ATI - Mental Health Proctored Exam
Study Guide Summer 2023|All Questions
and Correct Detailed Answers |A grade|
77 Pages
The client is responsive and able to fully respond by opening their eyes and attending to
a normal tone of voice and speech. What is the level of consciousness? - -Alert
-The client is able to open their eyes and respond but is drowsy and falls asleep readily.
What is the level of consciousness? - -Lethargic
-The client requires vigorous or painful stimuli (pinching a tendon or rubbing the
sternum) to elicit a brief response. They might not be able to respond verbally. What is
the level of consciousness? - -Stuporous
-The client is unconscious and does not respond to painful stimuli. What is the level of
consciousness? - -Comatose
-How to test a client's immediate memory - -Ask the client to repeat a series of
numbers or a list of objects
-How to test a client's recent memory - -Ask the client to recall recent events, such as
visitors from the current day, or the purpose of the current mental health appointment
or admission
-How to test a client's remote memory - -Ask the client to state a fact from his past that
is verifiable, such as his birth date or his mother's maiden name
-How to assess a client's ability to calculate - -Ask the client to count backward from
100 in sevens
-How to assess a client's ability to think abstractly - -Ask the client to interpret
something complex such as, "A bird in the hand is worth two in the bush."
-Glasgow coma scale - -Used to obtain a baseline assessment of a client's level of
consciousness; highest score is 15 and indicates that the client is awake and responding
appropriately; a score of 7 or less indicates that the client is in a coma
, -Serious mental illness - -Includes disorders classified as severe and persistent mental
illnesses; clients often have difficulty with ADLs; can be chronic or recurrent
-A charge nurse is discussing mental status exams with a newly licensed nurse. Which
of the following statements by the newly licensed nurse indicates an understanding of
the teaching? (Select all that apply)
A. "To assess cognitive ability, I should ask the client to count backward by sevens."
B. "To assess affect, I should observe the client's facial expression."
C. "To assess language ability, I should instruct the client to write a sentence."
D. "To assess remote memory, I should have the client repeat a list of objects."
E. "To assess the client's abstract thinking, I should ask the client to identify our most
recent presidents." - -A. Counting backward by sevens is an appropriate technique to
assess a client's cognitive ability.
B. Observing a client's facial expression is appropriate when assessing affect.
C. Writing a sentence is an indication of language ability. Remote language is tested by
asking the client to state a fact from his past that his verifiable (date of birth). Abstract
thinking is tested by asking the client to interpret something.
-A nurse is planning care for a client who has a mental health disorder. Which of the
following actions should the nurse include as a psychobiological intervention?
A. Assist the client with systematic desensitization therapy.
B. Teach the client appropriate coping mechanisms.
C. Assess the client for comorbid health conditions.
D. Monitor the client for adverse effects of the medications. - -D. Monitoring for
adverse effects of medications is an example of a psychobiological intervention.
Systematic desensitization is cognitive and behavioral. Teaching coping mechanisms is a
counseling or health teaching. Assessing for comorbid conditions is health promotion
and maintenance.
-A nurse in an outpatient mental health clinic is preparing to conduct an initial client
interview. When conducting the interview, which of the following actions should the
nurse identify as the priority?
A. Coordinate holistic care with social services.
B. Identify the client's perception of her mental health status.
C. Include the client's family in the interview.
D. Teach the client about her current mental health disorder. - -B. Assessment is the
priority action. Identifying the client's perception of her mental health status provides
important information about the client's psychosocial history.
, -A nurse is told during change of shift report that a client is stuporous. When assessing
the client, which of the following findings should the nurse expect?
A. The client arouses briefly in response to a sternal rub.
B. The client has a glasgow coma scale score less than 7.
C. The client exhibits decorticate rigidity.
D. The client is alert but disoriented to time and place. - -A. A client who is stuporous
requires vigorous or painful stimuli to elicit a response. B & C occur with comatose
patients.
-A nurse is planning a peer group discussion about the DSM-5. Which of the following
information is appropriate to include in the discussion? (Select all that apply)
A. The DSM-5 includes client education handouts for mental health disorders.
B. The DSM-5 establishes diagnostic criteria for individual mental health disorders.
C. The DSM-5 indicates recommended pharmacological treatment for mental health
disorders.
D. The DSM-5 assists nurses in planning care for client's who have mental health
disorders.
E. The DSM-5 indicates expected assessment findings of mental health disorders. - -B,
D, & E.
The DSM-5 establishes diagnostic criteria, assists nurses in planning care, and identifies
expected findings for mental health disorders. The DSM-5 does not contain client
education handouts or recommended pharmacological treatment.
-Beneficence - -The quality of doing good, can be described as charity
-Autonomy - -The client's right to make their own decisions
-Justice - -Fair and equal treatment for all
-Fidelity - -Loyalty and faithfulness to the client and to one's duty
-Veracity - -Honesty when dealing with a client
-Requirements for restraining a patient - -Provider must prescribe the restraint in
writing; time limits are based on age, 4 hr for adults, 2 hr for ages 9-17, 1 hr for age 8
and younger; must be reviewed every 24 hr; documentation must be done every 15-30
min
, -False imprisonment - -Confining a client to a specific area if the reason for such
confinement is for the convenience of the staff
-Assault - -Making a threat to a client's person
-Battery - -Touching a client in a harmful or offensive way
-A nurse in an emergency mental health facility is caring for a group of clients. The
nurse should identify that which of the following clients requires a temporary
emergency admission?
A. A client who has schizophrenia with delusions of grandeur
B. A client who has manifestations of depression and attempted suicide a year ago
C. A client who has borderline personality disorder and assaulted a homeless man with a
metal rod
D. A client who has bipolar disorder and paces quickly around the room while talking to
himself - -C. A client who is a current danger to self or others is a candidate for a
temporary emergency admission.
-A nurse decides to put a client who has a psychotic disorder in seclusion overnight
because the unit is very short-staffed, and the client frequently fights with other clients.
The nurse's actions are an example of which of the following torts?
A. Invasion of privacy
B. False imprisonment
C. Assault
D. Battery - -B. Secluding a client for the convenience of the staff is false imprisonment.
-A client tells a nurse, "Don't tell anyone but I hid a sharp knife under my mattress in
order to protect myself from my roommate, who is always yelling at me and threatening
me." Which of the following actions should the nurse take?
A. Keep the client's communication confidential, but talk to the client daily, using
therapeutic communication to convince him to admit to hiding the knife.
B. Keep the client's communication confidential, but watch the client and his roommate
closely.
C. Tell the client that this must be reported to the health care team because it concerns
the health and safety of the client and others.
D. Report the incident to the health care team, but do not inform the client of the
intention to do so. - -C. The information presented by the client is a serious safety issue
that the nurse must report to the health care team, using the ethical principle of
veracity.
Study Guide Summer 2023|All Questions
and Correct Detailed Answers |A grade|
77 Pages
The client is responsive and able to fully respond by opening their eyes and attending to
a normal tone of voice and speech. What is the level of consciousness? - -Alert
-The client is able to open their eyes and respond but is drowsy and falls asleep readily.
What is the level of consciousness? - -Lethargic
-The client requires vigorous or painful stimuli (pinching a tendon or rubbing the
sternum) to elicit a brief response. They might not be able to respond verbally. What is
the level of consciousness? - -Stuporous
-The client is unconscious and does not respond to painful stimuli. What is the level of
consciousness? - -Comatose
-How to test a client's immediate memory - -Ask the client to repeat a series of
numbers or a list of objects
-How to test a client's recent memory - -Ask the client to recall recent events, such as
visitors from the current day, or the purpose of the current mental health appointment
or admission
-How to test a client's remote memory - -Ask the client to state a fact from his past that
is verifiable, such as his birth date or his mother's maiden name
-How to assess a client's ability to calculate - -Ask the client to count backward from
100 in sevens
-How to assess a client's ability to think abstractly - -Ask the client to interpret
something complex such as, "A bird in the hand is worth two in the bush."
-Glasgow coma scale - -Used to obtain a baseline assessment of a client's level of
consciousness; highest score is 15 and indicates that the client is awake and responding
appropriately; a score of 7 or less indicates that the client is in a coma
, -Serious mental illness - -Includes disorders classified as severe and persistent mental
illnesses; clients often have difficulty with ADLs; can be chronic or recurrent
-A charge nurse is discussing mental status exams with a newly licensed nurse. Which
of the following statements by the newly licensed nurse indicates an understanding of
the teaching? (Select all that apply)
A. "To assess cognitive ability, I should ask the client to count backward by sevens."
B. "To assess affect, I should observe the client's facial expression."
C. "To assess language ability, I should instruct the client to write a sentence."
D. "To assess remote memory, I should have the client repeat a list of objects."
E. "To assess the client's abstract thinking, I should ask the client to identify our most
recent presidents." - -A. Counting backward by sevens is an appropriate technique to
assess a client's cognitive ability.
B. Observing a client's facial expression is appropriate when assessing affect.
C. Writing a sentence is an indication of language ability. Remote language is tested by
asking the client to state a fact from his past that his verifiable (date of birth). Abstract
thinking is tested by asking the client to interpret something.
-A nurse is planning care for a client who has a mental health disorder. Which of the
following actions should the nurse include as a psychobiological intervention?
A. Assist the client with systematic desensitization therapy.
B. Teach the client appropriate coping mechanisms.
C. Assess the client for comorbid health conditions.
D. Monitor the client for adverse effects of the medications. - -D. Monitoring for
adverse effects of medications is an example of a psychobiological intervention.
Systematic desensitization is cognitive and behavioral. Teaching coping mechanisms is a
counseling or health teaching. Assessing for comorbid conditions is health promotion
and maintenance.
-A nurse in an outpatient mental health clinic is preparing to conduct an initial client
interview. When conducting the interview, which of the following actions should the
nurse identify as the priority?
A. Coordinate holistic care with social services.
B. Identify the client's perception of her mental health status.
C. Include the client's family in the interview.
D. Teach the client about her current mental health disorder. - -B. Assessment is the
priority action. Identifying the client's perception of her mental health status provides
important information about the client's psychosocial history.
, -A nurse is told during change of shift report that a client is stuporous. When assessing
the client, which of the following findings should the nurse expect?
A. The client arouses briefly in response to a sternal rub.
B. The client has a glasgow coma scale score less than 7.
C. The client exhibits decorticate rigidity.
D. The client is alert but disoriented to time and place. - -A. A client who is stuporous
requires vigorous or painful stimuli to elicit a response. B & C occur with comatose
patients.
-A nurse is planning a peer group discussion about the DSM-5. Which of the following
information is appropriate to include in the discussion? (Select all that apply)
A. The DSM-5 includes client education handouts for mental health disorders.
B. The DSM-5 establishes diagnostic criteria for individual mental health disorders.
C. The DSM-5 indicates recommended pharmacological treatment for mental health
disorders.
D. The DSM-5 assists nurses in planning care for client's who have mental health
disorders.
E. The DSM-5 indicates expected assessment findings of mental health disorders. - -B,
D, & E.
The DSM-5 establishes diagnostic criteria, assists nurses in planning care, and identifies
expected findings for mental health disorders. The DSM-5 does not contain client
education handouts or recommended pharmacological treatment.
-Beneficence - -The quality of doing good, can be described as charity
-Autonomy - -The client's right to make their own decisions
-Justice - -Fair and equal treatment for all
-Fidelity - -Loyalty and faithfulness to the client and to one's duty
-Veracity - -Honesty when dealing with a client
-Requirements for restraining a patient - -Provider must prescribe the restraint in
writing; time limits are based on age, 4 hr for adults, 2 hr for ages 9-17, 1 hr for age 8
and younger; must be reviewed every 24 hr; documentation must be done every 15-30
min
, -False imprisonment - -Confining a client to a specific area if the reason for such
confinement is for the convenience of the staff
-Assault - -Making a threat to a client's person
-Battery - -Touching a client in a harmful or offensive way
-A nurse in an emergency mental health facility is caring for a group of clients. The
nurse should identify that which of the following clients requires a temporary
emergency admission?
A. A client who has schizophrenia with delusions of grandeur
B. A client who has manifestations of depression and attempted suicide a year ago
C. A client who has borderline personality disorder and assaulted a homeless man with a
metal rod
D. A client who has bipolar disorder and paces quickly around the room while talking to
himself - -C. A client who is a current danger to self or others is a candidate for a
temporary emergency admission.
-A nurse decides to put a client who has a psychotic disorder in seclusion overnight
because the unit is very short-staffed, and the client frequently fights with other clients.
The nurse's actions are an example of which of the following torts?
A. Invasion of privacy
B. False imprisonment
C. Assault
D. Battery - -B. Secluding a client for the convenience of the staff is false imprisonment.
-A client tells a nurse, "Don't tell anyone but I hid a sharp knife under my mattress in
order to protect myself from my roommate, who is always yelling at me and threatening
me." Which of the following actions should the nurse take?
A. Keep the client's communication confidential, but talk to the client daily, using
therapeutic communication to convince him to admit to hiding the knife.
B. Keep the client's communication confidential, but watch the client and his roommate
closely.
C. Tell the client that this must be reported to the health care team because it concerns
the health and safety of the client and others.
D. Report the incident to the health care team, but do not inform the client of the
intention to do so. - -C. The information presented by the client is a serious safety issue
that the nurse must report to the health care team, using the ethical principle of
veracity.
