ATI RN CAPSTONE MENTAL HEALTH PRE-ASSESSMENT
COMPREHENSIVE ASSESSMENT FORM A 2024/2025
COMPLETE QUESTIONS AND ANSWERS GUARANTEED
PASS | RATED A+
A nurse is assessing a parent who lost a 12-year-old child in a car crash 2 years ago. Which of the
following findings indicates the client is exhibiting manifestations of prolonged grieving?
a. Leaves the child's room exactly as it was before the loss.
b. Volunteers at a local children's hospital.
c. Talks about the child in the past tense.
d. Visits the child's grave every week after worship services. - Answer>>> a. Leaves the child's
room as it was before the loss.
Grieving becomes dysfunctional when the client is unable to resume regular activities of daily
living or experience emotions other than sadness or depression. An example of dysfunctional
grieving is making the loved one's room a shrine for more than a year.
The nurse is assessing the client for Chvostek's sign. Which of the following actions should the
nurse take?
a. Apply a BP cuff to the client's arm
b. Place a stethoscope bell over the client's carotid artery
c. Ask the client to lower their chin to their chest
d. Tap lightly on the client's cheek - Answer>>> d. Tap lightly on the client's cheek
Tap over the facial nerve just below and anterior to the ear to elicit Chvostek's sign.
A positive sign = Facial twitching on the side of the face
A nurse is planning care for a client following the insertion of a chest tube and drainage system.
Which of the following actions should be included in the place of care? SATA
a. Encourage the client to cough and deep breathe
b. Check for continuous bubbling in the suction chamber
c. Strip the chest tube drainage tubing every 4 hr
d. Clamp the chest tube once a day
e. Obtain a chest x-ray - Answer>>> a, b, e
,Cough and deep breathe = promotes oxygenation and lung re-expansion
Continuous bubbling in the suction chamber = suction is maintained
CXR = Chest tube placement
A nurse is caring for a client who has a chest tube and drainage system in place. The nurse
observes that the chest tube was accidentally removed. In what order should the nurse perform
the following actions?
a. Assess respiratory status
b. Apply sterile gauze to the insertion site
c. Obtain a CXR
d. Place tape around the insertion site - Answer>>> b, d, a, c
The greatest risk to the client is injury from air entering the pleural space and causing a tension
pneumothorax.
A nurse is assessing a client who has a chest tube and drainage system in place. Which of the
following are expected findings? SATA
a. Continuous bubbling in the water seal chamber
b. Gentle constant bubbling in the suction control chamber
c. Rise and fall in the level of water in the water seal chamber with inspiration and expiration
d. Exposure sutures without dressing
e. Drainage system upright at chest level - Answer>>> b, c
A nurse is assisting a client who has schizophrenia prepare a relapse plan. Which of the following
statements should the nurse make?
a. "You should be aware that excessive sleeping is an early sign of relapse."
b. "Relapse is an indication that you are not taking your medications properly."
c. "You should keep your provider's and therapist's number with you."
d. "Taking an additional dose of medication is appropriate as soon as signs of relapse appear." -
Answer>>> c. "You should keep your provider's and therapist's number with you."
The client should have a written plan, including important numbers, available at all times in case
relapse occurs.
A nurse in the emergency department is caring for a client experiencing alcohol intoxication.
, Which of the following interventions should the nurse plan to include? (SATA)
a. Contact the laboratory to obtain a blood sample.
b. Prepare the client for a CT scan.
c. Check the client's pupil reactivity.
d. Obtain a urine specimen.
e. Performa. developmental screening test. - Answer>>> a. Contact the laboratory to obtain a
blood sample - A blood sample allows for a blood alcohol level test to be performed.
b. Prepare the client for a CT scan - A CT scan or other neurological tests is performed to rule out
brain injury or head trauma.
c. Check the client's pupil reactivity - Checking for pupil reactivity provides information about a
client's neurological status.
d. Obtain a urine specimen - A urine specimen is needed to perform a urine toxicology screen.
The nurse is caring for a client who is extremely suspicious of the nursing staff and other clients.
Which of the following nursing approaches is appropriate when establishing a therapeutic
relationship with this client?
a. Disclose some personal information to the client to demonstrate approachability.
b. Wait for the client to initiate interaction.
c. Approach the client frequently throughout the day for brief interactions.
d. Adopt a neutral attitude when providing care. - Answer>>> d. Adopt a neutral attitude when
providing care.
To promote a therapeutic relationship, the nurse should use a neutral, nonthreatening attitude
during care and communication.
A nurse is teaching a female client who has anxiety disorder about alprazolam. Which of the
following information should the nurse include in the teaching?
a. "Use a reliable form of contraception while taking this medication."
b. "If a dose is missed, double the next dose of medication."
c. "This medication may increase your blood pressure."
COMPREHENSIVE ASSESSMENT FORM A 2024/2025
COMPLETE QUESTIONS AND ANSWERS GUARANTEED
PASS | RATED A+
A nurse is assessing a parent who lost a 12-year-old child in a car crash 2 years ago. Which of the
following findings indicates the client is exhibiting manifestations of prolonged grieving?
a. Leaves the child's room exactly as it was before the loss.
b. Volunteers at a local children's hospital.
c. Talks about the child in the past tense.
d. Visits the child's grave every week after worship services. - Answer>>> a. Leaves the child's
room as it was before the loss.
Grieving becomes dysfunctional when the client is unable to resume regular activities of daily
living or experience emotions other than sadness or depression. An example of dysfunctional
grieving is making the loved one's room a shrine for more than a year.
The nurse is assessing the client for Chvostek's sign. Which of the following actions should the
nurse take?
a. Apply a BP cuff to the client's arm
b. Place a stethoscope bell over the client's carotid artery
c. Ask the client to lower their chin to their chest
d. Tap lightly on the client's cheek - Answer>>> d. Tap lightly on the client's cheek
Tap over the facial nerve just below and anterior to the ear to elicit Chvostek's sign.
A positive sign = Facial twitching on the side of the face
A nurse is planning care for a client following the insertion of a chest tube and drainage system.
Which of the following actions should be included in the place of care? SATA
a. Encourage the client to cough and deep breathe
b. Check for continuous bubbling in the suction chamber
c. Strip the chest tube drainage tubing every 4 hr
d. Clamp the chest tube once a day
e. Obtain a chest x-ray - Answer>>> a, b, e
,Cough and deep breathe = promotes oxygenation and lung re-expansion
Continuous bubbling in the suction chamber = suction is maintained
CXR = Chest tube placement
A nurse is caring for a client who has a chest tube and drainage system in place. The nurse
observes that the chest tube was accidentally removed. In what order should the nurse perform
the following actions?
a. Assess respiratory status
b. Apply sterile gauze to the insertion site
c. Obtain a CXR
d. Place tape around the insertion site - Answer>>> b, d, a, c
The greatest risk to the client is injury from air entering the pleural space and causing a tension
pneumothorax.
A nurse is assessing a client who has a chest tube and drainage system in place. Which of the
following are expected findings? SATA
a. Continuous bubbling in the water seal chamber
b. Gentle constant bubbling in the suction control chamber
c. Rise and fall in the level of water in the water seal chamber with inspiration and expiration
d. Exposure sutures without dressing
e. Drainage system upright at chest level - Answer>>> b, c
A nurse is assisting a client who has schizophrenia prepare a relapse plan. Which of the following
statements should the nurse make?
a. "You should be aware that excessive sleeping is an early sign of relapse."
b. "Relapse is an indication that you are not taking your medications properly."
c. "You should keep your provider's and therapist's number with you."
d. "Taking an additional dose of medication is appropriate as soon as signs of relapse appear." -
Answer>>> c. "You should keep your provider's and therapist's number with you."
The client should have a written plan, including important numbers, available at all times in case
relapse occurs.
A nurse in the emergency department is caring for a client experiencing alcohol intoxication.
, Which of the following interventions should the nurse plan to include? (SATA)
a. Contact the laboratory to obtain a blood sample.
b. Prepare the client for a CT scan.
c. Check the client's pupil reactivity.
d. Obtain a urine specimen.
e. Performa. developmental screening test. - Answer>>> a. Contact the laboratory to obtain a
blood sample - A blood sample allows for a blood alcohol level test to be performed.
b. Prepare the client for a CT scan - A CT scan or other neurological tests is performed to rule out
brain injury or head trauma.
c. Check the client's pupil reactivity - Checking for pupil reactivity provides information about a
client's neurological status.
d. Obtain a urine specimen - A urine specimen is needed to perform a urine toxicology screen.
The nurse is caring for a client who is extremely suspicious of the nursing staff and other clients.
Which of the following nursing approaches is appropriate when establishing a therapeutic
relationship with this client?
a. Disclose some personal information to the client to demonstrate approachability.
b. Wait for the client to initiate interaction.
c. Approach the client frequently throughout the day for brief interactions.
d. Adopt a neutral attitude when providing care. - Answer>>> d. Adopt a neutral attitude when
providing care.
To promote a therapeutic relationship, the nurse should use a neutral, nonthreatening attitude
during care and communication.
A nurse is teaching a female client who has anxiety disorder about alprazolam. Which of the
following information should the nurse include in the teaching?
a. "Use a reliable form of contraception while taking this medication."
b. "If a dose is missed, double the next dose of medication."
c. "This medication may increase your blood pressure."
