ATI RN Mental Health Online Practice 2019
B
A nurse is assessing a family's dynamics during a counseling session. The nurse should
recognize which of the following findings as an indication of a boundary issues?
A. An adolescent family member who questions parental authority
B. A family with three generations in the same household
C. Older children who are responsible for their younger siblings
D. Two adults and their children from prior relationships in the same household - ANSCorrect: C
- This is an example of enmeshed boundaries in which there are no distinctions between the
roles of family members.
A - incorrect - An adolescent who questions parental authority is demonstrating appropriate
behaviors for developmental age
B - incorrect - This scenario occurs in many households, not indication of boundary issue
D. This is an example of a blended family, not indication of boundary issue
A nurse is performing an admission assessment on a client and notices that the client appears
withdrawn and fearful. To establish a trusting nurse=client relationship, which of the following
actions should the nurse take first?
A. Inform the client that this admission is confidential
B. Introduce the client to other clients in the day room
C. Assist the client in facilitating behavioral change
D. Determine coping strategies that the client used in the past - ANSA - CORRECt
- According to evidence-based practice, the nurse should first inform the client about
confidentiality during the orientation phase of the nurse-client relationship.
B - Incorrect The nurse should introduce the client to other clients in the day room to help the
client interact with others during the working phase of the nurse-client relationship. However,
evidence-based practice indicates that the nurse should take a different action first.
C. INCORRECT The nurse should assist the client with behavioral change during the working
phase of the nurse-client relationship. However, evidence-based practice indicates that the
nurse should take a different action first.
D. Incorrect The nurse should determine what coping strategies the client used in the past
during the working phase of the nurse-client relationship. However, evidence-based practice
indicates that the nurse should take a different action first.
,A nurse is performing a cognitive assessment to distinguish delirium form dementia in a client
whose family reports episodes of confusion. Which of the following assessment findings
supports the nurse's suspicion of delirium?
A. Slow onset
B. Aphasia
C. Confabulation
D. Easily distracted - ANSD - CORRECT
- Extreme distractibility is a hallmark manifestation of delirium.
A - INCORRECT
Delirium has an acute onset. Dementia is a slow, progressive decline.
B. INCORRECT
Aphasia is a manifestation of dementia
C. INCORRECT
Confabulation is a manifestation of dementia.
A nurse is caring for an older adult client who is experiencing delirium. Which of the following
interventions should the nurse include in the client's plan of care?
A. Offer the client various choices for meal selection
B. Assign different nursing personnel for each shift
C. Permit the client to perform daily rituals to decrease anxiety
D. Maintain an environment that has low lighting - ANSC - CORRECT
The nurse should provide a client who has delirium with a plan of care that decreases agitation
and anxiety by permitting the client to perform daily rituals.
A- INCORRECT
The nurse should provide a client who has delirium with a plan of care that decreases agitation
and anxiety by limiting the choices the client is asked to make.
B - The nurse should provide a client who has delirium with a plan of care that decreases
agitation and anxiety by providing consistent nursing personnel.
D - The nurse should provide a client who has delirium with a plan of care that decreases
agitation and anxiety by providing a well-lit environment.
A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which
of the following interventions should the nurse include in the plan of care?
A. Encourage the client to participate in group therapy
B. Instruct the client to avoid napping during the day
C. Offer the client high-calorie finger foods frequently
D. Decrease the client's daily fiber intake - ANSC - CORRECT
, The nurse should frequently offer the client high-calorie foods that can be eaten while the client
is on the go. Clients experiencing mania might be unable to sit down for meals and can
experience weight loss and dehydration.
A - INCORRECT
The nurse should maintain a low-stimuli environment for a client who is experiencing mania.
The nurse should dim the lights, decrease noise, and limit the number of people the client is
around.
B - The nurse should encourage the client to take frequent rest periods throughout the day.
Clients experiencing mania are at risk of exhaustion that can be life threatening.
D - The nurse should encourage the client to eat foods and snacks that are high in fiber. Clients
experiencing mania can experience dehydration and nutritional deficiencies from decreased
intake, which can lead to constipation.
A nurse is teaching the partner of a client who has bipolar disorder how to identify acute mania.
Which of the following findings should the client's partner report to the provider?
A. Obsessive attention to detail
B. Inability to sleep
C. Reports of fatigue
D. Isolation from others - ANSB - CORRECT
During acute mania, the client is extremely active and does not sleep, which can lead to
exhaustion. Therefore, the nurse should instruct the partner to report this finding
A - INCORRECT
During the manic phase of bipolar disorder, a client's behavior becomes disorganized and
chaotic, which renders the client unable to focus on detail.
C - INCORRECT
Although the client who is experiencing acute mania might eventually become exhausted, there
is a characteristic unawareness of fatigue during this phase.
D - INCORRECT
Clients who are in the manic phase of bipolar disorder often talk and joke incessantly and are
highly interactive.
A nurse is caring for a client who is experiencing a panic attack. Which of the following actions
should the nurse take?
A. Orient the client to person, place and time
B. Assist the client with deep-breathing exercises
C. Calm the client by using therapeutic touch
D. Have the client sit alone in a quiet room - ANSB - CORRECt
Relaxation techniques, such as deep, abdominal breathing exercises, help defuse
manifestations of anxiety.
B
A nurse is assessing a family's dynamics during a counseling session. The nurse should
recognize which of the following findings as an indication of a boundary issues?
A. An adolescent family member who questions parental authority
B. A family with three generations in the same household
C. Older children who are responsible for their younger siblings
D. Two adults and their children from prior relationships in the same household - ANSCorrect: C
- This is an example of enmeshed boundaries in which there are no distinctions between the
roles of family members.
A - incorrect - An adolescent who questions parental authority is demonstrating appropriate
behaviors for developmental age
B - incorrect - This scenario occurs in many households, not indication of boundary issue
D. This is an example of a blended family, not indication of boundary issue
A nurse is performing an admission assessment on a client and notices that the client appears
withdrawn and fearful. To establish a trusting nurse=client relationship, which of the following
actions should the nurse take first?
A. Inform the client that this admission is confidential
B. Introduce the client to other clients in the day room
C. Assist the client in facilitating behavioral change
D. Determine coping strategies that the client used in the past - ANSA - CORRECt
- According to evidence-based practice, the nurse should first inform the client about
confidentiality during the orientation phase of the nurse-client relationship.
B - Incorrect The nurse should introduce the client to other clients in the day room to help the
client interact with others during the working phase of the nurse-client relationship. However,
evidence-based practice indicates that the nurse should take a different action first.
C. INCORRECT The nurse should assist the client with behavioral change during the working
phase of the nurse-client relationship. However, evidence-based practice indicates that the
nurse should take a different action first.
D. Incorrect The nurse should determine what coping strategies the client used in the past
during the working phase of the nurse-client relationship. However, evidence-based practice
indicates that the nurse should take a different action first.
,A nurse is performing a cognitive assessment to distinguish delirium form dementia in a client
whose family reports episodes of confusion. Which of the following assessment findings
supports the nurse's suspicion of delirium?
A. Slow onset
B. Aphasia
C. Confabulation
D. Easily distracted - ANSD - CORRECT
- Extreme distractibility is a hallmark manifestation of delirium.
A - INCORRECT
Delirium has an acute onset. Dementia is a slow, progressive decline.
B. INCORRECT
Aphasia is a manifestation of dementia
C. INCORRECT
Confabulation is a manifestation of dementia.
A nurse is caring for an older adult client who is experiencing delirium. Which of the following
interventions should the nurse include in the client's plan of care?
A. Offer the client various choices for meal selection
B. Assign different nursing personnel for each shift
C. Permit the client to perform daily rituals to decrease anxiety
D. Maintain an environment that has low lighting - ANSC - CORRECT
The nurse should provide a client who has delirium with a plan of care that decreases agitation
and anxiety by permitting the client to perform daily rituals.
A- INCORRECT
The nurse should provide a client who has delirium with a plan of care that decreases agitation
and anxiety by limiting the choices the client is asked to make.
B - The nurse should provide a client who has delirium with a plan of care that decreases
agitation and anxiety by providing consistent nursing personnel.
D - The nurse should provide a client who has delirium with a plan of care that decreases
agitation and anxiety by providing a well-lit environment.
A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which
of the following interventions should the nurse include in the plan of care?
A. Encourage the client to participate in group therapy
B. Instruct the client to avoid napping during the day
C. Offer the client high-calorie finger foods frequently
D. Decrease the client's daily fiber intake - ANSC - CORRECT
, The nurse should frequently offer the client high-calorie foods that can be eaten while the client
is on the go. Clients experiencing mania might be unable to sit down for meals and can
experience weight loss and dehydration.
A - INCORRECT
The nurse should maintain a low-stimuli environment for a client who is experiencing mania.
The nurse should dim the lights, decrease noise, and limit the number of people the client is
around.
B - The nurse should encourage the client to take frequent rest periods throughout the day.
Clients experiencing mania are at risk of exhaustion that can be life threatening.
D - The nurse should encourage the client to eat foods and snacks that are high in fiber. Clients
experiencing mania can experience dehydration and nutritional deficiencies from decreased
intake, which can lead to constipation.
A nurse is teaching the partner of a client who has bipolar disorder how to identify acute mania.
Which of the following findings should the client's partner report to the provider?
A. Obsessive attention to detail
B. Inability to sleep
C. Reports of fatigue
D. Isolation from others - ANSB - CORRECT
During acute mania, the client is extremely active and does not sleep, which can lead to
exhaustion. Therefore, the nurse should instruct the partner to report this finding
A - INCORRECT
During the manic phase of bipolar disorder, a client's behavior becomes disorganized and
chaotic, which renders the client unable to focus on detail.
C - INCORRECT
Although the client who is experiencing acute mania might eventually become exhausted, there
is a characteristic unawareness of fatigue during this phase.
D - INCORRECT
Clients who are in the manic phase of bipolar disorder often talk and joke incessantly and are
highly interactive.
A nurse is caring for a client who is experiencing a panic attack. Which of the following actions
should the nurse take?
A. Orient the client to person, place and time
B. Assist the client with deep-breathing exercises
C. Calm the client by using therapeutic touch
D. Have the client sit alone in a quiet room - ANSB - CORRECt
Relaxation techniques, such as deep, abdominal breathing exercises, help defuse
manifestations of anxiety.
