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ATI CAPSTONE MENTAL HEALTH ASSESSMENT EXAM A
A nurse is collecting data from a client following a recent suicide attempt. Which
of the following findings in the client's history places him at the greatest risk for
another suicide attempt?
Impulsivity
A client who has impulsivity is at risk for suicide because he is more likely to take an
action quickly without thinking about the consequences.
A nurse is caring for client who escapes anxiety - causing thoughts by ignoring
their existence. The nurse should recognize this behavior as which of the
following defense mechanisms?
Undoing
The nurse correctly identifies this as an example of denial which is escaping unpleasant
or anxiety - causing thoughts or feelings by ignoring their existence.
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ATI CAPSTONE MENTAL HEALTH ASSESSMENT EXAM A
A nurse is caring for an older adult client who is scheduled for surgery. The client
becomes upset when the nurse asks her to remove her dentures prior to the
surgery. Which of the following is a therapeutic response by the nurse?
" You seem worried. Are you concerned someone may see you without your teeth?"
The nurse uses two therapeutic communication tools in this response. One is empathy,
which is shown by focusing on the client's feelings. The other is validation/clarification,
in which the nurse seeks to validate the reason for the client's feelings.
A nurse is talking with a client who has schizophrenia. Suddenly the client states,
"Im tightened. Do you hear that? The voices are telling me to do terrible things."
Which of the following responses by the nurse is appropriate ?
"What are the voices telling you to do?"
This statement recognizes the risk involved with a command hallucination an asks there
client directly about the hallucination. This is a therapeutic approach to communicating
with a client who is experiencing a hallucination.
A nurse is collecting data from a client who has a major depressive disorder
(MDD). Which of the following findings should the nurse expect?
Significant change in weight
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A signifiant change in weight, either loss or gain, is an expected finding of MDD.
A nurse is reinforcing teaching with a client about a new prescription for lithium.
Which of the following statements should the nurse include in the teaching?
"We will need to check your lithium levels in the next 3 to 5 days."
Lithium is prescribed to treat bipolar disorder. The medications has a narrow therapeutic
range and establishing a therapeutic lithium level is an essential component of care. It is
recommended to check lithium levels within the first 5 days of beginning of treatment
and possibly twice weekly until a maintenance dosage has been reached. Lithium levels
are checked about every 3 months during maintenance therapy when lithium levels
have stabilized.
A nurse is discussing comorbidities associated with eating disorders with a
newly licensed nurse. Which of the following comorbidities should the nurse
include in the discussion? SATA
- Anxiety
Anxiety is a comordid condition common in clients who have an eating disorder.
-Obsessive-compulsive Disorder
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OCD is a comorbid condition common in clients who have an eating disorder, especially
anorexia nervosa.
-Depression
Depression is a comorbid condition common in clients who have an eating disorder.
A nurse is caring for a client who has been diagnosed with end-stage liver cancer.
Which of the following statements by the client indicates that the client is in the
denial phase of the grief process?
"The doctor says I only have a few months to live, but I know he is exaggerating to get
me to take my medication."
The Five stages of Grief may not be experienced in order, and the length of each stage
will vary from person to person.
A nurse is discussing restraint with a newly licensed nurse. Which of the
following situations should the nurse identify as an acceptable indication for
using restraints for a client?
Continued self-destructive behavior
A nurse my use mechanical restraints for a client who presents a specific danger to
themselves or others. The nurse must follow all facility policies, such as documentation
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ATI CAPSTONE MENTAL HEALTH ASSESSMENT EXAM A