ATI Capstone Mental Health
A client who has a femur fracture states, "I cant stay in this bed any longer. I need to get
home so I can take care of my family." The nurse response by saying, "You have talked
about your family. Can you tell me more about your specific concerns?" Which of the
following therapeutic communications techniques is the nurse using? - ANS-Focusing
The nurse's open-ended statement is a means of focusing on the problem and obtaining
more information about the client's concerns, which helps the nurse to identify issues and
concerns clearly.
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? -
ANS-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 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? -
ANS-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 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? - ANS-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 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? -
ANS-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 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? - ANS-"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 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? -
ANS-Protecting the client from self-harm behavior
The greatest risk to the client is harm to self or others, therefore this is the nurse's priority. C.
Encouraging the client to talk about her feelings.
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? - ANS-"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 caring for a client who reports acute anxiety. Which of the following actions should
the nurse take first? - ANS-Remain with the client.
The nurse should stay with the client to reduce anxiety and the risk for injury to self and
others.
A nurse is caring for a client who witnessed her brother's homicide and has post traumatic
stress disorder (PTSD). Which of the following findings should the nurse expect? - ANS-The
client is easily startled by loud voices.
A hyperactive startle reflex (hyper vigilance) due to constant anxiety, is a common finding in
client who have PTSD.
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? -
ANS-Disturbed self-esteem
A client who has disturbed self-esteem, such as feeling of worthlessness, is likely having a
maladaptive grieving response, which can precipitate depression.
A nurse is caring for a group of older adult clients. Which of the following client findings
indicates delirium? - ANS-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 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
A client who has a femur fracture states, "I cant stay in this bed any longer. I need to get
home so I can take care of my family." The nurse response by saying, "You have talked
about your family. Can you tell me more about your specific concerns?" Which of the
following therapeutic communications techniques is the nurse using? - ANS-Focusing
The nurse's open-ended statement is a means of focusing on the problem and obtaining
more information about the client's concerns, which helps the nurse to identify issues and
concerns clearly.
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? -
ANS-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 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? -
ANS-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 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? - ANS-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 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? -
ANS-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 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? - ANS-"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 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? -
ANS-Protecting the client from self-harm behavior
The greatest risk to the client is harm to self or others, therefore this is the nurse's priority. C.
Encouraging the client to talk about her feelings.
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? - ANS-"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 caring for a client who reports acute anxiety. Which of the following actions should
the nurse take first? - ANS-Remain with the client.
The nurse should stay with the client to reduce anxiety and the risk for injury to self and
others.
A nurse is caring for a client who witnessed her brother's homicide and has post traumatic
stress disorder (PTSD). Which of the following findings should the nurse expect? - ANS-The
client is easily startled by loud voices.
A hyperactive startle reflex (hyper vigilance) due to constant anxiety, is a common finding in
client who have PTSD.
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? -
ANS-Disturbed self-esteem
A client who has disturbed self-esteem, such as feeling of worthlessness, is likely having a
maladaptive grieving response, which can precipitate depression.
A nurse is caring for a group of older adult clients. Which of the following client findings
indicates delirium? - ANS-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 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
