ATI MENTAL HEALTH CMS EXAM
VERSION C 90 Actual Exam
Questions with Detailed Answers &
Rationales
**Question 1**
A patient with major depressive disorder sits in a corner, head down, and does not speak. Which nursing
response is most therapeutic?
A. "Why won't you talk to me?"
,B. "You'll feel better if you join the group activity."
C. **"I'll sit with you for a while. You don't have to talk."**
D. "If you don't participate, you won't get better."
**Rationale:** Offering presence without pressure conveys acceptance and allows the patient to
engage when ready. Asking "why" can be probing and judgmental. Forcing participation or making
threats is non-therapeutic; silence and presence are powerful tools in establishing trust .
**Question 2**
A nurse is caring for a patient who repeatedly asks for pain medication despite no physiological need.
The nurse feels frustrated. What should the nurse do first?
A. Tell the patient to stop asking.
B. **Explore the meaning of the behavior with the patient.**
C. Ignore the requests.
D. Administer a placebo.
**Rationale:** Exploring the meaning helps identify underlying emotional needs (e.g., anxiety,
loneliness). The nurse should also process personal feelings in clinical supervision to avoid
countertransference. Placebos are unethical without informed consent .
**Question 3**
A patient says, "I'm a burden to everyone." Which response by the nurse best demonstrates active
listening?
A. "You shouldn't feel that way."
B. **"It sounds like you're feeling as though you don't matter to others."**
C. "Why do you think you're a burden?"
D. "Let's talk about something more positive."
,**Rationale:** Reflecting feelings validates the patient's experience and encourages further expression.
Option A dismisses feelings, C is probing, and D changes the subject. Active listening involves
paraphrasing and reflecting emotions .
**Question 4**
A patient with a history of violence is pacing and clenching his fists. Which de-escalation technique
should the nurse use first?
A. Call security to restrain the patient.
B. Offer PRN medication immediately.
C. **Use a calm voice, acknowledge the patient's feelings, and offer choices.**
D. Tell the patient to go to his room.
**Rationale:** Early de-escalation includes maintaining a calm demeanor, acknowledging feelings, and
giving the patient a sense of control through choices. Physical intervention and medications are used if
verbal techniques fail. Direct commands may escalate anger .
**Question 5**
A patient experiencing panic-level anxiety is pacing and unable to focus. The priority nursing
intervention is:
A. Teach the patient coping skills.
B. **Remain with the patient and provide a quiet environment.**
C. Ask the patient to describe what is happening.
D. Encourage the patient to join a group activity.
**Rationale:** During panic-level anxiety, the patient cannot process complex information or learn new
skills. The nurse should provide safety through presence and reduce external stimuli. The patient cannot
problem-solve or attend groups until anxiety decreases .
**Question 6**
, A patient who is involuntarily admitted asks about their rights. The nurse should inform the patient that
they have the right to:
A. Leave the hospital at any time.
B. **Refuse treatment (in some cases), communicate with others, and have legal representation.**
C. No rights while hospitalized.
D. Only receive medication.
**Rationale:** Involuntary commitment does not strip a patient of all rights. Patients retain the right to
refuse treatment (unless an emergency or court-ordered), communicate with counsel, send/receive
mail, and be treated in the least restrictive environment .
**Question 7**
A patient tells the nurse, "I have a secret, but you must promise not to tell anyone." What is the nurse's
best response?
A. "I promise I won't tell."
B. **"I can't make that promise. If the information relates to harm to yourself or others, I must share it
to keep you safe."**
C. "Just tell me; I'll decide if it needs to be shared."
D. "You shouldn't keep secrets in therapy."
**Rationale:** The nurse must be honest about the limits of confidentiality (duty to warn and protect).
Making a false promise erodes trust and violates ethical/legal obligations. Patients have a right to know
the limits before disclosing .
**Question 8**
A patient with borderline personality disorder frequently calls the nurse a "hero" then later says the
nurse is "useless." The nurse recognizes this as:
A. Projection
B. **Splitting**
VERSION C 90 Actual Exam
Questions with Detailed Answers &
Rationales
**Question 1**
A patient with major depressive disorder sits in a corner, head down, and does not speak. Which nursing
response is most therapeutic?
A. "Why won't you talk to me?"
,B. "You'll feel better if you join the group activity."
C. **"I'll sit with you for a while. You don't have to talk."**
D. "If you don't participate, you won't get better."
**Rationale:** Offering presence without pressure conveys acceptance and allows the patient to
engage when ready. Asking "why" can be probing and judgmental. Forcing participation or making
threats is non-therapeutic; silence and presence are powerful tools in establishing trust .
**Question 2**
A nurse is caring for a patient who repeatedly asks for pain medication despite no physiological need.
The nurse feels frustrated. What should the nurse do first?
A. Tell the patient to stop asking.
B. **Explore the meaning of the behavior with the patient.**
C. Ignore the requests.
D. Administer a placebo.
**Rationale:** Exploring the meaning helps identify underlying emotional needs (e.g., anxiety,
loneliness). The nurse should also process personal feelings in clinical supervision to avoid
countertransference. Placebos are unethical without informed consent .
**Question 3**
A patient says, "I'm a burden to everyone." Which response by the nurse best demonstrates active
listening?
A. "You shouldn't feel that way."
B. **"It sounds like you're feeling as though you don't matter to others."**
C. "Why do you think you're a burden?"
D. "Let's talk about something more positive."
,**Rationale:** Reflecting feelings validates the patient's experience and encourages further expression.
Option A dismisses feelings, C is probing, and D changes the subject. Active listening involves
paraphrasing and reflecting emotions .
**Question 4**
A patient with a history of violence is pacing and clenching his fists. Which de-escalation technique
should the nurse use first?
A. Call security to restrain the patient.
B. Offer PRN medication immediately.
C. **Use a calm voice, acknowledge the patient's feelings, and offer choices.**
D. Tell the patient to go to his room.
**Rationale:** Early de-escalation includes maintaining a calm demeanor, acknowledging feelings, and
giving the patient a sense of control through choices. Physical intervention and medications are used if
verbal techniques fail. Direct commands may escalate anger .
**Question 5**
A patient experiencing panic-level anxiety is pacing and unable to focus. The priority nursing
intervention is:
A. Teach the patient coping skills.
B. **Remain with the patient and provide a quiet environment.**
C. Ask the patient to describe what is happening.
D. Encourage the patient to join a group activity.
**Rationale:** During panic-level anxiety, the patient cannot process complex information or learn new
skills. The nurse should provide safety through presence and reduce external stimuli. The patient cannot
problem-solve or attend groups until anxiety decreases .
**Question 6**
, A patient who is involuntarily admitted asks about their rights. The nurse should inform the patient that
they have the right to:
A. Leave the hospital at any time.
B. **Refuse treatment (in some cases), communicate with others, and have legal representation.**
C. No rights while hospitalized.
D. Only receive medication.
**Rationale:** Involuntary commitment does not strip a patient of all rights. Patients retain the right to
refuse treatment (unless an emergency or court-ordered), communicate with counsel, send/receive
mail, and be treated in the least restrictive environment .
**Question 7**
A patient tells the nurse, "I have a secret, but you must promise not to tell anyone." What is the nurse's
best response?
A. "I promise I won't tell."
B. **"I can't make that promise. If the information relates to harm to yourself or others, I must share it
to keep you safe."**
C. "Just tell me; I'll decide if it needs to be shared."
D. "You shouldn't keep secrets in therapy."
**Rationale:** The nurse must be honest about the limits of confidentiality (duty to warn and protect).
Making a false promise erodes trust and violates ethical/legal obligations. Patients have a right to know
the limits before disclosing .
**Question 8**
A patient with borderline personality disorder frequently calls the nurse a "hero" then later says the
nurse is "useless." The nurse recognizes this as:
A. Projection
B. **Splitting**
