2023/2024 ATI MENTAL HEALTH CMS EXAM REVIEW UPDATED (100% Correct answers)

LOC - ALERT (Correct Answer) - patient is responsive opens eyes spontaneously answers questions appropriately LOC - LETHARGIC (Correct Answer) - patient can open eyes and respond to questions falls asleep easily LOC - OBTUNDED (Correct Answer) - patient responds to light shaking is confused slow to respond LOC - STUPOROUS (Correct Answer) - patient barely responds to painful stimuli *example* rubbing sternum abnormal posturing may be present DECORTICATE POSTURING (Correct Answer) - arms flexed/internally rotated legs extended/internally rotated DECEREBRATE POSTURING (Correct Answer) - head arched back arms/legs extended AUTONOMY (Correct Answer) - patient has the right to make their own decisions even if not in their best interest BENEFICENCE (Correct Answer) - do what is best for the patient *do good* FIDELITY (Correct Answer) - keep your promises loyalty/faithfulness JUSTICE (Correct Answer) - provide fairness in care and allocation of resources NONMALEFICENCE (Correct Answer) - do no harm VERACITY (Correct Answer) - tell the truth PATIENT RIGHTS - REFUSAL OF TREATMENT (Correct Answer) - even patients who are involuntarily admitted have the right to refuse treatment PATIENT RIGHTS - CONFIDENTIALITY (Correct Answer) - HIPAA states that health information cannot be released without patient's permission client's right to privacy continues even after death CONFIDENTIALITY - NURSING ACTIONS (Correct Answer) - if someone calls to get an update, suggest they reach out to the patient's family if you overhear a conversation in a public space, take action to stop the violation PATIENT RIGHTS - MANDATORY REPORTING (Correct Answer) - nurses are required to report suspicion of abuse warn/protect third parties who are at risk for harm INFORMED CONSENT - PROVIDER RESPONSIBILITIES (Correct Answer) - communicate purpose of procedure 4 provide a complete description of procedure in patient's primary language (use interpreter if needed) explain risks vs. benefits describe other options to treat condition INFORMED CONSENT - NURSE/RN RESPONSIBILITIES (Correct Answer) - make sure provider gave patient appropriate information regarding procedure ensure that patient is competent to give informed consent have patient sign consent document notify provider if patient has more questions or doesn't understand information provided RESTRAINTS - TYPES (Correct Answer) - *Physical* - vest - belt - mitten *Chemical* - sedative Rx - antipsychotic Rx 5 RESTRAINTS - ALTERNATIVES (Correct Answer) - provide verbal interventions diversions calm/quiet environment RESTRAINTS - PRESCRIPTIONS (Correct Answer) - *MUST BE IN WRITING* prescription must be rewritten every 24 hours in an emergency situation, a nurse may use restraints, but must obtain a written prescription per facility policy (usually within 15-30 minutes) RESTRAINTS - TIME LIMITS (Correct Answer) - *Adults* 4 hours *Ages 9 - 17* 2 hours *Ages 8 and Under* 1 hour RESTRAINTS - DOCUMENTATION (Correct Answer) - complete every 15- 30 minutes *include the following:* - precipitating event - alternative interventions attempted - time treatment began - medication(s) administered - patient assessment (current behavior, VS, pain) - patient care provided (food, toileting) RESTRAINTS - DISCONTINUATION (Correct Answer) - restraints can be discontinued when patient can follow nurse's directions UNINTENTIONAL TORTS (Correct Answer) - *Negligence* forgetting to set bed alarm for a fall risk patient *Malpractice* medication error that harms patient INTENTIONAL TORTS (Correct Answer) - *Assault* nurse threatens patient *Battery* - nurse hits patient - gives Rx against patient's will *False Imprisonment* - nurse inappropriately restrains a patient - nurse administers a chemical restraint (Rx) INTRAPERSONAL COMMUNICATION (Correct Answer) - self-talk thinking thoughts, but not verbalizing them INTERPERSONAL COMMUNICATION (Correct Answer) - one-on-one communication with another person OPEN-ENDED QUESTIONS (Correct Answer) - promotes interactive discussion *example* "tell me more..." CLOSED-ENDED QUESTIONS (Correct Answer) - used to obtain specific data use sparingly as it can block communication *example" questions that can be answered with a "yes" or "no" RESTATING (Correct Answer) - repeat the patient's exact words REFLECTING (Correct Answer) - return focus back to the patient 8 PARAPHRASING (Correct Answer) - restate patient's feelings to confirm understanding of what patient is saying EXPLORING (Correct Answer) - gathering more information about something that patient mentioned GENERAL LEADS (Correct Answer) - allows patient to guide discussion PRESENTING REALITY (Correct Answer) - communicate what is actually happening dispel hallucinations/delusions/disbeliefs OFFERING SELF (Correct Answer) - limited self-disclosure by nurse return focus to the patient ASAP THERAPEUTIC COMMUNICATION - WRONG WAY (Correct Answer) - asking "why" questions offering your opinion giving false reassurance giving advice changing the subject minimizing the patient's feelings THERAPEUTIC COMMUNICATION - RIGHT WAY (Correct Answer) - asking open-ended questions maintaining eye contact to convey interest sitting/standing at eye level therapeutic touch to convey caring/provide comfort THERAPEUTIC COMMUNICATION - BEST PRACTICE FOR OLDER ADULTS (Correct Answer) - minimize distractions discuss health in private setting face patient when speaking use lower pitch voice begin interview by asking the patient to identify their needs/concerns limit number of items on questionnaire when gathering data allow plenty of time for patient to respond DEFENSE MECHANISM - ALTRUISM (Correct Answer) - dealing with stress/anxiety by helping others DEFENSE MECHANISM - SUBLIMATION (Correct Answer) - substitute negative impulses into acceptable forms of expression *example* working out hard at the gym DEFENSE MECHANISM - SUPRESSION (Correct Answer) - *voluntary* denial of unpleasant thoughts/feelings DEFENSE MECHANISM - REPRESSION (Correct Answer) - *unconscious* denial of unpleasant thoughts/feelings DEFENSE MECHANISM - REGRESSION (Correct Answer) - reverting back to childlike behaviors that are inappropriate for current level of development DEFENSE MECHANISM - DISPLACEMENT (Correct Answer) - redirecting feelings about a person/situation towards a less threatening object/person *example* dad loses job, destroys his child's toy DEFENSE MECHANISM - REACTION FORMATION (Correct Answer) - demonstrated the opposite behavior vs. what is actually felt *example* "I love nursing exams!" DEFENSE MECHANISM - UNDOING (Correct Answer) - performing an act to make up for prior behavior *example* bringing home flowers after domestic abuse DEFENSE MECHANISM - RATIONALIZATION (Correct Answer) - creating an acceptable excuse to justify an unacceptable behavior DEFENSE MECHANISM - DISSOCIATION (Correct Answer) - temporary compartmentalization of feelings/thoughts *example* forgetting who you are during sexual assault DEFENSE MECHANISM - DENIAL (Correct Answer) - pretending truth is not reality DEFENSE MECHANISM - COMPENSATION (Correct Answer) - emphasizing strengths to make up for weaknesses *example* physically disabled person excel academically 12 DEFENSE MECHANISM - IDENTIFICATION (Correct Answer) - adopting characteristics of another individual or group DEFENSE MECHANISM - INTELLECTUALIZATION (Correct Answer) - separation of feelings/emotions from logistical facts to facilitate coping DEFENSE MECHANISM - CONVERSION (Correct Answer) - unconscious development of physical symptoms as a response to stress DEFENSE MECHANISM - SPLITTING (Correct Answer) - inability to recognize positive *AND* negative attributes in others or self *example* "all or nothing" mentality "all good or all bad" DEFENSE MECHANISM - PROJECTION (Correct Answer) - attributing your own thoughts/feelings onto someone else who does not have those thoughts/feelings MILD ANXIETY (Correct Answer) - enhances an individual's perception promotes sharp focus of reality normal experience MILD ANXIETY - SYMPTOMS (Correct Answer) - alert restlessness irritibility fidgeting foot tapping MODERATE ANXIETY (Correct Answer) - slightly reduced perception slightly reduced ability to think MODERATE ANXIETY - SYMPTOMS (Correct Answer) - pacing difficulty concentrating increased RR increased HR SEVERE ANXIETY (Correct Answer) - perception greatly reduced *no ability to problem solve* SEVERE ANXIETY - SYMPTOMS (Correct Answer) - feeling of doom tachycardia hyperventilation rapid speech PANIC LEVEL ANXIETY (Correct Answer) - individual loses touch with reality disturbed behavior PANIC LEVEL ANXIETY - SYMPTOMS (Correct Answer) - dilated pupils hallucinations severe withdrawal severe shakiness MILD/MODERATE ANXIETY - NURSING INTERVENTIONS (Correct Answer) - active listening evaluate patient's past coping mechanisms assist patient with problem solving teach relaxation techniques - abdominal breathing exercises encourage exercise to reduce anxiety SEVERE/PANIC LEVEL ANXIETY - NURSING INTERVENTIONS (Correct Answer) - *provide a quiet environment with minimal stimulation* instruct client to take slow, deep breaths remain with patient set limits with short/simple statements help patient focus on reality *problem solving is NOT realistic at this level of anxiety* NONPHARMACOLOGIC STRESS REDUCTION THERAPY TECHNIQUES - MINDFULNESS (Correct Answer) - engages the insular cortex of the brain as the person focuses on the sensations and surroundings of the present moment client learns to stop the mind from wandering to multiple thoughts and worries client concentrates on a single thought that is important to them at that time 16 NONPHARMACOLOGIC STRESS REDUCTION THERAPY TECHNIQUES - GUIDED IMAGERY (Correct Answer) - allows a client to focus on pleasant mental images NONPHARMACOLOGIC STRESS REDUCTION THERAPY TECHNIQUES - PROGRESSIVE RELAXATION (Correct Answer) - focuses on tightening muscle groups to reduce muscle tension client focuses on the relaxation activity rather than the thoughts that contribute to stress THERAPEUTIC RELATIONSHIP - ORIENTATION PHASE (Correct Answer) - introduce self discuss confidentiality establish boundaries/expectations set the contract build trust and rapport THERAPEUTIC RELATIONSHIP - WORKING PHASE (Correct Answer) - perform ongoing assessments assist patient with problem solving and behavior changes evaluate coping strategies used by the patient in the past introduce patient to others on the unit revise goals/plans as needed support patient's use of new coping skills THERAPEUTIC RELATIONSHIP - TERMINATION PHASE (Correct Answer) - summarize goals and achievements discuss new coping strategies allow patient to share feelings about termination of relationship discuss ways for patient to incorporate new healthy behaviors into their life