,ATI RN MENTAL HEALTH * 2026/2027 EDITON * STUDY GUIDE
⩥ 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that the client appears withdrawn and fearful.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. Answer:
A - CORRECt
- According to evidence-based practice, the nurse should first inform the
client about confidentiality during the orientation phase of the
nurseclient 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. Answer: D - 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?
, ATI RN MENTAL HEALTH * 2026/2027 EDITON * STUDY GUIDE
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. Answer: C -
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.
⩥ 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. Answer:
A - CORRECt
- According to evidence-based practice, the nurse should first inform the
client about confidentiality during the orientation phase of the
nurseclient 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. Answer: D - 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?
, ATI RN MENTAL HEALTH * 2026/2027 EDITON * STUDY GUIDE
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. Answer: C -
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.
