ATI Mental Health Proctored Exam 2021(UPDATED
)(REVISED QUESTIONS AND ANSWERS)(A+
ANSWER KEY)
Section 1: Foundations of Mental Health Nursing & Legal/Ethical Concepts
1. A nurse is admitting a client who has schizophrenia. During the initial interview, the client
takes off his belt and screams, "A snake!" Which of the following responses is appropriate?
A. "You know that is your belt and not a snake, don't you?"
B. "This is your belt. I understand how this is scary for you."
C. "Your belt doesn't look like a snake."
D. "Why do you think your belt is a snake?"
Rationale: Option B is therapeutic because it presents reality (the belt) while acknowledging
the client's fear without reinforcing the delusion. Confronting the client (A), arguing about the
appearance (C), or asking "why" (D) may increase anxiety and defensiveness .
2. 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
Rationale: False imprisonment is the unjustified detention of a client. Seclusion requires a
provider's prescription, specific indications of imminent danger, and is never used for staff
convenience or understaffing. This action constitutes false imprisonment .
3. 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.
Rationale: The nurse must report any situation that poses a threat to the safety of the client
or others. The client's statement indicates a weapon is present and a potential for violence,
overriding confidentiality. Informing the client of the report maintains trust and transparency .
4. A nurse working in a mental health facility has just put a client in provider-prescribed
seclusion. Which of the following is the nurse required to document? (Select all that apply)
A. The client's behaviors that resulted in the need for seclusion
B. Previous interventions used to prevent the need for seclusion
C. The client's vital signs
D. The time the client entered seclusion
E. The client's feelings about being secluded
Rationale: Documentation for seclusion must include the precipitating behaviors, less
restrictive interventions attempted, vital signs (per protocol frequency), and the time seclusion
began. The client's feelings are important for care but not a required legal documentation
element .
5. 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.
Rationale: Stupor is a state of near-unconsciousness in which the client responds only to
vigorous or painful stimuli, such as a sternal rub. A GCS less than 7 indicates coma, decorticate
rigidity indicates severe brain damage, and being alert but disoriented describes delirium, not
stupor .
,6. 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
Rationale: Emergency admission is indicated when a client poses an imminent danger to
self or others. Assaulting another person with a weapon demonstrates dangerousness to others
requiring immediate intervention. The other clients may need treatment but do not present an
immediate safety emergency .
7. A charge nurse is discussing mental status examinations 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."
Rationale: Counting backward by sevens assesses cognitive ability and calculation.
Observing facial expression assesses affect. Writing a sentence assesses language ability.
Repeating objects assesses immediate memory, not remote. Naming presidents assesses fund
of knowledge, not abstract thinking .
8. 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.
, Rationale: Psychobiological interventions focus on the biological and pharmacological
aspects of mental health care. Monitoring for medication adverse effects is a psychobiological
nursing intervention. Systematic desensitization and teaching coping mechanisms are
psychotherapeutic interventions .
9. 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 clients who have mental health disorders.
E. The DSM-5 indicates expected assessment findings of mental health disorders.
Rationale: The DSM-5 provides diagnostic criteria, expected assessment findings, and is
used for care planning. It does not include client education handouts or recommend specific
pharmacological treatments .
10. A nurse is caring for a client who is in mechanical restraints. Which of the following
statements should the nurse include in the documentation? (Select all that apply)
A. "Client ate most of his breakfast."
B. "Client was offered 8 oz of water every hr."
C. "Client shouted obscenities at assistive personnel."
D. "Client received chlorpromazine 15 mg by mouth at 1000."
E. "Client acted out after lunch."
Rationale: Documentation during restraints must include objective, specific information:
fluid offered, specific behaviors observed (not vague terms like "acted out"), and medications
administered. "Ate most of breakfast" is not specific to restraint monitoring .
11. A nurse is caring for a client who has borderline personality disorder. The client says, "The
nurse on the evening shift is always nice! You are the meanest nurse ever!" The nurse should
recognize the client's statement as an example of which of the following defense
mechanisms?
)(REVISED QUESTIONS AND ANSWERS)(A+
ANSWER KEY)
Section 1: Foundations of Mental Health Nursing & Legal/Ethical Concepts
1. A nurse is admitting a client who has schizophrenia. During the initial interview, the client
takes off his belt and screams, "A snake!" Which of the following responses is appropriate?
A. "You know that is your belt and not a snake, don't you?"
B. "This is your belt. I understand how this is scary for you."
C. "Your belt doesn't look like a snake."
D. "Why do you think your belt is a snake?"
Rationale: Option B is therapeutic because it presents reality (the belt) while acknowledging
the client's fear without reinforcing the delusion. Confronting the client (A), arguing about the
appearance (C), or asking "why" (D) may increase anxiety and defensiveness .
2. 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
Rationale: False imprisonment is the unjustified detention of a client. Seclusion requires a
provider's prescription, specific indications of imminent danger, and is never used for staff
convenience or understaffing. This action constitutes false imprisonment .
3. 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.
Rationale: The nurse must report any situation that poses a threat to the safety of the client
or others. The client's statement indicates a weapon is present and a potential for violence,
overriding confidentiality. Informing the client of the report maintains trust and transparency .
4. A nurse working in a mental health facility has just put a client in provider-prescribed
seclusion. Which of the following is the nurse required to document? (Select all that apply)
A. The client's behaviors that resulted in the need for seclusion
B. Previous interventions used to prevent the need for seclusion
C. The client's vital signs
D. The time the client entered seclusion
E. The client's feelings about being secluded
Rationale: Documentation for seclusion must include the precipitating behaviors, less
restrictive interventions attempted, vital signs (per protocol frequency), and the time seclusion
began. The client's feelings are important for care but not a required legal documentation
element .
5. 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.
Rationale: Stupor is a state of near-unconsciousness in which the client responds only to
vigorous or painful stimuli, such as a sternal rub. A GCS less than 7 indicates coma, decorticate
rigidity indicates severe brain damage, and being alert but disoriented describes delirium, not
stupor .
,6. 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
Rationale: Emergency admission is indicated when a client poses an imminent danger to
self or others. Assaulting another person with a weapon demonstrates dangerousness to others
requiring immediate intervention. The other clients may need treatment but do not present an
immediate safety emergency .
7. A charge nurse is discussing mental status examinations 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."
Rationale: Counting backward by sevens assesses cognitive ability and calculation.
Observing facial expression assesses affect. Writing a sentence assesses language ability.
Repeating objects assesses immediate memory, not remote. Naming presidents assesses fund
of knowledge, not abstract thinking .
8. 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.
, Rationale: Psychobiological interventions focus on the biological and pharmacological
aspects of mental health care. Monitoring for medication adverse effects is a psychobiological
nursing intervention. Systematic desensitization and teaching coping mechanisms are
psychotherapeutic interventions .
9. 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 clients who have mental health disorders.
E. The DSM-5 indicates expected assessment findings of mental health disorders.
Rationale: The DSM-5 provides diagnostic criteria, expected assessment findings, and is
used for care planning. It does not include client education handouts or recommend specific
pharmacological treatments .
10. A nurse is caring for a client who is in mechanical restraints. Which of the following
statements should the nurse include in the documentation? (Select all that apply)
A. "Client ate most of his breakfast."
B. "Client was offered 8 oz of water every hr."
C. "Client shouted obscenities at assistive personnel."
D. "Client received chlorpromazine 15 mg by mouth at 1000."
E. "Client acted out after lunch."
Rationale: Documentation during restraints must include objective, specific information:
fluid offered, specific behaviors observed (not vague terms like "acted out"), and medications
administered. "Ate most of breakfast" is not specific to restraint monitoring .
11. A nurse is caring for a client who has borderline personality disorder. The client says, "The
nurse on the evening shift is always nice! You are the meanest nurse ever!" The nurse should
recognize the client's statement as an example of which of the following defense
mechanisms?
