RN ATI CAPSTONE PROCTURED
COMPREHENSIVE ASSESMENT 2023
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
- ANSWER-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 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?
a. "You really shouldn't change the schedule we established here in the facility."
b. "Let's work together to devise a time schedule that is convenient for you on a daily basis."
c. "We'll have to talk to your provider about switching to an alternative schedule."
d. "It doesn't really matter what time you take your medications as long as you don't skip any doses." -
ANSWER-b. "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 providing discharge teaching to. client who has bipolar disorder and will be discharged with a
prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk
for lithium toxicity?
a. The client runs 4 miles outdoors every afternoon.
b. The client drinks 2 liters of liquids daily.
c. The client eats 2 to 3 grams of sodium-containing foods daily.
d. The client eats foods high in tyramine.
- ANSWER-a. The client runs 4 miles outdoors every afternoon.
Strenuous exercise in outdoor heat, which can lead to dehydration, puts the client at risk for lithium toxicity.
Mild to moderate exercise will not lead to lithium toxicity, but if the client engages in strenuous exercise
during hot weather, she should take care to replace any water that may have been lost through profuse
sweating. this also applies to other factors that can cause the client to become dehydrated, such as having
diarrhea or taking diuretics.
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
- ANSWER-b. Dilated pupils
Dilated pupils are a finding of cocaine intoxication due to the stimulation of the sympathetic nervous system.
A nurse enters the room of a client who becomes verbally abusive. Which of the following actions should the
nurse take?
,RN ATI CAPSTONE PROCTURED
COMPREHENSIVE ASSESMENT 2023
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.
- ANSWER-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 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 think right now." Which of the following actions should the nurse take?
a. Identify other housing options and sources of transportation.
b. Notify the facility chaplain to request scheduling an appointment.
c. Confirm that everything will be alright because belongings can be replaced.
d. Maintain eye contact with client and summarize the client's feeings.
- ANSWER-d. Maintain eye contact with the 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 the someone is genuinely concerned,
then he may believe that help is available. Maintaining eye contact demonstrates support, empathy, and
advocacy.
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.
- ANSWER-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 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 following behaviors is this client displaying?
a. Grandeur
b. Flight of ideas
c. Erotomania
d. Ideas of reference
- ANSWER-d. Ideas of reference
Ideas of reference occur when a client believes that conversation of others always concern him and that
others are ridiculing him.
, RN ATI CAPSTONE PROCTURED
COMPREHENSIVE ASSESMENT 2023
A nurse is preparing to administer diphenhydramine 50 mg PO every 6 hr to a client who has acute dystonia.
Available is diphenhydramine 25 mg tablets. How many tablets should the nurse administer per dose? (Round
to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
- ANSWER-2 tablet(s)
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?
a. "The ritualistic behavior provides sexual satisfaction."
b. "The client performs ritualistic behavior to boost self-esteem."
c. "The ritualistic behavior temporarily relieves anxiety."
d. "The client performs ritualistic behavior to decrease feelings of shame."
- ANSWER-c. "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 assisting a client who has schizophrenia prepare a relapse plan. Which of the following statements
should the nurse make?
a. "You should be aware that excessive sleeping is an early sign of relapse."
b. "Relapse is an indication that you are not taking your medications properly."
c. "You should keep your provider's and therapist's number with you."
d. "Taking an additional dose of medication is appropriate as soon as signs of relapse appear."
- ANSWER-c. "You should keep your provider's and therapist's number with you."
The client should have a written plan, including important numbers, available at all times in case relapse
occurs.
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)
a. Contact the laboratory to obtain a blood sample.
b. Prepare the client for a CT scan.
c. Check the client's pupil reactivity.
d. Obtain a urine specimen.
e. Performa. developmental screening test.
- ANSWER-a. Contact the laboratory to obtain a blood sample - A blood sample allows for a blood alcohol
level test to be performed.
b. Prepare the client for a CT scan - A CT scan or other neurological tests is performed to rule out brain
injury or head trauma.
c. Check the client's pupil reactivity - Checking for pupil reactivity provides information about a client's
neurological status.
d. Obtain a urine specimen - A urine specimen is needed to perform a urine toxicology screen.
The nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of
the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?
a. Disclose some personal information to the client to demonstrate approachability.
b. Wait for the client to initiate interaction.
COMPREHENSIVE ASSESMENT 2023
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
- ANSWER-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 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?
a. "You really shouldn't change the schedule we established here in the facility."
b. "Let's work together to devise a time schedule that is convenient for you on a daily basis."
c. "We'll have to talk to your provider about switching to an alternative schedule."
d. "It doesn't really matter what time you take your medications as long as you don't skip any doses." -
ANSWER-b. "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 providing discharge teaching to. client who has bipolar disorder and will be discharged with a
prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk
for lithium toxicity?
a. The client runs 4 miles outdoors every afternoon.
b. The client drinks 2 liters of liquids daily.
c. The client eats 2 to 3 grams of sodium-containing foods daily.
d. The client eats foods high in tyramine.
- ANSWER-a. The client runs 4 miles outdoors every afternoon.
Strenuous exercise in outdoor heat, which can lead to dehydration, puts the client at risk for lithium toxicity.
Mild to moderate exercise will not lead to lithium toxicity, but if the client engages in strenuous exercise
during hot weather, she should take care to replace any water that may have been lost through profuse
sweating. this also applies to other factors that can cause the client to become dehydrated, such as having
diarrhea or taking diuretics.
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
- ANSWER-b. Dilated pupils
Dilated pupils are a finding of cocaine intoxication due to the stimulation of the sympathetic nervous system.
A nurse enters the room of a client who becomes verbally abusive. Which of the following actions should the
nurse take?
,RN ATI CAPSTONE PROCTURED
COMPREHENSIVE ASSESMENT 2023
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.
- ANSWER-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 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 think right now." Which of the following actions should the nurse take?
a. Identify other housing options and sources of transportation.
b. Notify the facility chaplain to request scheduling an appointment.
c. Confirm that everything will be alright because belongings can be replaced.
d. Maintain eye contact with client and summarize the client's feeings.
- ANSWER-d. Maintain eye contact with the 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 the someone is genuinely concerned,
then he may believe that help is available. Maintaining eye contact demonstrates support, empathy, and
advocacy.
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.
- ANSWER-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 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 following behaviors is this client displaying?
a. Grandeur
b. Flight of ideas
c. Erotomania
d. Ideas of reference
- ANSWER-d. Ideas of reference
Ideas of reference occur when a client believes that conversation of others always concern him and that
others are ridiculing him.
, RN ATI CAPSTONE PROCTURED
COMPREHENSIVE ASSESMENT 2023
A nurse is preparing to administer diphenhydramine 50 mg PO every 6 hr to a client who has acute dystonia.
Available is diphenhydramine 25 mg tablets. How many tablets should the nurse administer per dose? (Round
to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
- ANSWER-2 tablet(s)
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?
a. "The ritualistic behavior provides sexual satisfaction."
b. "The client performs ritualistic behavior to boost self-esteem."
c. "The ritualistic behavior temporarily relieves anxiety."
d. "The client performs ritualistic behavior to decrease feelings of shame."
- ANSWER-c. "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 assisting a client who has schizophrenia prepare a relapse plan. Which of the following statements
should the nurse make?
a. "You should be aware that excessive sleeping is an early sign of relapse."
b. "Relapse is an indication that you are not taking your medications properly."
c. "You should keep your provider's and therapist's number with you."
d. "Taking an additional dose of medication is appropriate as soon as signs of relapse appear."
- ANSWER-c. "You should keep your provider's and therapist's number with you."
The client should have a written plan, including important numbers, available at all times in case relapse
occurs.
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)
a. Contact the laboratory to obtain a blood sample.
b. Prepare the client for a CT scan.
c. Check the client's pupil reactivity.
d. Obtain a urine specimen.
e. Performa. developmental screening test.
- ANSWER-a. Contact the laboratory to obtain a blood sample - A blood sample allows for a blood alcohol
level test to be performed.
b. Prepare the client for a CT scan - A CT scan or other neurological tests is performed to rule out brain
injury or head trauma.
c. Check the client's pupil reactivity - Checking for pupil reactivity provides information about a client's
neurological status.
d. Obtain a urine specimen - A urine specimen is needed to perform a urine toxicology screen.
The nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of
the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?
a. Disclose some personal information to the client to demonstrate approachability.
b. Wait for the client to initiate interaction.
