ATI RN Capstone Mental Health
Pre-Assessment
A charge nurse is conducting a staff education in-service about depressive disorders. Which
of the following should the nurse identify as a risk factor for depression?
a. Being married.
b. Pregnancy.
c. Male gender.
d. Chronic illness. - ANS-d. Chronic illness
Having a medical illness, especially one that is chronic, is a primary risk factor for
depression.
A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted,
superficial cuts going up and down his right arm. Which of the following actions should the
nurse take first?
a. Implement the client's behavioral modification plan.
b. Document the size and location of the cuts.
c. Inspect the cuts for debris.
d. Administer a tetanus antitoxin. - ANS-c. Inspect the cuts for debris.
The first action the nurse should take when using the nursing process is to assess the client,
therefore inspecting the cuts is the first action the nurse should take.
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. - ANS-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 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 - ANS-b. Dilated pupils
Dilated pupils are a finding of cocaine intoxication due to the stimulation of the sympathetic
nervous system.
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 - ANS-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 in a psychiatric unit is caring for several clients. Which of the following clients should
the nurse recommend for group therapy?
a. A client who has been taking amitriptyline for 3 months for depression.
b. A client exhibiting psychotic behavior.
c. A client admitted 12 hr ago for acute mania.
d. A client who is experiencing alcohol intoxication. - ANS-a. A client who has been taking
amitriptyline for 3 months for depression.
Psychotherapy groups provide clients with the opportunity to enhance their personal
relationships, increase self-awareness and try new behaviors in a safe social setting.
Amitriptyline can take 4 to 8 weeks to become effective; therefore, this client should be
experiencing improvement in depressive manifestations and be ready to interact in a group
setting.
A nurse in an acute care facility is admitting an older adult client who has dementia due to
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 wife. Which of the following
interventions is the nurse's priority?
a. Recommend that the partner place the client in a long-term care facility.
b. Suggest that the partner see a counselor to help him cope with his exhaustion.
c. Ask the partner to talk about his difficulties in caring for the client.
d.. Tell the partner to call a family meeting to get help. - ANS-c. 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
assess the partner's difficulties in caring for his wife.
A nurse in an acute care mental health facility is admitting a client who reports feeling
depressed, sad, moody, and overly anxious. Which of the following is the nurse's
assessment priority?
a. Coping abilities.
b. Support systems.
c. Suicide risk.
d. Psychiatric history. - ANS-c. Suicide risk
The greatest risk to the safety of a client who is depressed is self-harm. Therefore, the
priority for the nurse to determine is the client's thoughts or plans for suicide.
A nurse in the emergency department is caring for a client experiencing alcohol intoxication.
Which of the following interventions should the nurse plan to include? (SATA)
Pre-Assessment
A charge nurse is conducting a staff education in-service about depressive disorders. Which
of the following should the nurse identify as a risk factor for depression?
a. Being married.
b. Pregnancy.
c. Male gender.
d. Chronic illness. - ANS-d. Chronic illness
Having a medical illness, especially one that is chronic, is a primary risk factor for
depression.
A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted,
superficial cuts going up and down his right arm. Which of the following actions should the
nurse take first?
a. Implement the client's behavioral modification plan.
b. Document the size and location of the cuts.
c. Inspect the cuts for debris.
d. Administer a tetanus antitoxin. - ANS-c. Inspect the cuts for debris.
The first action the nurse should take when using the nursing process is to assess the client,
therefore inspecting the cuts is the first action the nurse should take.
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. - ANS-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 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 - ANS-b. Dilated pupils
Dilated pupils are a finding of cocaine intoxication due to the stimulation of the sympathetic
nervous system.
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 - ANS-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 in a psychiatric unit is caring for several clients. Which of the following clients should
the nurse recommend for group therapy?
a. A client who has been taking amitriptyline for 3 months for depression.
b. A client exhibiting psychotic behavior.
c. A client admitted 12 hr ago for acute mania.
d. A client who is experiencing alcohol intoxication. - ANS-a. A client who has been taking
amitriptyline for 3 months for depression.
Psychotherapy groups provide clients with the opportunity to enhance their personal
relationships, increase self-awareness and try new behaviors in a safe social setting.
Amitriptyline can take 4 to 8 weeks to become effective; therefore, this client should be
experiencing improvement in depressive manifestations and be ready to interact in a group
setting.
A nurse in an acute care facility is admitting an older adult client who has dementia due to
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 wife. Which of the following
interventions is the nurse's priority?
a. Recommend that the partner place the client in a long-term care facility.
b. Suggest that the partner see a counselor to help him cope with his exhaustion.
c. Ask the partner to talk about his difficulties in caring for the client.
d.. Tell the partner to call a family meeting to get help. - ANS-c. 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
assess the partner's difficulties in caring for his wife.
A nurse in an acute care mental health facility is admitting a client who reports feeling
depressed, sad, moody, and overly anxious. Which of the following is the nurse's
assessment priority?
a. Coping abilities.
b. Support systems.
c. Suicide risk.
d. Psychiatric history. - ANS-c. Suicide risk
The greatest risk to the safety of a client who is depressed is self-harm. Therefore, the
priority for the nurse to determine is the client's thoughts or plans for suicide.
A nurse in the emergency department is caring for a client experiencing alcohol intoxication.
Which of the following interventions should the nurse plan to include? (SATA)
