ATI Capstone Mental Health,
A nurse in an acute care facility is assisting with the admission of an older adult client who has late stage
Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is
finding it more and more difficult to care for his partner. Which of the following actions should the nurse
take first? - (correct Answer) - Ask the partner to talk about his difficulties in caring for the client.
The first action the nurse should take, using the nursing process priority framework, is to collect data
regarding the partner's ability to take care of the client.
A nurse is collecting data from a client who is taking bupropion. Which of the following findings indicates
the medications is effective? - (correct Answer) - Decrease in urge to smoke
Bupropion is an antidepressant that is also used for smoking cessation.
A nurse is evaluating the outcome for a client who has depression following the death of his wife 3
months ago. Which of the following client statements indicates a need for further intervention? -
(correct Answer) - "I just don't feel like eating because I never like to eat alone."
At risk for malnutrition and injury.
A nurse in a long-term care setting is caring for a client who has Alzheimer's disease. The client states, "I
just came back from a hard day's work in my office." The nurse should identify this statement is an
example of which of the following coping mechanisms? - (correct Answer) - Confabulation
Confabulation is the creation of information which is untrue to fill in gaps in memory and to protect self-
esteem in clients who have dementia.
A nurse is planning care for a new client. Which of the following actions should the nurse plan to take in
order to use the technique of presence to establish the nurse- client relationship? - (correct Answer) -
Use active listening when with the client.
The nurse should use active listening to establish presence with the client. presence involves eye
contact, body language, voice tone, listening, and reflection to convay openness and understanding.
A nurse is assessing a client in the emergency department who drank alcohol while taking disulfiram. The
client states, "The nurse told me not to drink when taking the medication. I am just a social drinker. I
didn't realize that having just one drink with my friends would cause such a problem." Which of the
following defense mechanisms is the client demonstrating? - (correct Answer) - Rationalization
,The client is demonstrating rationalization when he creates reasonable and acceptable explanations for
unacceptable behavior. The client is using rationalization asa defense mechanisms to justify why he had
just one drink. Even though the nurse told him not to drink alcohol.
A nurse is caring for a group of older adult clients. Which of the following client findings indicates
delirium? - (correct Answer) - A client asks when family members will be arriving after visiting 1 hr
earlier.
Delirium is characterized by a change in cognition that occurs over a short period of time. It always
results from secondary physiological condition, ( infection, surgery, prolonged hospitalization, hypoxia,
fever, medication) and is a transient disorder. Although delirium can occur at any age, it is more common
in older adults. It frequently progresses in the evening hours and is sometimes called "sundown
syndrome"
A nurse is collecting data from a client newly admitted for anorexia nervousa. Which of the following
findings should the nurse expect? - (correct Answer) - Amenorrhea
The nurse should expect the client to report amenorrhea due to low body weight.
A nurse is collecting data from a client who has bipolar disorder with main. Which of the following
findings is the nurse's priority? - (correct Answer) - The client paces in the hallway during the day and
most of the night.
When using Maslow's hierarchy of needs, the nurse determines that the priority findings is the client's
physiological need for rest and food. Nonstop activity is an emergency situation for a client who has
mania, since the client might go for long periods without eating or sleep.
A nurse is preparing to assist with the care of a client of a client who is undergo electroconvulsive
therapy (ECT). Which of the following pieces of equipment should the nurse set up in the room prior to
the treatment? SATA - (correct Answer) - - Electroencephalogram (EEG) monitor.
The provider will monitor the client's brainwave patterns during the procedure.
- Oxygen saturation monitor
The client requires continuous oxygen saturation monitoring because she will receive a short-acting
barbiturate to induce sleep and a muscle-paralyzing agent to prevent muscle distress and injury.
-Electrocardiogram (ECG) monitor.
,The provider will monitor the client's cardiac response during the procedure.
A nurse is assisting with a family therapy session for parents and 2 school-age children. Which of the
following statements should the nurse recognize as an example of effective communication among
family members? - (correct Answer) - "Can you tell me the reason you get upset each time I go to the
mall?"
This is an expel of effective and healthy communication. Healthy communication expresses clear,
understandable messages between family members. Each family member is encourage to express his or
her feelings and thoughts.
A n urse is reinforcing teaching with a client who is 2 days postpartum and has a history of postpartum
depression. Which of the following instructions should the nurse include? - (correct Answer) - Sleep as
much as possible.
The nurse should encourage the client to sleep as much as she can during the next few weeks. Sleep
deprivation can increase the risk for postpartum depression.
A nurse is reinforcing teaching with a female client who is prescribed chlorpromazine. Which of the
following statements by the client indicates an understanding of the teaching? - (correct Answer) - "I will
contact my provider if I have difficulty urinating"
Chlorpromazine is a first-generation, or typical, antipsychotic medication prescribed for schizophrenia.
The client should monitor for anticholinergic adverse effects, such as dry mouth and urinary retention.
Difficulty urinating could be a sign of urinary retention and should be reported to the provider for further
evaluation.
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? - (correct Answer) -
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? - (correct Answer) -
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.
, 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? - (correct Answer) - " 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 ? - (correct Answer) - "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? - (correct Answer) - Significant change in weight
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? - (correct Answer) - "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 - (correct Answer) - -
Anxiety
Anxiety is a comordid condition common in clients who have an eating disorder.
-Obsessive-compulsive Disorder
OCD is a comorbid condition common in clients who have an eating disorder, especially anorexia
A nurse in an acute care facility is assisting with the admission of an older adult client who has late stage
Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is
finding it more and more difficult to care for his partner. Which of the following actions should the nurse
take first? - (correct Answer) - Ask the partner to talk about his difficulties in caring for the client.
The first action the nurse should take, using the nursing process priority framework, is to collect data
regarding the partner's ability to take care of the client.
A nurse is collecting data from a client who is taking bupropion. Which of the following findings indicates
the medications is effective? - (correct Answer) - Decrease in urge to smoke
Bupropion is an antidepressant that is also used for smoking cessation.
A nurse is evaluating the outcome for a client who has depression following the death of his wife 3
months ago. Which of the following client statements indicates a need for further intervention? -
(correct Answer) - "I just don't feel like eating because I never like to eat alone."
At risk for malnutrition and injury.
A nurse in a long-term care setting is caring for a client who has Alzheimer's disease. The client states, "I
just came back from a hard day's work in my office." The nurse should identify this statement is an
example of which of the following coping mechanisms? - (correct Answer) - Confabulation
Confabulation is the creation of information which is untrue to fill in gaps in memory and to protect self-
esteem in clients who have dementia.
A nurse is planning care for a new client. Which of the following actions should the nurse plan to take in
order to use the technique of presence to establish the nurse- client relationship? - (correct Answer) -
Use active listening when with the client.
The nurse should use active listening to establish presence with the client. presence involves eye
contact, body language, voice tone, listening, and reflection to convay openness and understanding.
A nurse is assessing a client in the emergency department who drank alcohol while taking disulfiram. The
client states, "The nurse told me not to drink when taking the medication. I am just a social drinker. I
didn't realize that having just one drink with my friends would cause such a problem." Which of the
following defense mechanisms is the client demonstrating? - (correct Answer) - Rationalization
,The client is demonstrating rationalization when he creates reasonable and acceptable explanations for
unacceptable behavior. The client is using rationalization asa defense mechanisms to justify why he had
just one drink. Even though the nurse told him not to drink alcohol.
A nurse is caring for a group of older adult clients. Which of the following client findings indicates
delirium? - (correct Answer) - A client asks when family members will be arriving after visiting 1 hr
earlier.
Delirium is characterized by a change in cognition that occurs over a short period of time. It always
results from secondary physiological condition, ( infection, surgery, prolonged hospitalization, hypoxia,
fever, medication) and is a transient disorder. Although delirium can occur at any age, it is more common
in older adults. It frequently progresses in the evening hours and is sometimes called "sundown
syndrome"
A nurse is collecting data from a client newly admitted for anorexia nervousa. Which of the following
findings should the nurse expect? - (correct Answer) - Amenorrhea
The nurse should expect the client to report amenorrhea due to low body weight.
A nurse is collecting data from a client who has bipolar disorder with main. Which of the following
findings is the nurse's priority? - (correct Answer) - The client paces in the hallway during the day and
most of the night.
When using Maslow's hierarchy of needs, the nurse determines that the priority findings is the client's
physiological need for rest and food. Nonstop activity is an emergency situation for a client who has
mania, since the client might go for long periods without eating or sleep.
A nurse is preparing to assist with the care of a client of a client who is undergo electroconvulsive
therapy (ECT). Which of the following pieces of equipment should the nurse set up in the room prior to
the treatment? SATA - (correct Answer) - - Electroencephalogram (EEG) monitor.
The provider will monitor the client's brainwave patterns during the procedure.
- Oxygen saturation monitor
The client requires continuous oxygen saturation monitoring because she will receive a short-acting
barbiturate to induce sleep and a muscle-paralyzing agent to prevent muscle distress and injury.
-Electrocardiogram (ECG) monitor.
,The provider will monitor the client's cardiac response during the procedure.
A nurse is assisting with a family therapy session for parents and 2 school-age children. Which of the
following statements should the nurse recognize as an example of effective communication among
family members? - (correct Answer) - "Can you tell me the reason you get upset each time I go to the
mall?"
This is an expel of effective and healthy communication. Healthy communication expresses clear,
understandable messages between family members. Each family member is encourage to express his or
her feelings and thoughts.
A n urse is reinforcing teaching with a client who is 2 days postpartum and has a history of postpartum
depression. Which of the following instructions should the nurse include? - (correct Answer) - Sleep as
much as possible.
The nurse should encourage the client to sleep as much as she can during the next few weeks. Sleep
deprivation can increase the risk for postpartum depression.
A nurse is reinforcing teaching with a female client who is prescribed chlorpromazine. Which of the
following statements by the client indicates an understanding of the teaching? - (correct Answer) - "I will
contact my provider if I have difficulty urinating"
Chlorpromazine is a first-generation, or typical, antipsychotic medication prescribed for schizophrenia.
The client should monitor for anticholinergic adverse effects, such as dry mouth and urinary retention.
Difficulty urinating could be a sign of urinary retention and should be reported to the provider for further
evaluation.
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? - (correct Answer) -
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? - (correct Answer) -
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.
, 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? - (correct Answer) - " 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 ? - (correct Answer) - "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? - (correct Answer) - Significant change in weight
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? - (correct Answer) - "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 - (correct Answer) - -
Anxiety
Anxiety is a comordid condition common in clients who have an eating disorder.
-Obsessive-compulsive Disorder
OCD is a comorbid condition common in clients who have an eating disorder, especially anorexia
