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VATI Mental Health Assessment Questions & Answers Updated Version with rationale
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VATI Mental Health Assessment Questions & AnswersUpdated Version with rationale
1. A nurse is planning care for a client following a suicide attempt. Which of the following
interventions should the nurse include in the plan?
- Provide the client with plastic eating utensils.
Rationale:
-The client can use glass dishes and metal silverware to cause self-harm, therefore, the nurse
should arrange for the client to have only plastic products on their meal tray.
2. A nurse is performing an admission assessment for a client who appears withdrawn and
fearful. Which of the following actions should the nurse take first?
- Inform the client that this admission is confidential.
Rationale:
-According to evidence-based practice, the nurse should first inform the client about
confidentiality during the orientation phase of the nurse client relationship. This action
establishes trust between the client and the nurse, which in turn decreases the client's anxiety
level.
3. A nurse is caring for an adolescent client who has anorexia nervosa. The client states, "Have I
done any permanent damage to my body?" Which of the following responses should the nurse
make?
- You're afraid you have caused physical injury to yourself?
Rationale:
-Repeating the main idea of what the client has said, which will allow for clarification of any
misunderstanding on the part of the client or the nurse.
4. A nurse is caring for a client following a fire that destroyed her home and killed one of her
children. The client is crying and does not make eye contact with the nurse. Which of the
following questions should the nurse ask first?
- Have you thought of harming yourself?
Rationale:
-The greatest risk to this client is self-harm due to the loss of her child and home, therefore, the
first question the nurse should ask a client who is having a personal crisis is to determine if the
client has suicidal ideation. If so, the nurse should take action to protect the client from self-
harm.
5. A nurse is checking laboratory values for a hospitalized young adult client who has bipolar
disorder and is taking lithium. Which of the following values is the priority for the nurse to
report to the provider?
- Serum creatinine 2.1 mg/dL
-Reference range of 0.5-1.2 mg/dL.
,Rationale:
The greatest risk to this client is decreased kidney function, which can cause an increase in the
client's lithium level; therefore, this value is the priority for the nurse to report to the provider.
The client’s lithium dosage might need to be modified based on this lab value. The cause of
increased serum creatinine include dehydration as well as renal disorders. Lithium is
contraindicated for clients who have severe renal disease, cardiac disease, or severe dehydration.
6. A nurse is providing information to a client who is seeking voluntary admission to a mental
health facility. Which of the following information should the nurse include?
- You will still need to give informed consent for treatment after admission.
Rationale:
-A client who seeks voluntary admission to a mental health facility has the same rights as clients
receiving any other kind of health care. The client will still need to give informed consent for
treatment and therapies, such as electroconvulsive therapy.
7. A nurse is developing a plan of care for an adolescent client who has conduct disorder. Which
of the following interventions should the nurse include in the plan?
- Initiate a behavioral contract with the client.
Rationale:
-A client who has conduct disorder can demonstrate patterns of behavior that are aggressive,
disrespectful of others’ rights, and can lead to injury of others. A behavioral contract helps to
develop trust between the client and the nurse and emphasizes the client's responsibility to
commit to work on changes in behavior.
8. A hospice nurse is talking with the family of a client who recently died from cancer following
a series of chemotherapy treatment. One of the adult children is angry with the provider and
blames the provider for their father's death. Which of the following defense mechanisms is the
family member using?
- Displacement
Rationale:
-When this family member uses displacement, they are transferring their feelings of anger to the
provider so they do not have to cope with their own feelings of sadness and loss.
9. A nurse in an acute care facility is providing teaching for the adult child of an older adult
client who is admitted with a urinary tract infection and delirium. The client has been living
independently at home. Which of the following statements by the adult child demonstrates the
teaching has been effective?
- I expect that my father will no longer be confused when he is discharged.
10.A nurse is caring for a client who is experiencing a manic episode. Which of the following
actions should the nurse take first?
- Encourage the client to rest each hour.
, Rationale:
-The greatest risk to this client is injury from exhaustion due to the manic phase, therefore, the
priority action the nurse should take is to encourage the client to rest for 3-5mins every hour.
11. A nurse is leading a medication education group for several clients. A client who is
sometimes violent becomes angry and begins yelling at others in the group. Which of the
following actions should the nurse take?
SATA - Move others away from the client.
Offer the client a PRN dose of lorazepam.
Ask the client open ended questions about the behavior.
Rationale:
-A large personal space should be maintained around the client who is angry. If the client's
behavior continues to escalate, the nurse should move others away from the client for their
safety.
-Antianxiety medication can be used in conjunction with de-escalation techniques to prevent a
violent episode.
-Communication technique is nonthreatening and encourages the client to express their feelings.
12. A charge nurse is planning an in-service for a group of newly licensed nurses about the use
of restraints. Which of the following information should the nurse include?
- Record the client's behavior every 15mins while in restraints.
Rationale:
-Complete a written record of the client's behavior every 15mins in the client's medical record
while in restraints. The client should be considered for reintegration when they are able to follow
commands and exhibit self-control of behavior.
13. A nurse is assessing a client who has bulimia nervosa. Which of the following findings
should the nurse expect?
- Dental caries
Rationale:
-Have dental caries and tooth erosion due to excessive exposure to stomach acid from frequent
vomiting.
14. A nurse is providing teaching to a client who has bipolar disorder and has been taking lithium
for 4 months. The client's serum lithium levels are within the therapeutic range. Which of the
following instructions should the nurse include to promote the maintenance of the therapeutic
lithium level?
- Limit outdoor exercise during hot weather.
Rationale:
-Spending time outdoors during hot weather, especially if exercising, promoting dehydration and
sodium loss through diuresis, which can increase lithium levels. Whenever the client exercises,
develops diarrhea, vomits, or has any circumstance that can cause dehydration, fluids and
electrolytes must be replaced promptly.
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