ATI CMS EXAM REVIEW - MENTAL HEALTH
Study online at https://quizlet.com/_68mi41
1. LOC - ALERT: patient is responsive
opens eyes spontaneously
answers questions appropriately
2. LOC - LETHARGIC: patient can open eyes and respond to questions
falls asleep easily
3. LOC - OBTUNDED: patient responds to light shaking
is confused
slow to respond
4. LOC - STUPOROUS: patient barely responds to painful stimuli
*example*
rubbing sternum
5. LOC - COMATOSE: patient is unresponsive
abnormal posturing may be present
6. DECORTICATE POSTURING: arms flexed/internally rotated
legs extended/internally rotated
7. DECEREBRATE POSTURING: head arched back
arms/legs extended
8. AUTONOMY: patient has the right to make their own decisions even if not in their
best interest
9. BENEFICENCE: do what is best for the patient
*do good*
10. FIDELITY: keep your promises
loyalty/faithfulness
11. JUSTICE: provide fairness in care and allocation of resources
12. NONMALEFICENCE: do no harm
13. VERACITY: tell the truth
14. PATIENT RIGHTS - REFUSAL OF TREATMENT: even patients who are invol-
untarily admitted have the right to refuse treatment
, ATI CMS EXAM REVIEW - MENTAL HEALTH
Study online at https://quizlet.com/_68mi41
15. PATIENT RIGHTS - CONFIDENTIALITY: HIPAA states that health information
cannot be released without patient's permission
client's right to privacy continues even after death
16. CONFIDENTIALITY - NURSING ACTIONS: 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
17. PATIENT RIGHTS - MANDATORY REPORTING: nurses are required to report
suspicion of abuse
warn/protect third parties who are at risk for harm
18. INFORMED CONSENT - PROVIDER RESPONSIBILITIES: communicate pur-
pose of procedure
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
19. INFORMED CONSENT - NURSE/RN RESPONSIBILITIES: 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
20. RESTRAINTS - TYPES: *Physical*
- vest
- belt
- mitten
*Chemical*
- sedative Rx
- antipsychotic Rx
, ATI CMS EXAM REVIEW - MENTAL HEALTH
Study online at https://quizlet.com/_68mi41
21. RESTRAINTS - ALTERNATIVES: provide verbal interventions
diversions
calm/quiet environment
22. RESTRAINTS - PRESCRIPTIONS: *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)
23. RESTRAINTS - TIME LIMITS: *Adults*
4 hours
*Ages 9 - 17*
2 hours
*Ages 8 and Under*
1 hour
24. RESTRAINTS - DOCUMENTATION: 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)
25. RESTRAINTS - DISCONTINUATION: restraints can be discontinued when pa-
tient can follow nurse's directions
26. UNINTENTIONAL TORTS: *Negligence*
forgetting to set bed alarm for a fall risk patient
*Malpractice*
medication error that harms patient
27. INTENTIONAL TORTS: *Assault*
nurse threatens patient
*Battery*
, ATI CMS EXAM REVIEW - MENTAL HEALTH
Study online at https://quizlet.com/_68mi41
- nurse hits patient
- gives Rx against patient's will
*False Imprisonment*
- nurse inappropriately restrains a patient
- nurse administers a chemical restraint (Rx)
28. INTRAPERSONAL COMMUNICATION: self-talk
thinking thoughts, but not verbalizing them
29. INTERPERSONAL COMMUNICATION: one-on-one communication with an-
other person
30. OPEN-ENDED QUESTIONS: promotes interactive discussion
*example*
"tell me more..."
31. CLOSED-ENDED QUESTIONS: used to obtain specific data
use sparingly as it can block communication
*example"
questions that can be answered with a "yes" or "no"
32. RESTATING: repeat the patient's exact words
33. REFLECTING: return focus back to the patient
34. PARAPHRASING: restate patient's feelings to confirm understanding of what
patient is saying
35. EXPLORING: gathering more information about something that patient men-
tioned
36. GENERAL LEADS: allows patient to guide discussion
37. PRESENTING REALITY: communicate what is actually happening
dispel hallucinations/delusions/disbeliefs
38. OFFERING SELF: limited self-disclosure by nurse
return focus to the patient ASAP
39. THERAPEUTIC COMMUNICATION - WRONG WAY: asking "why" questions
offering your opinion
giving false reassurance
Study online at https://quizlet.com/_68mi41
1. LOC - ALERT: patient is responsive
opens eyes spontaneously
answers questions appropriately
2. LOC - LETHARGIC: patient can open eyes and respond to questions
falls asleep easily
3. LOC - OBTUNDED: patient responds to light shaking
is confused
slow to respond
4. LOC - STUPOROUS: patient barely responds to painful stimuli
*example*
rubbing sternum
5. LOC - COMATOSE: patient is unresponsive
abnormal posturing may be present
6. DECORTICATE POSTURING: arms flexed/internally rotated
legs extended/internally rotated
7. DECEREBRATE POSTURING: head arched back
arms/legs extended
8. AUTONOMY: patient has the right to make their own decisions even if not in their
best interest
9. BENEFICENCE: do what is best for the patient
*do good*
10. FIDELITY: keep your promises
loyalty/faithfulness
11. JUSTICE: provide fairness in care and allocation of resources
12. NONMALEFICENCE: do no harm
13. VERACITY: tell the truth
14. PATIENT RIGHTS - REFUSAL OF TREATMENT: even patients who are invol-
untarily admitted have the right to refuse treatment
, ATI CMS EXAM REVIEW - MENTAL HEALTH
Study online at https://quizlet.com/_68mi41
15. PATIENT RIGHTS - CONFIDENTIALITY: HIPAA states that health information
cannot be released without patient's permission
client's right to privacy continues even after death
16. CONFIDENTIALITY - NURSING ACTIONS: 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
17. PATIENT RIGHTS - MANDATORY REPORTING: nurses are required to report
suspicion of abuse
warn/protect third parties who are at risk for harm
18. INFORMED CONSENT - PROVIDER RESPONSIBILITIES: communicate pur-
pose of procedure
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
19. INFORMED CONSENT - NURSE/RN RESPONSIBILITIES: 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
20. RESTRAINTS - TYPES: *Physical*
- vest
- belt
- mitten
*Chemical*
- sedative Rx
- antipsychotic Rx
, ATI CMS EXAM REVIEW - MENTAL HEALTH
Study online at https://quizlet.com/_68mi41
21. RESTRAINTS - ALTERNATIVES: provide verbal interventions
diversions
calm/quiet environment
22. RESTRAINTS - PRESCRIPTIONS: *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)
23. RESTRAINTS - TIME LIMITS: *Adults*
4 hours
*Ages 9 - 17*
2 hours
*Ages 8 and Under*
1 hour
24. RESTRAINTS - DOCUMENTATION: 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)
25. RESTRAINTS - DISCONTINUATION: restraints can be discontinued when pa-
tient can follow nurse's directions
26. UNINTENTIONAL TORTS: *Negligence*
forgetting to set bed alarm for a fall risk patient
*Malpractice*
medication error that harms patient
27. INTENTIONAL TORTS: *Assault*
nurse threatens patient
*Battery*
, ATI CMS EXAM REVIEW - MENTAL HEALTH
Study online at https://quizlet.com/_68mi41
- nurse hits patient
- gives Rx against patient's will
*False Imprisonment*
- nurse inappropriately restrains a patient
- nurse administers a chemical restraint (Rx)
28. INTRAPERSONAL COMMUNICATION: self-talk
thinking thoughts, but not verbalizing them
29. INTERPERSONAL COMMUNICATION: one-on-one communication with an-
other person
30. OPEN-ENDED QUESTIONS: promotes interactive discussion
*example*
"tell me more..."
31. CLOSED-ENDED QUESTIONS: used to obtain specific data
use sparingly as it can block communication
*example"
questions that can be answered with a "yes" or "no"
32. RESTATING: repeat the patient's exact words
33. REFLECTING: return focus back to the patient
34. PARAPHRASING: restate patient's feelings to confirm understanding of what
patient is saying
35. EXPLORING: gathering more information about something that patient men-
tioned
36. GENERAL LEADS: allows patient to guide discussion
37. PRESENTING REALITY: communicate what is actually happening
dispel hallucinations/delusions/disbeliefs
38. OFFERING SELF: limited self-disclosure by nurse
return focus to the patient ASAP
39. THERAPEUTIC COMMUNICATION - WRONG WAY: asking "why" questions
offering your opinion
giving false reassurance
