ATI Learning Systems - Mental Health 1
Exam Review Guide (answered) 2022
While taking a health history from a client in the outpatient mental health clinic,
nurse observes that the client is persistent in making personal inquiries. Which of
the following is the most therapeutic response?
- Explain to the client that this time is for him
Focus of relationship is on the client's ideas, experiences, and feelings.
A nurse is caring for a client diagnosed with dementia. She should understand that
the goal of reminiscence therapy in long term care facilities is to....
- share memories of past experiences and events
Which of the following is an important short term goal for a nurse to plan with a
suicidal client?
- sign a contract pledging not to act on suicide plans
A nurse's neighbor has just found out that her teenage child died in a motor vehicle
accident. The neighbor is crying inconsolably. Which of the following is an
appropriate therapeutic nursing response?
- Sit silently with the client while he cries. Being silent is a communication that is
appropriate at times of grieving
A parent brings an 18 month old child to the ER, the child sustained a fractured left
femur. Which of the following statements by the parent might make the nurse
suspect child abuse?
- My child was riding a bicycle and got the right foot caught in the spokes. Kid is
TOO young and not developmentally capable of riding a bike
A nurse should assess that the client with the highest potential for suicide is the
depressed client who states which of the following?
- I don't feel like going to group therapy today. I don't want to be with other
people.
- manifestation of severe depression
A nurse is caring for a client dx with disorganized schizophrenia. The client does
not return a visitors greeting and instead lies down on the bed and curls up in the
fetal position. Which of the following defense mechanisms is the client exhibiting?
,- Regression - represents dysfunctional attempt to reduce anxiety and conflict by
returning to less mature behaviors that help the client tolerate the anxiety
A client was admitted to the psychiatric unit with a dx of bippolar d/o. At 3a the
client runs to the nurses station and demands to see the therapist immediately.
Which of the following responses by the nurse is appropriate?
- You must be very upset about something to want to see your therapist in the
middle of the night
A client is admitted to the psych unit following tx in the ER for an intentional OD
ingestion. As the nurse performs the admission assessment, the client says Why
would you want to waste your time on a worthless person like me? Appropriate
therapeutic response?
- I think you are worthwhile, and I want to talk to you - offering one's self
The nurse should document that a client is experiencing mild anxiety when the
nurse observes which of the following?
- The client is extremely alert. A heightened perceptual field and increased
awareness
Sharpened perceptions are an expected finding for a client who is experiencing
mild anxiety. Mild anxiety occurs daily during normal experiences and allows an
individual to grasp more information and problem-solve more effectively. As stress
increases, the client's perceptual field narrows and they are able to focus only on
the source of the anxiety..
A nurse is working in a busy pediatric ER. In which of the following cases should
the nurse maintain a high index of suspicion of physical child abuse?
- A 9 month old who reportedly nearly drowned after climbing into the tub and
turning on the water - inconsistent with developmental abilities
A client who is bipolar states to the psych nurse in the mental health outreach
clinic, "I no longer take my meds because I like to feel manic." Appropriate
response?
A) You might feel good now, but what about when you get depressed?
B) Why do you think you like feeling manic?
C) You feel better when you don't take your medication?
D) What do you think your provider will say about you going off your medication?
- C) You feel better when you don't take your medication?
, Rationale: Therapeutic communication tool of validating or clarifying the client's
feelings. This open-ended paraphrasing acknowledges the client's statement and
allows for further exploration of the subject.
The nurse in the oncology unit provides support to the parents of a child newly dx
with a glioblastoma tumor of the brain. In planning care, the nurse understands the
parents initial reaction to a potentially terminal illiness in their child is....
- denial and disbelief
A widow is brought to the clinic by her adult son, who found her at home crying.
She said that she could not go on alone. He tells the nurse that when his father died
six months earlier, and the family was amazed at his mother's fortitude during and
immediately after the funeral. She did not cry or seem unduly upset. The nurse
recognizes that his mother had previously dealt with her husbands death by using
which defense mechanism?
- Denial
A nurse is caring for a client who is scheduled for a cardiac catheterization. When
arriving for the procedure, the nurse reports waking that morning with butterflies in
the stomach, a sense of restlessness, urinary frequency, and some difficulty
concentrating while driving to the hospital. The admitting nurse should assess the
client's anxiety level as which of the following?
- Moderate - combination of physical s/s and difficulty concentrating
The nurse asks a client who is suicidal to make a safety contract. The client states
to the nurse I cannot make a safety contract, because I can't promise that I will not
harm myself. Nurse's plan of care, initial action to ensure client safety?
- Have a staff member stay with the client at all times.
A client is admitted to the detoxification center for AA. On the day after
admission, the client develops hand tremors, and asks the nurse about them.
Appropriate nurse response?
- They will persist for a few days, now that you are not drinking
A client dx with borderline personality d/o, has become attached to one of the
nurses who calls in sick one day. When given the news the client breaks a glass
bottle, and uses it to self-inflict a deep scratch. After providing first aid, therapeutic
nursing response to client behavior?
- Help the client verbalize her feelings and reasons for the acting out behavior
Exam Review Guide (answered) 2022
While taking a health history from a client in the outpatient mental health clinic,
nurse observes that the client is persistent in making personal inquiries. Which of
the following is the most therapeutic response?
- Explain to the client that this time is for him
Focus of relationship is on the client's ideas, experiences, and feelings.
A nurse is caring for a client diagnosed with dementia. She should understand that
the goal of reminiscence therapy in long term care facilities is to....
- share memories of past experiences and events
Which of the following is an important short term goal for a nurse to plan with a
suicidal client?
- sign a contract pledging not to act on suicide plans
A nurse's neighbor has just found out that her teenage child died in a motor vehicle
accident. The neighbor is crying inconsolably. Which of the following is an
appropriate therapeutic nursing response?
- Sit silently with the client while he cries. Being silent is a communication that is
appropriate at times of grieving
A parent brings an 18 month old child to the ER, the child sustained a fractured left
femur. Which of the following statements by the parent might make the nurse
suspect child abuse?
- My child was riding a bicycle and got the right foot caught in the spokes. Kid is
TOO young and not developmentally capable of riding a bike
A nurse should assess that the client with the highest potential for suicide is the
depressed client who states which of the following?
- I don't feel like going to group therapy today. I don't want to be with other
people.
- manifestation of severe depression
A nurse is caring for a client dx with disorganized schizophrenia. The client does
not return a visitors greeting and instead lies down on the bed and curls up in the
fetal position. Which of the following defense mechanisms is the client exhibiting?
,- Regression - represents dysfunctional attempt to reduce anxiety and conflict by
returning to less mature behaviors that help the client tolerate the anxiety
A client was admitted to the psychiatric unit with a dx of bippolar d/o. At 3a the
client runs to the nurses station and demands to see the therapist immediately.
Which of the following responses by the nurse is appropriate?
- You must be very upset about something to want to see your therapist in the
middle of the night
A client is admitted to the psych unit following tx in the ER for an intentional OD
ingestion. As the nurse performs the admission assessment, the client says Why
would you want to waste your time on a worthless person like me? Appropriate
therapeutic response?
- I think you are worthwhile, and I want to talk to you - offering one's self
The nurse should document that a client is experiencing mild anxiety when the
nurse observes which of the following?
- The client is extremely alert. A heightened perceptual field and increased
awareness
Sharpened perceptions are an expected finding for a client who is experiencing
mild anxiety. Mild anxiety occurs daily during normal experiences and allows an
individual to grasp more information and problem-solve more effectively. As stress
increases, the client's perceptual field narrows and they are able to focus only on
the source of the anxiety..
A nurse is working in a busy pediatric ER. In which of the following cases should
the nurse maintain a high index of suspicion of physical child abuse?
- A 9 month old who reportedly nearly drowned after climbing into the tub and
turning on the water - inconsistent with developmental abilities
A client who is bipolar states to the psych nurse in the mental health outreach
clinic, "I no longer take my meds because I like to feel manic." Appropriate
response?
A) You might feel good now, but what about when you get depressed?
B) Why do you think you like feeling manic?
C) You feel better when you don't take your medication?
D) What do you think your provider will say about you going off your medication?
- C) You feel better when you don't take your medication?
, Rationale: Therapeutic communication tool of validating or clarifying the client's
feelings. This open-ended paraphrasing acknowledges the client's statement and
allows for further exploration of the subject.
The nurse in the oncology unit provides support to the parents of a child newly dx
with a glioblastoma tumor of the brain. In planning care, the nurse understands the
parents initial reaction to a potentially terminal illiness in their child is....
- denial and disbelief
A widow is brought to the clinic by her adult son, who found her at home crying.
She said that she could not go on alone. He tells the nurse that when his father died
six months earlier, and the family was amazed at his mother's fortitude during and
immediately after the funeral. She did not cry or seem unduly upset. The nurse
recognizes that his mother had previously dealt with her husbands death by using
which defense mechanism?
- Denial
A nurse is caring for a client who is scheduled for a cardiac catheterization. When
arriving for the procedure, the nurse reports waking that morning with butterflies in
the stomach, a sense of restlessness, urinary frequency, and some difficulty
concentrating while driving to the hospital. The admitting nurse should assess the
client's anxiety level as which of the following?
- Moderate - combination of physical s/s and difficulty concentrating
The nurse asks a client who is suicidal to make a safety contract. The client states
to the nurse I cannot make a safety contract, because I can't promise that I will not
harm myself. Nurse's plan of care, initial action to ensure client safety?
- Have a staff member stay with the client at all times.
A client is admitted to the detoxification center for AA. On the day after
admission, the client develops hand tremors, and asks the nurse about them.
Appropriate nurse response?
- They will persist for a few days, now that you are not drinking
A client dx with borderline personality d/o, has become attached to one of the
nurses who calls in sick one day. When given the news the client breaks a glass
bottle, and uses it to self-inflict a deep scratch. After providing first aid, therapeutic
nursing response to client behavior?
- Help the client verbalize her feelings and reasons for the acting out behavior
