ATI Mental Health Proctored
Exam 2019 (Answers)
1. A nurse is performing a mental status examination on an older adult client who has
dementia. Which of the following questions should the nurse ask to assess the client's remote
memory?
A) "What did you eat for breakfast this morning?"
B) "What year did you graduate from high school?"
C) "Can you count backward from 100 by sevens?"
D) "Do you know where you are right now?"
Correct Answer: B
Rationale: Remote memory refers to the ability to recall distant past events. Asking about
high school graduation assesses long-term memory. Current breakfast assesses recent memory;
counting backward assesses attention and calculation; orientation to place assesses
orientation .
2. A nurse is caring for a client who has borderline personality disorder. The nurse finds the
client cutting into their flesh with a paperclip. Which of the following actions should the nurse
take first?
A) Identify the client's feelings that led to the self-injurious behavior
B) Administer a PRN anti-anxiety medication
C) Place the client in seclusion
D) Notify the provider
Correct Answer: A
Rationale: The nursing process priority framework requires assessment before intervention.
Before formulating a plan or implementing an intervention, the nurse must first collect data by
identifying the client's feelings that led to the behavior .
,3. A nurse is caring for a client whose child has a terminal illness. The client requests
information about how to deal with the upcoming loss. Which of the following statements
should the nurse make?
A) "It will be better for you to keep busy to avoid thinking about your child's death."
B) "You will complete the grieving process about a year after your child's death."
C) "The grief process will start once your child actually dies."
D) "It is not uncommon to feel angry toward yourself or others."
Correct Answer: D
Rationale: Feelings of blame and anger toward oneself or others are expected reactions
during anticipatory grief. This therapeutic response validates the client's experience without
minimizing or prescribing a timeline .
4. A nurse is talking with a client about their admission to a mental health unit. The client
states, "I just don't know if I should be here. What will my family think?" Which of the
following responses by the nurse uses the therapeutic communication technique of
reflection?
A) "It sounds like you are concerned about your family's opinion."
B) "You should focus on your own recovery right now."
C) "What do you think your family will say?"
D) "Families often have difficulty understanding mental illness."
Correct Answer: A
Rationale: Reflection directs the client's feelings, questions, or content back to the client for
consideration. The nurse restates the client's expressed concern about family perception,
encouraging further exploration .
5. A nurse is communicating with a client who states, "I can't sleep. I stay up all night." The
nurse responds, "You are having difficulty sleeping?" Which therapeutic communication
technique is the nurse demonstrating?
A) Offering general leads
B) Summarizing
C) Focusing
D) Restating
, Correct Answer: D
Rationale: Restating is repeating the main idea expressed by the client back to them, which
enhances understanding and lets the client know the nurse is listening .
6. A nurse is caring for a client who is experiencing moderate anxiety. Which of the following
findings should the nurse expect?
A) The client has difficulty concentrating
B) The client has a heightened perceptual field
C) The client is unable to learn new information
D) The client does not respond to redirection
Correct Answer: A
Rationale: Moderate anxiety causes a narrowed perceptual field, difficulty concentrating,
and increased heart and respiratory rates. Severe and panic-level anxiety result in inability to
learn and failure to respond to redirection .
7. A nurse is providing preoperative teaching for a client who was just informed of the need
for emergency surgery. The client has a respiratory rate of 30/min and states, "This is difficult
to comprehend. I feel shaky and nervous." The nurse should identify that the client is
experiencing which level of anxiety?
A) Mild
B) Moderate
C) Severe
D) Panic
Correct Answer: B
Rationale: Moderate anxiety manifests with increased heart and respiratory rates, difficulty
concentrating, and subjective feelings of nervousness. The client's ability to speak and
acknowledge difficulty concentrating is consistent with moderate, not severe, anxiety .
8. A charge nurse is discussing mental status examinations with a newly licensed nurse. Which
of the following statements by the newly licensed nurse indicate 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 ask the client to name common objects."
D) "To assess remote memory, I should ask what the client ate for breakfast."
E) "To assess judgment, I should ask the client to interpret a proverb."
Correct Answers: A, B, C
Rationale: Counting backward by sevens assesses cognitive ability/attention. Observing
facial expression assesses affect. Naming objects assesses language. Asking about breakfast
assesses recent (not remote) memory, and interpreting proverbs assesses abstract thinking (not
judgment) .
9. A nurse is caring for a client who has a new diagnosis of colon cancer. Shortly after
receiving the diagnosis, the client begins yelling, "I have received terrible care here and no
one cares about me." The nurse should recognize that the client is demonstrating which
defense mechanism?
A) Denial
B) Displacement
C) Projection
D) Reaction formation
Correct Answer: B
Rationale: Displacement is the redirection of thoughts, feelings, and impulses from an
object that causes anxiety to a safer, more acceptable one. The client is redirecting anxiety
about the cancer diagnosis onto the staff .
10. A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm
coughing because I have that cold that everyone has been getting." The nurse should identify
that the client is using which defense mechanism?
A) Reaction formation
B) Denial
C) Displacement
D) Sublimation
Correct Answer: B
Exam 2019 (Answers)
1. A nurse is performing a mental status examination on an older adult client who has
dementia. Which of the following questions should the nurse ask to assess the client's remote
memory?
A) "What did you eat for breakfast this morning?"
B) "What year did you graduate from high school?"
C) "Can you count backward from 100 by sevens?"
D) "Do you know where you are right now?"
Correct Answer: B
Rationale: Remote memory refers to the ability to recall distant past events. Asking about
high school graduation assesses long-term memory. Current breakfast assesses recent memory;
counting backward assesses attention and calculation; orientation to place assesses
orientation .
2. A nurse is caring for a client who has borderline personality disorder. The nurse finds the
client cutting into their flesh with a paperclip. Which of the following actions should the nurse
take first?
A) Identify the client's feelings that led to the self-injurious behavior
B) Administer a PRN anti-anxiety medication
C) Place the client in seclusion
D) Notify the provider
Correct Answer: A
Rationale: The nursing process priority framework requires assessment before intervention.
Before formulating a plan or implementing an intervention, the nurse must first collect data by
identifying the client's feelings that led to the behavior .
,3. A nurse is caring for a client whose child has a terminal illness. The client requests
information about how to deal with the upcoming loss. Which of the following statements
should the nurse make?
A) "It will be better for you to keep busy to avoid thinking about your child's death."
B) "You will complete the grieving process about a year after your child's death."
C) "The grief process will start once your child actually dies."
D) "It is not uncommon to feel angry toward yourself or others."
Correct Answer: D
Rationale: Feelings of blame and anger toward oneself or others are expected reactions
during anticipatory grief. This therapeutic response validates the client's experience without
minimizing or prescribing a timeline .
4. A nurse is talking with a client about their admission to a mental health unit. The client
states, "I just don't know if I should be here. What will my family think?" Which of the
following responses by the nurse uses the therapeutic communication technique of
reflection?
A) "It sounds like you are concerned about your family's opinion."
B) "You should focus on your own recovery right now."
C) "What do you think your family will say?"
D) "Families often have difficulty understanding mental illness."
Correct Answer: A
Rationale: Reflection directs the client's feelings, questions, or content back to the client for
consideration. The nurse restates the client's expressed concern about family perception,
encouraging further exploration .
5. A nurse is communicating with a client who states, "I can't sleep. I stay up all night." The
nurse responds, "You are having difficulty sleeping?" Which therapeutic communication
technique is the nurse demonstrating?
A) Offering general leads
B) Summarizing
C) Focusing
D) Restating
, Correct Answer: D
Rationale: Restating is repeating the main idea expressed by the client back to them, which
enhances understanding and lets the client know the nurse is listening .
6. A nurse is caring for a client who is experiencing moderate anxiety. Which of the following
findings should the nurse expect?
A) The client has difficulty concentrating
B) The client has a heightened perceptual field
C) The client is unable to learn new information
D) The client does not respond to redirection
Correct Answer: A
Rationale: Moderate anxiety causes a narrowed perceptual field, difficulty concentrating,
and increased heart and respiratory rates. Severe and panic-level anxiety result in inability to
learn and failure to respond to redirection .
7. A nurse is providing preoperative teaching for a client who was just informed of the need
for emergency surgery. The client has a respiratory rate of 30/min and states, "This is difficult
to comprehend. I feel shaky and nervous." The nurse should identify that the client is
experiencing which level of anxiety?
A) Mild
B) Moderate
C) Severe
D) Panic
Correct Answer: B
Rationale: Moderate anxiety manifests with increased heart and respiratory rates, difficulty
concentrating, and subjective feelings of nervousness. The client's ability to speak and
acknowledge difficulty concentrating is consistent with moderate, not severe, anxiety .
8. A charge nurse is discussing mental status examinations with a newly licensed nurse. Which
of the following statements by the newly licensed nurse indicate 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 ask the client to name common objects."
D) "To assess remote memory, I should ask what the client ate for breakfast."
E) "To assess judgment, I should ask the client to interpret a proverb."
Correct Answers: A, B, C
Rationale: Counting backward by sevens assesses cognitive ability/attention. Observing
facial expression assesses affect. Naming objects assesses language. Asking about breakfast
assesses recent (not remote) memory, and interpreting proverbs assesses abstract thinking (not
judgment) .
9. A nurse is caring for a client who has a new diagnosis of colon cancer. Shortly after
receiving the diagnosis, the client begins yelling, "I have received terrible care here and no
one cares about me." The nurse should recognize that the client is demonstrating which
defense mechanism?
A) Denial
B) Displacement
C) Projection
D) Reaction formation
Correct Answer: B
Rationale: Displacement is the redirection of thoughts, feelings, and impulses from an
object that causes anxiety to a safer, more acceptable one. The client is redirecting anxiety
about the cancer diagnosis onto the staff .
10. A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm
coughing because I have that cold that everyone has been getting." The nurse should identify
that the client is using which defense mechanism?
A) Reaction formation
B) Denial
C) Displacement
D) Sublimation
Correct Answer: B
