RN ATI PRE ASSESSMENT, PROCTORED EXAM FOR
LEVEL 3|TEST BANK 2024-25 COMPREHENSIVE
QUESTIONS AND ANSWERS
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? - (correct
answer) Alert
The client is able to open their eyes and respond but is drowsy and falls asleep readily.
What is the level of consciousness? - (correct answer) 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? - (correct answer) Stuporous
The client is unconscious and does not respond to painful stimuli. What is the level of
consciousness? - (correct answer) Comatose
How to test a client's immediate memory - (correct answer) Ask the client to repeat a
series of numbers or a list of objects
How to test a client's recent memory - (correct answer) 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 - (correct answer) 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 - (correct answer) Ask the client to count
backward from 100 in sevens
How to assess a client's ability to think abstractly - (correct answer) Ask the client to
interpret something complex such as, "A bird in the hand is worth two in the bush."
Glasgow coma scale - (correct answer) 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 - (correct answer) 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." - (correct answer) 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. - (correct answer) 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. - (correct answer) 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. - (correct answer) 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. -
(correct answer) 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 - (correct answer) The quality of doing good, can be described as charity
Autonomy - (correct answer) The client's right to make their own decisions
Justice - (correct answer) Fair and equal treatment for all
Fidelity - (correct answer) Loyalty and faithfulness to the client and to one's duty
Veracity - (correct answer) Honesty when dealing with a client
Requirements for restraining a patient - (correct answer) 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 - (correct answer) Confining a client to a specific area if the
reason for such confinement is for the convenience of the staff
Assault - (correct answer) Making a threat to a client's person
Battery - (correct answer) 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 - (correct answer) 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 - (correct answer) 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. - (correct answer) 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.
A nurse is caring for a client who is in mechanical restraints. Which of the following
statements should the nurse include in the documentation? (Select all that apply)
A. "Client ate most of his breakfast."
B. "Client was offered 8 oz of water every hr."
C. "Client shouted obscenities at assistive personnel."
D. "Client received chlorpromazine 15 mg by mouth at 1000."
LEVEL 3|TEST BANK 2024-25 COMPREHENSIVE
QUESTIONS AND ANSWERS
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? - (correct
answer) Alert
The client is able to open their eyes and respond but is drowsy and falls asleep readily.
What is the level of consciousness? - (correct answer) 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? - (correct answer) Stuporous
The client is unconscious and does not respond to painful stimuli. What is the level of
consciousness? - (correct answer) Comatose
How to test a client's immediate memory - (correct answer) Ask the client to repeat a
series of numbers or a list of objects
How to test a client's recent memory - (correct answer) 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 - (correct answer) 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 - (correct answer) Ask the client to count
backward from 100 in sevens
How to assess a client's ability to think abstractly - (correct answer) Ask the client to
interpret something complex such as, "A bird in the hand is worth two in the bush."
Glasgow coma scale - (correct answer) 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 - (correct answer) 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." - (correct answer) 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. - (correct answer) 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. - (correct answer) 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. - (correct answer) 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. -
(correct answer) 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 - (correct answer) The quality of doing good, can be described as charity
Autonomy - (correct answer) The client's right to make their own decisions
Justice - (correct answer) Fair and equal treatment for all
Fidelity - (correct answer) Loyalty and faithfulness to the client and to one's duty
Veracity - (correct answer) Honesty when dealing with a client
Requirements for restraining a patient - (correct answer) 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 - (correct answer) Confining a client to a specific area if the
reason for such confinement is for the convenience of the staff
Assault - (correct answer) Making a threat to a client's person
Battery - (correct answer) 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 - (correct answer) 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 - (correct answer) 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. - (correct answer) 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.
A nurse is caring for a client who is in mechanical restraints. Which of the following
statements should the nurse include in the documentation? (Select all that apply)
A. "Client ate most of his breakfast."
B. "Client was offered 8 oz of water every hr."
C. "Client shouted obscenities at assistive personnel."
D. "Client received chlorpromazine 15 mg by mouth at 1000."
