brand of truck he drives and described it instead.
Mood and Affect
Mood, in his words: "Flat. Not really sad, just nothing." Affect: range narrow; facial expression changed little across topics. He smiled briefly once, when mentioning his grandchildren, and his voice became quieter and slower when talking about his mother's dementia. Affect consistent with his stated mood.
Thought Process
Answers were relevant to the questions and followed a logical sequence. Twice he lost the thread of a longer answer and asked, "What was the question?" No looseness of associations, tangential answers, or flight of ideas.
Thought Content
Preoccupied with fatigue and with fear of "losing my mind, like my mother." Passive thoughts of not waking up, without active thoughts of killing himself, plan, intent, or preparation; has access to firearms at home. Denied thoughts of harming others. No delusional content elicited; his worries about his memory were proportionate to what he described and to his family history. No obsessions or compulsions reported.
Perception
Denied hearing or seeing things others do not. Did not appear to respond to anything unseen during the interview.
Cognition
Alert, although he closed his eyes twice as described. Oriented to person, place, day, month, and year; gave the date as the 28th rather than the 29th. Attention: serial sevens from 100, correct for the first three subtractions and then two errors; spelled WORLD backward correctly. Memory: registered three words after one trial; recalled one of three at five minutes, and both remaining words with a category cue. Naming and repetition intact for the items tested. A formal cognitive screen was planned rather than drawing conclusions from these bedside items.
Insight and Judgment
Insight: recognizes that he has changed and that he needs help; attributes the change to "getting old" or to dementia and did not connect his sleep to his daytime symptoms until it was discussed. Judgment: agreed to remove the rifles to his brother-in-law's house while evaluation continues and to call the crisis line if thoughts of death became active; kept his appointment and brought his wife with him.
What the Record Shows Without Concluding
The record contains observations that fit several explanations: yawning and closing his eyes during the interview, slow responses, reduced recall that improved with cues, and flat affect. Recall that improves with cues suggests difficulty retrieving information rather than storing it, a pattern seen in depression, sleep deprivation, and some other conditions, and less typical of early Alzheimer disease (Carlat, 2017). His orientation error, one day off, is common in people who are tired or depressed and does not on its own point to a cognitive disorder, but it is recorded so that it can be compared at later visits. The record deliberately stops there; the weighting of these findings belongs to the diagnostic reasoning that follows, with the laboratory, sleep, and cognitive screening results in hand (American Psychiatric Association, 2016).
References
American Psychiatric Association. (2016). The American Psychiatric Association practice guidelines for the psychiatric evaluation of adults (3rd ed.). American Psychiatric Association. https://doi.org/10.1176/appi.books.9780890426760
Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
Trzepacz, P. T., & Baker, R. W. (1993). The psychiatric mental status examination. Oxford University Press.
The Herzing NU 671 Unit 2 instructions
Unit 2 asks you to write a mental status examination record for a patient. Expect to cover appearance, behavior and psychomotor activity, attitude, speech, mood and affect, thought process, thought content, perception, cognition, and insight and judgment. Many versions emphasize observational language, describing what was seen and heard rather than interpreting it. Check whether your section expects a cognitive screening instrument within the record. Use the patient's own words for mood and quote them. Each domain needs specific detail, such as the length of pauses or what the patient wore. A record that separates observations from conclusions is more useful to the next clinician, who may interpret the same findings differently once test results arrive.
Inside the NU 671 Unit 2 example
The record opens with context in a sentence, linking it to the intake. Each domain then gets its own heading with specific observations. Appearance describes clothing and grooming without words like disheveled or appropriate. Behavior counts gestures and records the two eye closings exactly. Speech quantifies pauses. Mood is quoted and affect is described by range and change across topics. Thought process notes two moments he lost his thread. Thought content records the dementia fear and passive death thoughts without active intent. Cognition reports orientation and a date error. The final section is unusual and valuable: it lists observations that fit several explanations, such as sleepiness pointing to a sleep disorder as much as to depression.
NU 671 Unit 2 rubric: what full points look like
Herzing's rubric for a mental status record typically covers completeness of domains, observational language, specificity, the use of the patient's words, the separation of observation from interpretation and writing. Observational language is where graders focus, rewarding descriptions another clinician could verify and penalizing labels without evidence. Completeness requires every standard domain. Specificity points go to measurable details, such as pause length. Mood should appear in quotation marks. Separation of observation and conclusion often earns its own credit. Professional formatting with domain headings helps. Carlat's text and Trzepacz and Baker belong in the APA 7 list. The final section listing observations that fit several explanations is unusual, and graders who see it tend to credit the record for clinical restraint.
Common NU 671 Unit 2 mistakes, and how to avoid them
Mental status records in Unit 2 usually lose points through interpretive labels, such as poor hygiene or depressed affect, without the observations behind them. Another frequent problem is skipping domains, especially perception and insight. Students often paraphrase mood instead of quoting the patient. Cognition is reduced to alert and oriented. Observations are vague, such as speech slow. The record jumps to a diagnosis. Finally, separate what you observed from what it might mean, because graders reward records that leave room for other explanations, especially when findings like sleepiness could point beyond the referral diagnosis. Thought content entries often miss passive death thoughts that the intake recorded, which creates an inconsistency the grader will notice. Insight should state what the patient believes is wrong, here getting old or dementia, not just good or poor.
Get a NU 671 Unit 2 example written to your instructions
Send the Unit 2 instructions and the rubric from your NU 671 classroom, with the presentation the record should describe. We write a custom example holding every domain at the level of description, process kept apart from content, cognitive tasks recorded with their responses, absent findings written in, and inference confined to one labeled paragraph. First custom sample free, back in 24 to 48 hours.
More NU 671 papers and PMHNP samples
- NU 671 Unit 1: Annotated intake interview
- NU 671 Unit 3: Diagnostic weighting table
- NU 671 Unit 4: Medical mimic exclusion log
- NU 671 Unit 5: Diagnostic criteria mapping
- NU 671 Unit 6: Rating instrument administration note
- NU 671 Unit 7: Collateral information summary
- NU 671 Unit 8: Biopsychosocial formulation
- NU 673 Unit 2: Community resource pathway
- NU 674 Unit 2: Chronic illness trajectory review
- NU 670 Unit 2: Clearance pathway table
- NU 672 Unit 2: Boundary and self-disclosure review
NU 671 Unit 2 questions, answered
Does the record need a cognitive screening instrument?
Only where the instructions or the presentation call for one. If an instrument is used, name it, record what was administered and what the person did, and report the score alongside the tasks behind it. Where none is used the domain still needs entries, since orientation, attention and memory can be examined conversationally and the record should say how.
How is appearance described without judgment?
By reporting observable features and leaving conclusions to the reader. Clothing, grooming, posture, movement and how the person engaged are observations; unkempt, bizarre and inappropriate are verdicts carrying cultural assumptions the record cannot support. Where a summary term genuinely helps, put it after the description it rests on rather than in place of that description.
Is the examination the same thing as the interview?
They run together and are recorded apart. Most of the examination is gathered while the history is being taken, but the record separates what the person reported from what the examiner observed, because those two carry different weight in the reasoning that follows. Formal cognitive testing is the portion usually conducted deliberately rather than absorbed from conversation.
Where can I find a free NU 671 Unit 2 sample paper?
Read the complete NU 671 Unit 2 mental status record here at no charge, every domain in observational language with the closing list of open findings. A record for another patient or setting can be prepared on request.
What is observational language in a mental status exam?
It describes what was seen and heard, such as pauses of three to four seconds before answers, rather than labels like psychomotor retardation without detail. This sample records Mr. K. that way so the next clinician can reach their own conclusion.