ANALYZED ATI RN CAPSTONE MENTAL
HEALTH COMPREHENSIVE ASSESSMENT
FORM A EXAM WITH CORRECT ANSWERS
Avnursevinvavmentalvhealthvclinicvisvassessingvavclientvwhovwasvbroughtvinvbyvhervadultvdaughtervstatingvtha
tvhervmothervhasvnotvbeenvablevtovleavevhervhomevforvweeksvbecausevshevisvafraidvtovbevoutdoorsvalone.vt
hevnursevshouldvanticipatevplanningvcarevforvmanagingvwhichvofvthevfollowingvphobias?
a.vXenophobia
b.vAcrophobia
c.vMysophobia
d.vAgoraphobiav-vCORRECTvANSWERv-d.vAgoraphobia
Agoraphobiavisvanvirrationalvfearvaboutvbeingvinvplacesvorvcircumstancesvwherevthevclientvwouldvnotvhavev
helpvinvtheveventvofvpanicvorvothervformsvofvanxiety.vFearvofvbeingvalonevoutdoorvisvavcommonvexample.
Avnursevisvprovidingvdischargevteachingvforvavclientvwhovhasvmultiplevmedicationvprescriptionsvandvmustvt
akevthevmedicationsvatvspecificvintervalsvwhenvatvhome.vWhichvofvthevfollowingvinstructionsvshouldvthevnu
rsevincludevinvthevteaching?
a.v"Youvreallyvshouldn'tvchangevthevschedulevwevestablishedvherevinvthevfacility."
b.v"Let'svworkvtogethervtovdevisevavtimevschedulevthatvisvconvenientvforvyouvonvavdailyvbasis."
c.v"We'llvhavevtovtalkvtovyourvprovidervaboutvswitchingvtovanvalternativevschedule."
d.v"Itvdoesn'tvreallyvmattervwhatvtimevyouvtakevyourvmedicationsvasvlongvasvyouvdon'tvskipvanyvdoses."v-
vCORRECTvANSWERv-
b.v"Let'svworkvtogethervtovdevisevavtimevschedulevthatvisvconvenientvforvyouvonvavdailyvbasis."
Thisvresponsevillustratesvthevtherapeuticvcommunicationvtechniquevofvformulatingvavplanvofvaction.vItvde
monstratesvthevnurse'svwillingnessvtovworkvwithvthevclientvtovmodifyvthevschedulevsovthatvitvmeetsvthevclie
nt'svneedsvatvthisvtime.
,Avnursevisvprovidingvdischargevteachingvto.vclientvwhovhasvbipolarvdisordervandvwillvbevdischargedvwithvavp
rescriptionvforvlithium.vThevnursevshouldvteachvthevclientvthatvwhichvofvthevfollowingvfactorsvputsvhervatvri
skvforvlithiumvtoxicity?
a.vThevclientvrunsv4vmilesvoutdoorsveveryvafternoon.
b.vThevclientvdrinksv2vlitersvofvliquidsvdaily.
c.vThevclientveatsv2vtov3vgramsvofvsodium-containingvfoodsvdaily.
d.vThevclientveatsvfoodsvhighvinvtyramine.v-vCORRECTvANSWERv-
a.vThevclientvrunsv4vmilesvoutdoorsveveryvafternoon.v
Strenuousvexercisevinvoutdoorvheat,vwhichvcanvleadvtovdehydration,vputsvthevclientvatvriskvforvlithiumvtoxic
ity.vMildvtovmoderatevexercisevwillvnotvleadvtovlithiumvtoxicity,vbutvifvthevclientvengagesvinvstrenuousvexerc
isevduringvhotvweather,vshevshouldvtakevcarevtovreplacevanyvwatervthatvmayvhavevbeenvlostvthroughvprofu
sevsweating.vthisvalsovappliesvtovothervfactorsvthatvcanvcausevthevclientvtovbecomevdehydrated,vsuchvasvha
vingvdiarrheavorvtakingvdiuretics.
Avnursevinvavemergencyvdepartmentvisvassessingvavclientvforvsuspectedvcocainevintoxication.vWhichvofvthev
followingvfindingsvshouldvthevnursevexpect?
a.vNystagmus
b.vDilatedvpupils
c.vHypersomnia
d.vDepressionv-vCORRECTvANSWERv-b.vDilatedvpupils
Dilatedvpupilsvarevavfindingvofvcocainevintoxicationvduevtovthevstimulationvofvthevsympatheticvnervousvsyst
em.
Avnurseventersvthevroomvofvavclientvwhovbecomesvverballyvabusive.vWhichvofvthevfollowingvactionsvshouldv
thevnursevtake?
a.vInformvthevclientvofvconsequences.
b.vSpeakvslowlyvinvavlow,vcalmvvoice.
, c.vForbidvthevclientvfromvspeakingvinvanvabusivevmanner.
d.vRemainvavdistancevofv1vftvawayvfromvthevclient.v-vCORRECTvANSWERv-
b.vSpeakvslowlyvinvavlow,vcalmvvoice.
Speakingvinvthisvmannervconveysvtovthevclientvthatvthevnursevisvcontrolled,vnonthreatening,vandvcaring.
Avnursevisvcaringvforvavclientvwhovlostvallvhisvpossessionsvinvavhousevfirevandvstates,v"IvhavevnovideavwhatvIva
mvgoingvtovdo.vIvcannotvthinkvrightvnow."vWhichvofvthevfollowingvactionsvshouldvthevnursevtake?
a.vIdentifyvothervhousingvoptionsvandvsourcesvofvtransportation.
b.vNotifyvthevfacilityvchaplainvtovrequestvschedulingvanvappointment.
c.vConfirmvthatveverythingvwillvbevalrightvbecausevbelongingsvcanvbevreplaced.
d.vMaintainveyevcontactvwithvclientvandvsummarizevthevclient'svfeeings.v-vCORRECTvANSWERv-
d.vMaintainveyevcontactvwithvthevclientvandvsummarizevthevclient'svfeelings.
Thisvdemonstratesvtherapeuticvcommunication.vDuringvthevinitialvinterview,vitvisvimportantvforvthevnursevt
ovprovidevanvatmospherevofvsupportvandvsafety.vIfvavpersonvbelievesvthatvthevsomeonevisvgenuinelyvconce
rned,vthenvhevmayvbelievevthatvhelpvisvavailable.vMaintainingveyevcontactvdemonstratesvsupport,vempath
y,vandvadvocacy.
Avnursevinvavpsychiatricvunitvisvcaringvforvseveralvclients.vWhichvofvthevfollowingvclientsvshouldvthevnursevre
commendvforvgroupvtherapy?
a.vAvclientvwhovhasvbeenvtakingvamitriptylinevforv3vmonthsvforvdepression.
b.vAvclientvexhibitingvpsychoticvbehavior.
c.vAvclientvadmittedv12vhrvagovforvacutevmania.
d.vAvclientvwhovisvexperiencingvalcoholvintoxication.v-vCORRECTvANSWERv-
a.vAvclientvwhovhasvbeenvtakingvamitriptylinevforv3vmonthsvforvdepression.
HEALTH COMPREHENSIVE ASSESSMENT
FORM A EXAM WITH CORRECT ANSWERS
Avnursevinvavmentalvhealthvclinicvisvassessingvavclientvwhovwasvbroughtvinvbyvhervadultvdaughtervstatingvtha
tvhervmothervhasvnotvbeenvablevtovleavevhervhomevforvweeksvbecausevshevisvafraidvtovbevoutdoorsvalone.vt
hevnursevshouldvanticipatevplanningvcarevforvmanagingvwhichvofvthevfollowingvphobias?
a.vXenophobia
b.vAcrophobia
c.vMysophobia
d.vAgoraphobiav-vCORRECTvANSWERv-d.vAgoraphobia
Agoraphobiavisvanvirrationalvfearvaboutvbeingvinvplacesvorvcircumstancesvwherevthevclientvwouldvnotvhavev
helpvinvtheveventvofvpanicvorvothervformsvofvanxiety.vFearvofvbeingvalonevoutdoorvisvavcommonvexample.
Avnursevisvprovidingvdischargevteachingvforvavclientvwhovhasvmultiplevmedicationvprescriptionsvandvmustvt
akevthevmedicationsvatvspecificvintervalsvwhenvatvhome.vWhichvofvthevfollowingvinstructionsvshouldvthevnu
rsevincludevinvthevteaching?
a.v"Youvreallyvshouldn'tvchangevthevschedulevwevestablishedvherevinvthevfacility."
b.v"Let'svworkvtogethervtovdevisevavtimevschedulevthatvisvconvenientvforvyouvonvavdailyvbasis."
c.v"We'llvhavevtovtalkvtovyourvprovidervaboutvswitchingvtovanvalternativevschedule."
d.v"Itvdoesn'tvreallyvmattervwhatvtimevyouvtakevyourvmedicationsvasvlongvasvyouvdon'tvskipvanyvdoses."v-
vCORRECTvANSWERv-
b.v"Let'svworkvtogethervtovdevisevavtimevschedulevthatvisvconvenientvforvyouvonvavdailyvbasis."
Thisvresponsevillustratesvthevtherapeuticvcommunicationvtechniquevofvformulatingvavplanvofvaction.vItvde
monstratesvthevnurse'svwillingnessvtovworkvwithvthevclientvtovmodifyvthevschedulevsovthatvitvmeetsvthevclie
nt'svneedsvatvthisvtime.
,Avnursevisvprovidingvdischargevteachingvto.vclientvwhovhasvbipolarvdisordervandvwillvbevdischargedvwithvavp
rescriptionvforvlithium.vThevnursevshouldvteachvthevclientvthatvwhichvofvthevfollowingvfactorsvputsvhervatvri
skvforvlithiumvtoxicity?
a.vThevclientvrunsv4vmilesvoutdoorsveveryvafternoon.
b.vThevclientvdrinksv2vlitersvofvliquidsvdaily.
c.vThevclientveatsv2vtov3vgramsvofvsodium-containingvfoodsvdaily.
d.vThevclientveatsvfoodsvhighvinvtyramine.v-vCORRECTvANSWERv-
a.vThevclientvrunsv4vmilesvoutdoorsveveryvafternoon.v
Strenuousvexercisevinvoutdoorvheat,vwhichvcanvleadvtovdehydration,vputsvthevclientvatvriskvforvlithiumvtoxic
ity.vMildvtovmoderatevexercisevwillvnotvleadvtovlithiumvtoxicity,vbutvifvthevclientvengagesvinvstrenuousvexerc
isevduringvhotvweather,vshevshouldvtakevcarevtovreplacevanyvwatervthatvmayvhavevbeenvlostvthroughvprofu
sevsweating.vthisvalsovappliesvtovothervfactorsvthatvcanvcausevthevclientvtovbecomevdehydrated,vsuchvasvha
vingvdiarrheavorvtakingvdiuretics.
Avnursevinvavemergencyvdepartmentvisvassessingvavclientvforvsuspectedvcocainevintoxication.vWhichvofvthev
followingvfindingsvshouldvthevnursevexpect?
a.vNystagmus
b.vDilatedvpupils
c.vHypersomnia
d.vDepressionv-vCORRECTvANSWERv-b.vDilatedvpupils
Dilatedvpupilsvarevavfindingvofvcocainevintoxicationvduevtovthevstimulationvofvthevsympatheticvnervousvsyst
em.
Avnurseventersvthevroomvofvavclientvwhovbecomesvverballyvabusive.vWhichvofvthevfollowingvactionsvshouldv
thevnursevtake?
a.vInformvthevclientvofvconsequences.
b.vSpeakvslowlyvinvavlow,vcalmvvoice.
, c.vForbidvthevclientvfromvspeakingvinvanvabusivevmanner.
d.vRemainvavdistancevofv1vftvawayvfromvthevclient.v-vCORRECTvANSWERv-
b.vSpeakvslowlyvinvavlow,vcalmvvoice.
Speakingvinvthisvmannervconveysvtovthevclientvthatvthevnursevisvcontrolled,vnonthreatening,vandvcaring.
Avnursevisvcaringvforvavclientvwhovlostvallvhisvpossessionsvinvavhousevfirevandvstates,v"IvhavevnovideavwhatvIva
mvgoingvtovdo.vIvcannotvthinkvrightvnow."vWhichvofvthevfollowingvactionsvshouldvthevnursevtake?
a.vIdentifyvothervhousingvoptionsvandvsourcesvofvtransportation.
b.vNotifyvthevfacilityvchaplainvtovrequestvschedulingvanvappointment.
c.vConfirmvthatveverythingvwillvbevalrightvbecausevbelongingsvcanvbevreplaced.
d.vMaintainveyevcontactvwithvclientvandvsummarizevthevclient'svfeeings.v-vCORRECTvANSWERv-
d.vMaintainveyevcontactvwithvthevclientvandvsummarizevthevclient'svfeelings.
Thisvdemonstratesvtherapeuticvcommunication.vDuringvthevinitialvinterview,vitvisvimportantvforvthevnursevt
ovprovidevanvatmospherevofvsupportvandvsafety.vIfvavpersonvbelievesvthatvthevsomeonevisvgenuinelyvconce
rned,vthenvhevmayvbelievevthatvhelpvisvavailable.vMaintainingveyevcontactvdemonstratesvsupport,vempath
y,vandvadvocacy.
Avnursevinvavpsychiatricvunitvisvcaringvforvseveralvclients.vWhichvofvthevfollowingvclientsvshouldvthevnursevre
commendvforvgroupvtherapy?
a.vAvclientvwhovhasvbeenvtakingvamitriptylinevforv3vmonthsvforvdepression.
b.vAvclientvexhibitingvpsychoticvbehavior.
c.vAvclientvadmittedv12vhrvagovforvacutevmania.
d.vAvclientvwhovisvexperiencingvalcoholvintoxication.v-vCORRECTvANSWERv-
a.vAvclientvwhovhasvbeenvtakingvamitriptylinevforv3vmonthsvforvdepression.
