ATI Mental Health B 2019
Verified Q&A
, ATI Mental Health B 2019
1) A nurse is assessing a family’s dynamics during a counseling session. The nurse should recognize which
of the following findings as an indication of a boundary issue?
-An adolescent family member who questions parental authority
An adolescent who questions parental authority is demonstrating appropriate behavior for developmental
age.
-A family with three generations in the same household
This scenario occurs in many households, and it is not an indication of a boundary issue.
-Older children who are responsible for their younger siblings
This is an example of enmeshed boundaries in which there are no distinctions between the roles of family
members.
-Two adults and their children from prior relationships in the same household
This is an example of a blended family, and it is not an indication of a boundary issue.
2) A nurse is performing an admission assessment on a client and notices that the client appears
withdrawn and fearful. To establish a trusting nurse client relationship. Which of the following actions
should the nurse take first?
-Inform the client that this admission is confidential.
According to evidence-based practice, the nurse should first inform the client about confidentiality during
the orientation phase of the nurse-client relationship.
-Introduce the client to other clients in the day room.
The nurse should introduce the client to other clients in the day room to help the client interact with others
during the working phase of the nurse-client relationship. However, evidence-based practice indicates that
the nurse should take a different action first.
-Assist the client in facilitating behavioral change.
The nurse should assist the client with behavioral change during the working phase of the nurse-client
relationship. However, evidence-based practice indicates that the nurse should take a different action first.
-Determine coping strategies that the client has used in the past.
The nurse should determine what coping strategies the client used in the past during the working phase of
the nurse-client relationship. However, evidence-based practice indicates that the nurse should take a
different action first.
3) A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client
whose family reports episodes of confusion. Which of the following assessment findings supports the
nurse’s suspicion of delirium?
-Slow onset
Delirium has an acute onset. Dementia is a slow, progressive decline.
-Aphasia
Aphasia is a manifestation of dementia.
-Confabulation
, Confabulation is a manifestation of dementia.
-Easily distracted
Extreme distractibility is a hallmark manifestation of delirium.
4) A nurse is caring for an older adult client who is experiencing delirium. Which of the following
interventions should the nurse include in the client’s plan of care?
-Offer the client various choices for meal selection.
The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety
by limiting the choices the client is asked to make.
-Assign different nursing personnel for each shift.
The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety
by providing consistent nursing personnel.
-Permit the client to perform daily rituals to decrease anxiety.
The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety
by permitting the client to perform daily rituals.
-Maintain an environment that has low lighting.
The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety
by providing a well-lit environment.
5) A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing
mania. Which of the following interventions should the nurse include in the plan of care?
-Encourage the client to participate in group therapy.
The nurse should maintain a low-stimuli environment for a client who is experiencing mania. The nurse
should dim the lights, decrease noise, and limit the number of people the client is around.
-Instruct the client to avoid napping during the day.
The nurse should encourage the client to take frequent rest periods throughout the day. Clients experiencing
mania are at risk of exhaustion that can be life threatening.
-Offer the client high-calorie finger foods frequently.
The nurse should frequently offer the client high-calorie foods that can be eaten while the client is on the
go. Clients experiencing mania might be unable to sit down for meals and can experience weight loss and
dehydration.
-Decrease the client's daily fiber intake.
The nurse should encourage the client to eat foods and snacks that are high in fiber. Clients experiencing
mania can experience dehydration and nutritional deficiencies from decreased intake, which can lead to
constipation.
6) A nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of
acute mania. Which of the following findings should the client's partner report to the provider?
-Obsessive attention to detail
During the manic phase of bipolar disorder, a client's behavior becomes disorganized and chaotic, which
renders the client unable to focus on detail.
-Inability to sleep
During acute mania, the client is extremely active and does not sleep, which can lead to exhaustion.
Therefore, the nurse should instruct the partner to report this finding.
-Reports of fatigue
Verified Q&A
, ATI Mental Health B 2019
1) A nurse is assessing a family’s dynamics during a counseling session. The nurse should recognize which
of the following findings as an indication of a boundary issue?
-An adolescent family member who questions parental authority
An adolescent who questions parental authority is demonstrating appropriate behavior for developmental
age.
-A family with three generations in the same household
This scenario occurs in many households, and it is not an indication of a boundary issue.
-Older children who are responsible for their younger siblings
This is an example of enmeshed boundaries in which there are no distinctions between the roles of family
members.
-Two adults and their children from prior relationships in the same household
This is an example of a blended family, and it is not an indication of a boundary issue.
2) A nurse is performing an admission assessment on a client and notices that the client appears
withdrawn and fearful. To establish a trusting nurse client relationship. Which of the following actions
should the nurse take first?
-Inform the client that this admission is confidential.
According to evidence-based practice, the nurse should first inform the client about confidentiality during
the orientation phase of the nurse-client relationship.
-Introduce the client to other clients in the day room.
The nurse should introduce the client to other clients in the day room to help the client interact with others
during the working phase of the nurse-client relationship. However, evidence-based practice indicates that
the nurse should take a different action first.
-Assist the client in facilitating behavioral change.
The nurse should assist the client with behavioral change during the working phase of the nurse-client
relationship. However, evidence-based practice indicates that the nurse should take a different action first.
-Determine coping strategies that the client has used in the past.
The nurse should determine what coping strategies the client used in the past during the working phase of
the nurse-client relationship. However, evidence-based practice indicates that the nurse should take a
different action first.
3) A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client
whose family reports episodes of confusion. Which of the following assessment findings supports the
nurse’s suspicion of delirium?
-Slow onset
Delirium has an acute onset. Dementia is a slow, progressive decline.
-Aphasia
Aphasia is a manifestation of dementia.
-Confabulation
, Confabulation is a manifestation of dementia.
-Easily distracted
Extreme distractibility is a hallmark manifestation of delirium.
4) A nurse is caring for an older adult client who is experiencing delirium. Which of the following
interventions should the nurse include in the client’s plan of care?
-Offer the client various choices for meal selection.
The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety
by limiting the choices the client is asked to make.
-Assign different nursing personnel for each shift.
The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety
by providing consistent nursing personnel.
-Permit the client to perform daily rituals to decrease anxiety.
The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety
by permitting the client to perform daily rituals.
-Maintain an environment that has low lighting.
The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety
by providing a well-lit environment.
5) A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing
mania. Which of the following interventions should the nurse include in the plan of care?
-Encourage the client to participate in group therapy.
The nurse should maintain a low-stimuli environment for a client who is experiencing mania. The nurse
should dim the lights, decrease noise, and limit the number of people the client is around.
-Instruct the client to avoid napping during the day.
The nurse should encourage the client to take frequent rest periods throughout the day. Clients experiencing
mania are at risk of exhaustion that can be life threatening.
-Offer the client high-calorie finger foods frequently.
The nurse should frequently offer the client high-calorie foods that can be eaten while the client is on the
go. Clients experiencing mania might be unable to sit down for meals and can experience weight loss and
dehydration.
-Decrease the client's daily fiber intake.
The nurse should encourage the client to eat foods and snacks that are high in fiber. Clients experiencing
mania can experience dehydration and nutritional deficiencies from decreased intake, which can lead to
constipation.
6) A nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of
acute mania. Which of the following findings should the client's partner report to the provider?
-Obsessive attention to detail
During the manic phase of bipolar disorder, a client's behavior becomes disorganized and chaotic, which
renders the client unable to focus on detail.
-Inability to sleep
During acute mania, the client is extremely active and does not sleep, which can lead to exhaustion.
Therefore, the nurse should instruct the partner to report this finding.
-Reports of fatigue
