NGN ATI Capstone Mental Health 2024/2025
A nurse in an acute care facility is assisting with the admission of an older adult
client who has late stage Alzheimer's disease. The nurse notes that the client's
partner appears exhausted. He states that he is finding it more and more difficult
to ...
A nurse in an acute care facility is assisting with the admission of an older adult
client who has late stage Alzheimer's disease. The nurse notes that the client's
partner appears exhausted. He states that he is finding it more and more difficult
to care for his partner. Which of the following actions should the nurse take first? -
CORRECT ANSWER Ask the partner to talk about his difficulties in caring for
the client.
A nurse is reinforcing teaching with a client about a new prescription for lithium.
Which of the following statements should the nurse include in the teaching? -
CORRECT ANSWER "We will need to check your lithium levels in the next 3 to 5
days."
Lithium is prescribed to treat bipolar disorder. The medications has a narrow
therapeutic range and establishing a therapeutic lithium level is an essential
component of care. It is recommended to check lithium levels within the first 5
days of beginning of treatment and possibly twice weekly until a maintenance
dosage has been reached. Lithium levels are checked about every 3 months during
maintenance therapy when lithium levels have stabilized.
A nurse is discussing comorbidities associated with eating disorders with a newly
licensed nurse. Which of the following comorbidities should the nurse include in
the discussion? SATA - CORRECT ANSWER - Anxiety
Anxiety is a comordid condition common in clients who have an eating disorder.
,-Obsessive-compulsive Disorder
OCD is a comorbid condition common in clients who have an eating disorder,
especially anorexia nervosa.
-Depression
Depression is a comorbid condition common in clients who have an eating
disorder.
A nurse is caring for a client who has been diagnosed with end-stage liver cancer.
Which of the following statements by the client indicates that the client is in the
denial phase of the grief process? - CORRECT ANSWER "The doctor says I only
have a few months to live, but I know he is exaggerating to get me to take my
medication."
The Five stages of Grief may not be experienced in order, and the length of each
stage will vary from person to person.
A nurse is discussing restraint with a newly licensed nurse. Which of the following
situations should the nurse identify as an acceptable indication for using restraints
for a client? - CORRECT ANSWER Continued self-destructive behavior
A nurse my use mechanical restraints for a client who presents a specific danger to
themselves or others. The nurse must follow all facility policies, such as
documentation of the behavior that led up to the use of restraints and other
interventions the staff used prior to the restraints.
A nurse is caring for a client whose wife died 6 months ago. For which of the
following findings should the nurse monitor to identify a maladaptive grieving
response? - CORRECT ANSWER Disturbed self-esteem
,A client who has disturbed self-esteem, such as feeling of worthlessness, is likely
having a maladaptive grieving response, which can precipitate depression.
A client who has a femur fracture states, "I cant stay in this bed any longer. I need
to get home so I can take care of my family." The nurse response by saying, "You
have talked about your family. Can you tell me more about your specific
concerns?" Which of the following therapeutic communications techniques is the
nurse using? - CORRECT ANSWER Focusing
The nurse's open-ended statement is a means of focusing on the problem and
obtaining more information about the client's concerns, which helps the nurse to
identify issues and concerns clearly.
A nurse is caring for a client who witnessed her brother's homicide and has post
traumatic stress disorder (PTSD). Which of the following findings should the nurse
expect? - CORRECT ANSWER The client is easily startled by loud voices.
A nurse is caring for a client who lost all his possessions in a house fire and states, "i have no idea what i
am going to do. I cannot even think right now". Which of the following actions should the nurse take?
Identify other housing options and sources of transportation.
Notify the facility chaplain to request scheduling an appointment.
Confirm that everything will be all right because belongings can be replaced.
Maintain eye contact with client and summarize the client's feelings. - CORRECT ANSWER Maintain eye
contact with client and summarize the client's feelings;
A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following actions
should the nurse take?
, Avoid the use of nonverbal gestures to prevent miscommunication.
Overlook the client's frustration with communication.
Inform the client about scheduled daily activities.
Present the client with multiple choices to promote autonomy. - CORRECT ANSWER Inform the client
about scheduled daily activities;
Discussing scheduled daily activities assists in orienting the client to time and reality throughout the day.
A nurse is caring for a client who has an anxiety disorder. Which of the following statements by the client
indicates successful use of guided imagery?
"I imagine my negative emotions consuming my thoughts."
"I imagine solving my problems over and over again."
"I imagine myself being overwhelmed during difficult times."
"I imagine myself lying on a beach when I start to feel stressed." - CORRECT ANSWER "I imagine myself
lying on a beach when I start to feel stressed.";
Envisioning oneself in a peaceful, calm environment enhances relaxation and is an example of using
guided imagery.
A nurse is assessing a toddler during a well child visit. Which of the following findings should the nurse
identify and report to the provider as an indication of physical maltreatment?
Several round burns on the soles of the feet
An abrasion on the elbow
Two bruises on the right shin in various stages of healing
A contusion on the forehead - CORRECT ANSWER Several round burns on the soles of the feet;
Although minor injuries are common in toddlers due to their general lack of coordination, the nurse
should identify that physical findings such as round burns on the soles of a child's feet can indicate
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