ATI CAPSTONE – MENTAL HEALTH PRE-ASSESSMENT EXAM LATEST UPDATE

ATI CAPSTONE – MENTAL HEALTH PRE-ASSESSMENT EXAM LATEST UPDATE 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? 1. Preservation 2. Confabulation 3. Though deletion 4. Tangentially - CORRECT ANSWER- 2 Confabulation A nurse is collecting data from a client who has major depression disorder ( MDD). Which of the following finding should the nurse expect? 1. Significant change in weight 2. Hyperexcitability 3.Exaggerated response of pleasure to stimuli 4. Attention-seeking behavior - CORRECT ANSWER- 1. Significant change in weight 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? 1. Telephone the client at his home prior to admission to make introduction. 2. Dominate the conversation to reduce the client's anxiety. 3. Share stories about personal experience with the client 4. Use active listening when with the client. - CORRECT ANSWER- 4. Use active listening when with the client. A client who has a femur fracture states, "I can't stay in this bed any longer. I need to get home so I can take care of my family." The nurse responds by saying, "You have talked about your family. Can you tell me more about your specific concerns?" Which of the following therapeutic communication techniques is the nurse using? 1. Summmarizing 2. Empathizing 3.Focusing 4. Clarifying - CORRECT ANSWER- 3. Focusing. 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? 1. Access to health care 2. Impulsivity 3. Close family ties 4. Effective problem -solving skills. - CORRECT ANSWER- 2. Impulsively 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. 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 medication has a narrow therapeutic rang and establishing a therapeutic lithium level is an essential component of care. it is recommend to check lithium level with the first 5 days. of beginning of treatment and possibly twice weekly until a maintenace dosage has been reached. Lithium levels are checked about every 3 months during maintenance therapy when lithium levels have stabilized. 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. Difficult urinating could be a sign of urinary retention and should be reported to the provider for further evaluation. 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?" A nurse is reinforcing discharge 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. A nurse is collecting data from a client who is receiving treatment for alcohol detoxification. Which of the following findings is the nurse's priority? - CORRECT ANSWER- Hallucinations A nurse is assisting with the plan of care for a client who is newly diagnosed with borderline personality disorder. Which of the following interventions is the nurse's priority? - CORRECT ANSWER- Protecting the client from self-harm behavior 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?" A nurse is collecting data from a client who has bipolar disorder with mania. 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. A nurse is collecting data from a school age child who has an intellectual development disorder. Which of the following findings should the nurse expect? - CORRECT ANSWER- Has difficulty performing age-appropriate self-care activities 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 A nurse is collecting data from a client who is taking bupropion. Which of the following findings indicates the medication is effective? - CORRECT ANSWER- Decrease in urge to smoke note: Bupropion is an antidepressant that is also used for smoke cessation. A nurse is caring for a client who reports acute anxiety. Which of the following actions should the nurse take first? - CORRECT ANSWER- Remain with the client. A nurse is caring for a 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 A nurse is caring for a client whose wife died 6 months ago. For which of the following findings should the nurse monitor to identify a maladaptive grieving response? - CORRECT ANSWER- Disturbed self-esteem A nurse is evaluating the outcomes 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