ATI RN Capstone Mental Health Pre-Assessment
A nurse in a mental health clinic is assessing a client who was brought in by her adult daughter stating
that her mother has not been able to leave her home for weeks because she is afraid to be outdoors
alone. the nurse should anticipate planning care for managing which of the following phobias?
a. Xenophobia
b. Acrophobia
c. Mysophobia
d. Agoraphobia - (correct Answer) - d. Agoraphobia
Agoraphobia is an irrational fear about being in places or circumstances where the client would not have
help in the event of panic or other forms of anxiety. Fear of being alone outdoor is a common example.
A nurse is providing discharge teaching for a client who has multiple medication prescriptions and must
take the medications at specific intervals when at home. Which of the following instructions should the
nurse include in the teaching?
a. "You really shouldn't change the schedule we established here in the facility."
b. "Let's work together to devise a time schedule that is convenient for you on a daily basis."
c. "We'll have to talk to your provider about switching to an alternative schedule."
d. "It doesn't really matter what time you take your medications as long as you don't skip any doses." -
(correct Answer) - b. "Let's work together to devise a time schedule that is convenient for you on a daily
basis."
This response illustrates the therapeutic communication technique of formulating a plan of action. It
demonstrates the nurse's willingness to work with the client to modify the schedule so that it meets the
client's needs at this time.
A nurse is providing discharge teaching to. client who has bipolar disorder and will be discharged with a
prescription for lithium. The nurse should teach the client that which of the following factors puts her at
risk for lithium toxicity?
a. The client runs 4 miles outdoors every afternoon.
b. The client drinks 2 liters of liquids daily.
c. The client eats 2 to 3 grams of sodium-containing foods daily.
d. The client eats foods high in tyramine. - (correct Answer) - a. The client runs 4 miles outdoors every
, afternoon.
Strenuous exercise in outdoor heat, which can lead to dehydration, puts the client at risk for lithium
toxicity. Mild to moderate exercise will not lead to lithium toxicity, but if the client engages in strenuous
exercise during hot weather, she should take care to replace any water that may have been lost through
profuse sweating. this also applies to other factors that can cause the client to become dehydrated, such
as having diarrhea or taking diuretics.
A nurse in a emergency department is assessing a client for suspected cocaine intoxication. Which of the
following findings should the nurse expect?
a. Nystagmus
b. Dilated pupils
c. Hypersomnia
d. Depression - (correct Answer) - b. Dilated pupils
Dilated pupils are a finding of cocaine intoxication due to the stimulation of the sympathetic nervous
system.
A nurse enters the room of a client who becomes verbally abusive. Which of the following actions should
the nurse take?
a. Inform the client of consequences.
b. Speak slowly in a low, calm voice.
c. Forbid the client from speaking in an abusive manner.
d. Remain a distance of 1 ft away from the client. - (correct Answer) - b. Speak slowly in a low, calm
voice.
Speaking in this manner conveys to the client that the nurse is controlled, nonthreatening, and caring.
A nurse is caring for a client who lost all his possessions in a house fire and states, "I have no idea what I
am going to do. I cannot think right now." Which of the following actions should the nurse take?
a. Identify other housing options and sources of transportation.
b. Notify the facility chaplain to request scheduling an appointment.
c. Confirm that everything will be alright because belongings can be replaced.
d. Maintain eye contact with client and summarize the client's feeings. - (correct Answer) - d. Maintain
A nurse in a mental health clinic is assessing a client who was brought in by her adult daughter stating
that her mother has not been able to leave her home for weeks because she is afraid to be outdoors
alone. the nurse should anticipate planning care for managing which of the following phobias?
a. Xenophobia
b. Acrophobia
c. Mysophobia
d. Agoraphobia - (correct Answer) - d. Agoraphobia
Agoraphobia is an irrational fear about being in places or circumstances where the client would not have
help in the event of panic or other forms of anxiety. Fear of being alone outdoor is a common example.
A nurse is providing discharge teaching for a client who has multiple medication prescriptions and must
take the medications at specific intervals when at home. Which of the following instructions should the
nurse include in the teaching?
a. "You really shouldn't change the schedule we established here in the facility."
b. "Let's work together to devise a time schedule that is convenient for you on a daily basis."
c. "We'll have to talk to your provider about switching to an alternative schedule."
d. "It doesn't really matter what time you take your medications as long as you don't skip any doses." -
(correct Answer) - b. "Let's work together to devise a time schedule that is convenient for you on a daily
basis."
This response illustrates the therapeutic communication technique of formulating a plan of action. It
demonstrates the nurse's willingness to work with the client to modify the schedule so that it meets the
client's needs at this time.
A nurse is providing discharge teaching to. client who has bipolar disorder and will be discharged with a
prescription for lithium. The nurse should teach the client that which of the following factors puts her at
risk for lithium toxicity?
a. The client runs 4 miles outdoors every afternoon.
b. The client drinks 2 liters of liquids daily.
c. The client eats 2 to 3 grams of sodium-containing foods daily.
d. The client eats foods high in tyramine. - (correct Answer) - a. The client runs 4 miles outdoors every
, afternoon.
Strenuous exercise in outdoor heat, which can lead to dehydration, puts the client at risk for lithium
toxicity. Mild to moderate exercise will not lead to lithium toxicity, but if the client engages in strenuous
exercise during hot weather, she should take care to replace any water that may have been lost through
profuse sweating. this also applies to other factors that can cause the client to become dehydrated, such
as having diarrhea or taking diuretics.
A nurse in a emergency department is assessing a client for suspected cocaine intoxication. Which of the
following findings should the nurse expect?
a. Nystagmus
b. Dilated pupils
c. Hypersomnia
d. Depression - (correct Answer) - b. Dilated pupils
Dilated pupils are a finding of cocaine intoxication due to the stimulation of the sympathetic nervous
system.
A nurse enters the room of a client who becomes verbally abusive. Which of the following actions should
the nurse take?
a. Inform the client of consequences.
b. Speak slowly in a low, calm voice.
c. Forbid the client from speaking in an abusive manner.
d. Remain a distance of 1 ft away from the client. - (correct Answer) - b. Speak slowly in a low, calm
voice.
Speaking in this manner conveys to the client that the nurse is controlled, nonthreatening, and caring.
A nurse is caring for a client who lost all his possessions in a house fire and states, "I have no idea what I
am going to do. I cannot think right now." Which of the following actions should the nurse take?
a. Identify other housing options and sources of transportation.
b. Notify the facility chaplain to request scheduling an appointment.
c. Confirm that everything will be alright because belongings can be replaced.
d. Maintain eye contact with client and summarize the client's feeings. - (correct Answer) - d. Maintain
