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ATI - Mental Health Proctored Exam Study Guide-935 Q and A
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ATI - Mental Health Proctored Exam StudyGuide-935 Q and A
The client is responsive and able to fully respond by opening their eyes and
attending to a normal tone of voice and speech. What is the level of
consciousness? - -Alert
The client is able to open their eyes and respond but is drowsy and falls
asleep readily. What is the level of consciousness? - -Lethargic
The client requires vigorous or painful stimuli (pinching a tendon or rubbing
the sternum) to elicit a brief response. They might not be able to respond
verbally. What is the level of consciousness? - -Stuporous
The client is unconscious and does not respond to painful stimuli. What is the
level of consciousness? - -Comatose
How to test a client's immediate memory - -Ask the client to repeat a series
of numbers or a list of objects
How to test a client's recent memory - -Ask the client to recall recent events,
such as visitors from the current day, or the purpose of the current mental
health appointment or admission
How to test a client's remote memory - -Ask the client to state a fact from
his past that is verifiable, such as his birth date or his mother's maiden name
How to assess a client's ability to calculate - -Ask the client to count
backward from 100 in sevens
How to assess a client's ability to think abstractly - -Ask the client to
interpret something complex such as, "A bird in the hand is worth two in the
bush."
Glasgow coma scale - -Used to obtain a baseline assessment of a client's
level of consciousness; highest score is 15 and indicates that the client is
awake and responding appropriately; a score of 7 or less indicates that the
client is in a coma
Serious mental illness - -Includes disorders classified as severe and
persistent mental illnesses; clients often have difficulty with ADLs; can be
chronic or recurrent
,A charge nurse is discussing mental status exams with a newly licensed
nurse. Which of the following statements by the newly licensed nurse
indicates an understanding of the teaching? (Select all that apply)
A. "To assess cognitive ability, I should ask the client to count backward by
sevens."
B. "To assess affect, I should observe the client's facial expression."
C. "To assess language ability, I should instruct the client to write a
sentence."
D. "To assess remote memory, I should have the client repeat a list of
objects."
E. "To assess the client's abstract thinking, I should ask the client to identify
our most recent presidents." - -A. Counting backward by sevens is an
appropriate technique to assess a client's cognitive ability.
B. Observing a client's facial expression is appropriate when assessing affect.
C. Writing a sentence is an indication of language ability. Remote language is
tested by asking the client to state a fact from his past that his verifiable
(date of birth). Abstract thinking is tested by asking the client to interpret
something.
A nurse is planning care for a client who has a mental health disorder. Which
of the following actions should the nurse include as a psychobiological
intervention?
A. Assist the client with systematic desensitization therapy.
B. Teach the client appropriate coping mechanisms.
C. Assess the client for comorbid health conditions.
D. Monitor the client for adverse effects of the medications. - -D. Monitoring
for adverse effects of medications is an example of a psychobiological
intervention. Systematic desensitization is cognitive and behavioral.
Teaching coping mechanisms is a counseling or health teaching. Assessing
for comorbid conditions is health promotion and maintenance.
A nurse in an outpatient mental health clinic is preparing to conduct an initial
client interview. When conducting the interview, which of the following
actions should the nurse identify as the priority?
A. Coordinate holistic care with social services.
B. Identify the client's perception of her mental health status.
C. Include the client's family in the interview.
D. Teach the client about her current mental health disorder. - -B.
Assessment is the priority action. Identifying the client's perception of her
mental health status provides important information about the client's
psychosocial history.
,A nurse is told during change of shift report that a client is stuporous. When
assessing the client, which of the following findings should the nurse expect?
A. The client arouses briefly in response to a sternal rub.
B. The client has a glasgow coma scale score less than 7.
C. The client exhibits decorticate rigidity.
D. The client is alert but disoriented to time and place. - -A. A client who is
stuporous requires vigorous or painful stimuli to elicit a response. B & C
occur with comatose patients.
A nurse is planning a peer group discussion about the DSM-5. Which of the
following information is appropriate to include in the discussion? (Select all
that apply)
A. The DSM-5 includes client education handouts for mental health disorders.
B. The DSM-5 establishes diagnostic criteria for individual mental health
disorders.
C. The DSM-5 indicates recommended pharmacological treatment for mental
health disorders.
D. The DSM-5 assists nurses in planning care for client's who have mental
health disorders.
E. The DSM-5 indicates expected assessment findings of mental health
disorders. - -B, D, & E.
The DSM-5 establishes diagnostic criteria, assists nurses in planning care,
and identifies expected findings for mental health disorders. The DSM-5 does
not contain client education handouts or recommended pharmacological
treatment.
Beneficence - -The quality of doing good, can be described as charity
Autonomy - -The client's right to make their own decisions
Justice - -Fair and equal treatment for all
Fidelity - -Loyalty and faithfulness to the client and to one's duty
Veracity - -Honesty when dealing with a client
Requirements for restraining a patient - -Provider must prescribe the
restraint in writing; time limits are based on age, 4 hr for adults, 2 hr for
ages 9-17, 1 hr for age 8 and younger; must be reviewed every 24 hr;
documentation must be done every 15-30 min
False imprisonment - -Confining a client to a specific area if the reason for
such confinement is for the convenience of the staff
, Assault - -Making a threat to a client's person
Battery - -Touching a client in a harmful or offensive way
A nurse in an emergency mental health facility is caring for a group of
clients. The nurse should identify that which of the following clients requires
a temporary emergency admission?
A. A client who has schizophrenia with delusions of grandeur
B. A client who has manifestations of depression and attempted suicide a
year ago
C. A client who has borderline personality disorder and assaulted a homeless
man with a metal rod
D. A client who has bipolar disorder and paces quickly around the room while
talking to himself - -C. A client who is a current danger to self or others is a
candidate for a temporary emergency admission.
A nurse decides to put a client who has a psychotic disorder in seclusion
overnight because the unit is very short-staffed, and the client frequently
fights with other clients. The nurse's actions are an example of which of the
following torts?
A. Invasion of privacy
B. False imprisonment
C. Assault
D. Battery - -B. Secluding a client for the convenience of the staff is false
imprisonment.
A client tells a nurse, "Don't tell anyone but I hid a sharp knife under my
mattress in order to protect myself from my roommate, who is always yelling
at me and threatening me." Which of the following actions should the nurse
take?
A. Keep the client's communication confidential, but talk to the client daily,
using therapeutic communication to convince him to admit to hiding the
knife.
B. Keep the client's communication confidential, but watch the client and his
roommate closely.
C. Tell the client that this must be reported to the health care team because
it concerns the health and safety of the client and others.
D. Report the incident to the health care team, but do not inform the client of
the intention to do so. - -C. The information presented by the client is a
serious safety issue that the nurse must report to the health care team,
using the ethical principle of veracity.
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