ATI Capstone: Mental Health
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 even think right now". Which of the following actions should the nurse take?
Identify other housing options and sources of transportation.
Notify the facility chaplain to request scheduling an appointment.
Confirm that everything will be all right because belongings can be replaced.
Maintain eye contact with client and summarize the client's feelings. - (correct Answer) - Maintain eye
contact with client and summarize the client's feelings;
This demonstrates therapeutic communication. During the initial interview, it is important for the nurse
to provide an atmosphere of support and safety. If a person believes that someone is genuinely
concerned, then he may believe that help is available. Maintaining eye contact demonstrates support,
empathy, and advocacy.
A nurse is discussing obsessive-compulsive disorder (OCD) with a newly licensed nurse. Which of the
following statements by the newly licensed nurse indicates an understanding of the underlying reason
clients with OCD perform ritualistic behaviors?
"The ritualistic behavior provides sexual satisfaction."
"The client performs ritualistic behavior to boost self-esteem."
"The ritualistic behavior temporarily relieves anxiety."
"The client performs ritualistic behavior to decrease feelings of shame." - (correct Answer) - "The
ritualistic behavior temporarily relieves anxiety.";
Clients with OCD perform ritualistic behaviors to provide a temporary relief from anxiety related to
obsessions.
,A nurse is teaching a female client who has anxiety disorder about alprazolam. Which of the following
information should the nurse include in the teaching?
"Use a reliable form of contraception while taking this medication."
"If a dose is missed, double the next dose of medication."
"This medication may increase your blood pressure."
"Do not eat aged cheeses while taking this medication." - (correct Answer) - "Use a reliable form of
contraception while taking this medication.";
Alprazolam is a pregnancy category D medication, indicating it causes definitive adverse effects on a
fetus.
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?
"You really shouldn't change the schedule we established here in the facility."
"Let's work together to devise a time schedule that is convenient for you on a daily basis."
"We'll have to talk to your provider about switching to an alternative schedule."
"It doesn't really matter what time you take your medications as long as you don't skip any doses." -
(correct Answer) - "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 conducting a group therapy meeting and is sharing a humorous story. When the group laughs
at the story, a client who has schizophrenia jumps up and runs out while yelling, "you are all making fun
of me." Which of the ff behaviors is this client displaying?
Grandeur
, Flight of ideas
Erotomania
Ideas of reference - (correct Answer) - Ideas of reference;
Ideas of reference occur when a client believes that conversations of others always concern him and
that others are ridiculing him.
A nurse is teaching a client who has a new prescription for paroxetine. Which of the following
statements by the client indicates an understanding of the teaching?
"I may experience an increased desire to have sex."
"My blood pressure may increase."
"I may notice excess saliva."
"I may not feel like eating as much." - (correct Answer) - "I may not feel like eating as much.";
Anorexia and a decreased appetite are adverse effects of paroxetine.
A nurse is caring for a client on an acute care mental health unit. Client has a history of bipolar disorder
and self-injurious behavior. 1330:
Client pacing rapidly across their room and shouting loudly at nursing staff. Client appears agitated.
Verbal de-escalation measures implemented. Client returned to their bed and is refusing to talk or make
eye contact.
1345: Client displays self-injurious behavior by attempting to cut themselves with plastic utensils from
their lunch tray.
Complete the following sentence by using the lists of options.
The nurse should _______________, followed by ____________________. - (correct Answer) - Assist
the charge nurse in placing the client in restraints;
Monitoring the client's behavior for their ability to be reintegrated into unit activities is correct.
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 even think right now". Which of the following actions should the nurse take?
Identify other housing options and sources of transportation.
Notify the facility chaplain to request scheduling an appointment.
Confirm that everything will be all right because belongings can be replaced.
Maintain eye contact with client and summarize the client's feelings. - (correct Answer) - Maintain eye
contact with client and summarize the client's feelings;
This demonstrates therapeutic communication. During the initial interview, it is important for the nurse
to provide an atmosphere of support and safety. If a person believes that someone is genuinely
concerned, then he may believe that help is available. Maintaining eye contact demonstrates support,
empathy, and advocacy.
A nurse is discussing obsessive-compulsive disorder (OCD) with a newly licensed nurse. Which of the
following statements by the newly licensed nurse indicates an understanding of the underlying reason
clients with OCD perform ritualistic behaviors?
"The ritualistic behavior provides sexual satisfaction."
"The client performs ritualistic behavior to boost self-esteem."
"The ritualistic behavior temporarily relieves anxiety."
"The client performs ritualistic behavior to decrease feelings of shame." - (correct Answer) - "The
ritualistic behavior temporarily relieves anxiety.";
Clients with OCD perform ritualistic behaviors to provide a temporary relief from anxiety related to
obsessions.
,A nurse is teaching a female client who has anxiety disorder about alprazolam. Which of the following
information should the nurse include in the teaching?
"Use a reliable form of contraception while taking this medication."
"If a dose is missed, double the next dose of medication."
"This medication may increase your blood pressure."
"Do not eat aged cheeses while taking this medication." - (correct Answer) - "Use a reliable form of
contraception while taking this medication.";
Alprazolam is a pregnancy category D medication, indicating it causes definitive adverse effects on a
fetus.
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?
"You really shouldn't change the schedule we established here in the facility."
"Let's work together to devise a time schedule that is convenient for you on a daily basis."
"We'll have to talk to your provider about switching to an alternative schedule."
"It doesn't really matter what time you take your medications as long as you don't skip any doses." -
(correct Answer) - "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 conducting a group therapy meeting and is sharing a humorous story. When the group laughs
at the story, a client who has schizophrenia jumps up and runs out while yelling, "you are all making fun
of me." Which of the ff behaviors is this client displaying?
Grandeur
, Flight of ideas
Erotomania
Ideas of reference - (correct Answer) - Ideas of reference;
Ideas of reference occur when a client believes that conversations of others always concern him and
that others are ridiculing him.
A nurse is teaching a client who has a new prescription for paroxetine. Which of the following
statements by the client indicates an understanding of the teaching?
"I may experience an increased desire to have sex."
"My blood pressure may increase."
"I may notice excess saliva."
"I may not feel like eating as much." - (correct Answer) - "I may not feel like eating as much.";
Anorexia and a decreased appetite are adverse effects of paroxetine.
A nurse is caring for a client on an acute care mental health unit. Client has a history of bipolar disorder
and self-injurious behavior. 1330:
Client pacing rapidly across their room and shouting loudly at nursing staff. Client appears agitated.
Verbal de-escalation measures implemented. Client returned to their bed and is refusing to talk or make
eye contact.
1345: Client displays self-injurious behavior by attempting to cut themselves with plastic utensils from
their lunch tray.
Complete the following sentence by using the lists of options.
The nurse should _______________, followed by ____________________. - (correct Answer) - Assist
the charge nurse in placing the client in restraints;
Monitoring the client's behavior for their ability to be reintegrated into unit activities is correct.
