ATI RN Mental Health Proctored-2019 (Questions
and Answers, Download for an A score)
1. A nurse is caring for a client who was voluntarily admitted for major depressive disorder.
The client states, "I want to leave right now. I don't need to be here." Which action should the
nurse take first?
A. Place the client on one-to-one observation
B. Notify the healthcare provider immediately
C. Inform the client of their right to request discharge and explain the process
D. Administer a PRN anxiolytic medication
Correct Answer: C
Rationale: Voluntarily admitted clients have the legal right to request discharge. The nurse's
first action is to acknowledge this right and explain the process, which typically involves the
provider evaluating whether the client meets criteria for continued involuntary hold. One-to-
one observation is only warranted if the client poses an imminent safety risk after assessment.
Medication is not indicated solely for requesting discharge.
2. A nurse is assessing a client using the SAD PERSONS scale. Which finding indicates
increased suicide risk?
A. The client is married
B. The client has diabetes mellitus
C. The client is 22 years old
D. The client reports adequate social support
Correct Answer: B
Rationale: The SAD PERSONS scale assesses suicide risk factors. "P" stands for Physical
illness, which includes chronic conditions such as diabetes mellitus. Other factors include Sex
(male), Age (elderly or adolescent), Depression, Previous attempts, Ethanol use, Rational
thinking loss, Social supports lacking, Organized plan, No spouse, and Sickness. Marriage and
adequate social support are protective factors.
3. A nurse is conducting a mental status examination. Which component involves assessing
the client's thought processes?
,A. Observing grooming and hygiene
B. Asking the client to describe their mood
C. Evaluating whether thoughts are logical and coherent
D. Testing recall of three objects after five minutes
Correct Answer: C
Rationale: Thought process assessment evaluates how the client thinks, including whether
thinking is logical, coherent, goal-directed, and free from loose associations, tangentiality, or
circumstantiality. Option A assesses appearance. Option B assesses mood and affect. Option D
assesses cognitive function and memory.
4. A nurse is implementing milieu therapy on an inpatient psychiatric unit. Which action best
demonstrates this principle?
A. Assigning identical schedules to all clients
B. Creating a therapeutic environment promoting safety, structure, and peer support
C. Restricting all personal belongings to prevent self-harm
D. Providing one-on-one therapy sessions daily for each client
Correct Answer: B
Rationale: Milieu therapy (therapeutic community) is a structured environment where
social, physical, and interpersonal aspects promote psychological healing. Key principles include
safety, structure, client involvement in decision-making, and peer support. Identical rigid
schedules do not account for individual needs. Restricting belongings and daily one-on-one
therapy are not core milieu therapy principles.
5. A nurse is assessing a client who is withdrawn and fearful. To establish a trusting nurse-
client relationship, which action 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 the client used previously
Correct Answer: A
Rationale: During the orientation phase, the nurse should first inform the client about
confidentiality to establish trust. Introducing clients to others, facilitating behavioral change,
,and determining past coping strategies occur during the working phase after trust has been
established.
6. A client with schizophrenia tells the nurse, "The CIA is using the television to send me
secret messages." The nurse should identify this as which type of delusion?
A. Somatic delusion
B. Delusion of persecution
C. Delusion of grandeur
D. Nihilistic delusion
Correct Answer: B
Rationale: A delusion of persecution is a fixed, false belief that one is being targeted,
harassed, or conspired against. This client believes the CIA is specifically targeting them. Somatic
delusions involve body functions. Grandiose delusions involve inflated self-importance. Nihilistic
delusions involve beliefs that self or others do not exist.
7. A nurse is caring for a client who requires seclusion due to violent behavior. According to
CMS regulations, how often must a provider conduct an in-person assessment of the client in
seclusion?
A. Within 15 minutes of initiation
B. Within 1 hour of initiation
C. Within 4 hours of initiation
D. Within 24 hours of initiation
Correct Answer: B
Rationale: CMS regulations require a provider or licensed independent practitioner to see
and evaluate the client in person within 1 hour of the initiation of seclusion or restraint.
Renewal orders are required every 4 hours for adults, every 2 hours for ages 9-17, and every 1
hour for children under 9.
8. A nurse is assessing a client from a different cultural background who avoids eye contact.
Which action is most appropriate?
, A. Ask the client why they will not make eye contact
B. Document the behavior as a sign of depression
C. Recognize that eye contact norms vary across cultures
D. Consult the psychiatrist to evaluate for autism spectrum disorder
Correct Answer: C
Rationale: Cultural competence requires recognizing that in many cultures, direct eye
contact is considered disrespectful, aggressive, or inappropriate, particularly with authority
figures. The nurse should recognize this as culturally normative rather than pathological.
Documenting it as a sign of depression without cultural context would be inaccurate.
9. A nurse is caring for a client who is being considered for involuntary commitment. Which
criteria must be met?
A. The client has a diagnosed mental illness and refuses medication
B. The client is a danger to self or others, or is unable to provide for basic needs
C. The client has been admitted voluntarily at least once before
D. The client's family has requested the commitment
Correct Answer: B
Rationale: Involuntary commitment requires clear and convincing evidence that the client
poses a danger to self or others, or is gravely disabled and unable to provide for basic needs. A
diagnosed mental illness alone does not justify involuntary commitment. Family requests do not
override the legal requirement that the client meets specific dangerousness criteria.
10. A nurse is discussing free association as a therapeutic tool with a client. Which client
statement indicates understanding of this technique?
A. "I will write down my dreams as soon as I wake up."
B. "I may begin to associate my therapist with important people in my life."
C. "I can learn to express myself in a nonaggressive manner."
D. "I should say the first thing that comes to my mind."
Correct Answer: D
Rationale: Free association involves the client spontaneously reporting feelings, thoughts,
and images as they come to mind without censorship. Writing down dreams is dream analysis.
and Answers, Download for an A score)
1. A nurse is caring for a client who was voluntarily admitted for major depressive disorder.
The client states, "I want to leave right now. I don't need to be here." Which action should the
nurse take first?
A. Place the client on one-to-one observation
B. Notify the healthcare provider immediately
C. Inform the client of their right to request discharge and explain the process
D. Administer a PRN anxiolytic medication
Correct Answer: C
Rationale: Voluntarily admitted clients have the legal right to request discharge. The nurse's
first action is to acknowledge this right and explain the process, which typically involves the
provider evaluating whether the client meets criteria for continued involuntary hold. One-to-
one observation is only warranted if the client poses an imminent safety risk after assessment.
Medication is not indicated solely for requesting discharge.
2. A nurse is assessing a client using the SAD PERSONS scale. Which finding indicates
increased suicide risk?
A. The client is married
B. The client has diabetes mellitus
C. The client is 22 years old
D. The client reports adequate social support
Correct Answer: B
Rationale: The SAD PERSONS scale assesses suicide risk factors. "P" stands for Physical
illness, which includes chronic conditions such as diabetes mellitus. Other factors include Sex
(male), Age (elderly or adolescent), Depression, Previous attempts, Ethanol use, Rational
thinking loss, Social supports lacking, Organized plan, No spouse, and Sickness. Marriage and
adequate social support are protective factors.
3. A nurse is conducting a mental status examination. Which component involves assessing
the client's thought processes?
,A. Observing grooming and hygiene
B. Asking the client to describe their mood
C. Evaluating whether thoughts are logical and coherent
D. Testing recall of three objects after five minutes
Correct Answer: C
Rationale: Thought process assessment evaluates how the client thinks, including whether
thinking is logical, coherent, goal-directed, and free from loose associations, tangentiality, or
circumstantiality. Option A assesses appearance. Option B assesses mood and affect. Option D
assesses cognitive function and memory.
4. A nurse is implementing milieu therapy on an inpatient psychiatric unit. Which action best
demonstrates this principle?
A. Assigning identical schedules to all clients
B. Creating a therapeutic environment promoting safety, structure, and peer support
C. Restricting all personal belongings to prevent self-harm
D. Providing one-on-one therapy sessions daily for each client
Correct Answer: B
Rationale: Milieu therapy (therapeutic community) is a structured environment where
social, physical, and interpersonal aspects promote psychological healing. Key principles include
safety, structure, client involvement in decision-making, and peer support. Identical rigid
schedules do not account for individual needs. Restricting belongings and daily one-on-one
therapy are not core milieu therapy principles.
5. A nurse is assessing a client who is withdrawn and fearful. To establish a trusting nurse-
client relationship, which action 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 the client used previously
Correct Answer: A
Rationale: During the orientation phase, the nurse should first inform the client about
confidentiality to establish trust. Introducing clients to others, facilitating behavioral change,
,and determining past coping strategies occur during the working phase after trust has been
established.
6. A client with schizophrenia tells the nurse, "The CIA is using the television to send me
secret messages." The nurse should identify this as which type of delusion?
A. Somatic delusion
B. Delusion of persecution
C. Delusion of grandeur
D. Nihilistic delusion
Correct Answer: B
Rationale: A delusion of persecution is a fixed, false belief that one is being targeted,
harassed, or conspired against. This client believes the CIA is specifically targeting them. Somatic
delusions involve body functions. Grandiose delusions involve inflated self-importance. Nihilistic
delusions involve beliefs that self or others do not exist.
7. A nurse is caring for a client who requires seclusion due to violent behavior. According to
CMS regulations, how often must a provider conduct an in-person assessment of the client in
seclusion?
A. Within 15 minutes of initiation
B. Within 1 hour of initiation
C. Within 4 hours of initiation
D. Within 24 hours of initiation
Correct Answer: B
Rationale: CMS regulations require a provider or licensed independent practitioner to see
and evaluate the client in person within 1 hour of the initiation of seclusion or restraint.
Renewal orders are required every 4 hours for adults, every 2 hours for ages 9-17, and every 1
hour for children under 9.
8. A nurse is assessing a client from a different cultural background who avoids eye contact.
Which action is most appropriate?
, A. Ask the client why they will not make eye contact
B. Document the behavior as a sign of depression
C. Recognize that eye contact norms vary across cultures
D. Consult the psychiatrist to evaluate for autism spectrum disorder
Correct Answer: C
Rationale: Cultural competence requires recognizing that in many cultures, direct eye
contact is considered disrespectful, aggressive, or inappropriate, particularly with authority
figures. The nurse should recognize this as culturally normative rather than pathological.
Documenting it as a sign of depression without cultural context would be inaccurate.
9. A nurse is caring for a client who is being considered for involuntary commitment. Which
criteria must be met?
A. The client has a diagnosed mental illness and refuses medication
B. The client is a danger to self or others, or is unable to provide for basic needs
C. The client has been admitted voluntarily at least once before
D. The client's family has requested the commitment
Correct Answer: B
Rationale: Involuntary commitment requires clear and convincing evidence that the client
poses a danger to self or others, or is gravely disabled and unable to provide for basic needs. A
diagnosed mental illness alone does not justify involuntary commitment. Family requests do not
override the legal requirement that the client meets specific dangerousness criteria.
10. A nurse is discussing free association as a therapeutic tool with a client. Which client
statement indicates understanding of this technique?
A. "I will write down my dreams as soon as I wake up."
B. "I may begin to associate my therapist with important people in my life."
C. "I can learn to express myself in a nonaggressive manner."
D. "I should say the first thing that comes to my mind."
Correct Answer: D
Rationale: Free association involves the client spontaneously reporting feelings, thoughts,
and images as they come to mind without censorship. Writing down dreams is dream analysis.
