2026 ATI Capstone Mental Health Exam
2026 ATI Capstone Mental Health Exam 2
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A client in the critical care unit who has been oriented suddenly becomes disoriented and
fearful. Assessment of vital signs and other physical parameters reveals no significant
changes, and the nurse formulates the diagnosis of Confusion related to ICU psychosis. Which
intervention is best to implement based on this client's behavior?
A.Move all medical equipment away from the client's bedside.
B.Allay fears by teaching the client about the causes of the disease.
C.Cluster care to allow for brief rest periods during the day.
D.Encourage visitation by the client's family members, including the client's young children.
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2026 ATI Capstone Mental Health Exam
ANS: C
The best intervention is to organize care so that the client can experience rest periods (C).
The critical care unit contains many lifesaving treatment modalities that offer clients an array
of auditory, visual, and even painful stimuli. These stressors can result in isolation and
confusion. (A) is not practical because the client may need assistance from medical
equipment to survive. The client is too ill to receive teaching (B). Although (D) may be
supportive, young children are routinely prohibited from critical care units because of
increased risk of infectious disease transmission.
A client is admitted with a diagnosis of depression. Which of the following characteristics is
most indicative of depression?
A.Grandiose ideation
B.Self-destructive thoughts
C.Suspiciousness of others
D.Negative self-image
ANS: D
A negative self-image (D) is a specific indicator for depression. (A) occurs with paranoia or
paranoid ideation (C). (B) may be seen in depressed clients, but not always.
The nurse notes multiple burns on the arms and chest of a 2-year-old Vietnamese child who is
being treated for dehydration. When questioned, the child's father states that he treated the
child's vomiting with the cultural practice termed coining, which resulted in burned areas.
Which expected outcome statement has the highest priority?
A.The child will be protected from further harm.
B.The family's cultural values will be respected.
C.The parents will express regret at harming their child.
D.The parents will demonstrate an ability to care for burn wounds.
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2026 ATI Capstone Mental Health Exam
ANS: A
The nurse's highest priority is to ensure that no further harm befalls the child (A). (B, C, and D)
are also important objectives but are secondary to (A).
An 8-year-old child is seen in the clinic with a green vaginal discharge. Which action is most
important for the nurse to implement?
A.Assess the child's blood pressure.
B.Counsel the child to wear cotton underwear.
C.Report as suspected child abuse.
D.Determine if the child takes bubble baths.
ANS: C
A green vaginal discharge is indicative of gonorrhea, a sexually transmitted disease. Because
the child is 8 years old, the nurse should suspect child abuse and report the incident to the
proper authorities (C). (A) is usually not related to infection. (B and D) are helpful in
preventing bladder infections, but a green vaginal discharge is not a symptom of a bladder
infection.
A 38-year-old client is admitted with a diagnosis of paranoid schizophrenia. When the lunch
tray is brought to the room, the client refuses to eat and tells the nurse, "I know you are
trying to poison me with that food." Which response by the nurse is the most therapeutic?
A."I'll leave your tray here. I am available if you need anything else."
B."You're not being poisoned. Why do you think someone is trying to poison you?"
C."No one on this unit has ever died from poisoning. You're safe here."
D."I will talk to your health care provider about the possibility of changing your diet."
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2026 ATI Capstone Mental Health Exam
ANS: A
(A) is the best choice because the nurse does not argue with the client or demand that that
the client eat but offers support by agreeing to be there if needed, which provides an open,
rather than closed, response to the client's statement. (B and C) are challenging the client's
delusions, and (B) asks "why." Probing questions, which start with "why," are usually not
therapeutic communication for a psychotic client. (D) has not addressed the actual
problem—that is, the client's delusions.
A 22-year-old client is admitted to the psychiatric unit from the medical unit following a suicide
attempt with an overdose of diazepam (Valium). When developing the nursing care plan for
this client, which intervention would be most important for the nurse to include?
A.Assist client to focus on personal strengths.
B.Set limits on self-defacing comments.
C.Remind the client of daily activities in the milieu.
D.Assist the client to identify why he or she was self-destructive.
ANS: A
Encouraging the client to focus on his or her strengths (A) helps the client become aware of
positive qualities, assists in improving self-image, and aids in coping with past and present
situations. Although nursing actions should assist the client in decreasing self-defacing
comments (B) and informing the client of (C), these interventions are not priorities at this
time. (D) is not as important as assisting the client to overcome the depression, which
resulted in the overdose, and asking "why" is not therapeutic.
Which ego defense mechanism is exhibited by a client with a phobia related to refusal to
leave home?
A.Denial
B.Symbolization