NGN ATI Capstone: Mental Health Final EXAM /LATEST GRADED A /NEW
VERSION
A nurse is caring for a client who lost all his possessions in a house fire and states, "i have no idea what i
am going to do. I cannot even think right now". Which of the following actions should the nurse take?
Identify other housing options and sources of transportation.
Notify the facility chaplain to request scheduling an appointment.
Confirm that everything will be all right because belongings can be replaced.
Maintain eye contact with client and summarize the client's feelings. - CORRECT ANSWER Maintain eye
contact with client and summarize the client's feelings;
A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following actions
should the nurse take?
Avoid the use of nonverbal gestures to prevent miscommunication.
Overlook the client's frustration with communication.
Inform the client about scheduled daily activities.
Present the client with multiple choices to promote autonomy. - CORRECT ANSWER Inform the client
about scheduled daily activities;
Discussing scheduled daily activities assists in orienting the client to time and reality throughout the day.
A nurse is caring for a client who has an anxiety disorder. Which of the following statements by the client
indicates successful use of guided imagery?
"I imagine my negative emotions consuming my thoughts."
"I imagine solving my problems over and over again."
"I imagine myself being overwhelmed during difficult times."
"I imagine myself lying on a beach when I start to feel stressed." - CORRECT ANSWER "I imagine myself
lying on a beach when I start to feel stressed.";
1
,Envisioning oneself in a peaceful, calm environment enhances relaxation and is an example of using
guided imagery.
A nurse is assessing a toddler during a well child visit. Which of the following findings should the nurse
identify and report to the provider as an indication of physical maltreatment?
Several round burns on the soles of the feet
An abrasion on the elbow
Two bruises on the right shin in various stages of healing
A contusion on the forehead - CORRECT ANSWER Several round burns on the soles of the feet;
Although minor injuries are common in toddlers due to their general lack of coordination, the nurse
should identify that physical findings such as round burns on the soles of a child's feet can indicate
potential physical maltreatment. Burns such as these can be made with a cigarette or a cigar and should
alert the nurse to a potential instance of maltreatment that should be reported to the provider.
A nurse is caring for a client who becomes agitated while playing a game of cards with other clients. The
client stands up, throws the cards on the floor, and says, "I don't want to play anymore." Which of the
following actions should the nurse take?
Ignore the client's outburst.
Whisper reassuring comments in the client's ear.
Allow the client to choose another activity.
Ask the client to accompany the nurse to another area. - CORRECT ANSWER Ask the client to
accompany the nurse to another area;
The nurse should ask the client in a calm and nonthreatening manner to walk with them to another area,
away from the location of the outburst. Removing the client from the situation will ensure the safety of
the other clients as well as deescalate the situation.
A nurse is discussing types of crises with a newly licensed nurse. Which of the following experiences
should the nurse include as an example of maturational crisis?
2
, Assault
Retirement
House fire
Job change - CORRECT ANSWER Retirement;
The nurse should include retirement as an example of a maturational crisis. A maturational crisis is an
internal crisis that leads to psychosocial regression or growth. It is a naturally occurring event in a client's
life. Other examples of a maturational crisis include marriage, the birth of children, and the death of
parents.
A nurse is caring for a client whose partner died 1 year ago. The client states I feel so lonely. I don't go
out with my friends anymore. The nurse should identify that the client is isn which of the following
stages of grief?
Anger
Bargaining
Depression
Denial - CORRECT ANSWER Depression;
The nurse should identify that the client is in the depression stage of the grieving process. This stage
includes withdrawal, regression, and social isolation.
A nurse is caring for a client who has schizophrenia. Which of the following manifestations should the
nurse identify as negative symptoms of schizophrenia?
Auditory hallucinations
Delusions
Lack of emotion
Loose association of ideas - CORRECT ANSWER Lack of emotion;
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VERSION
A nurse is caring for a client who lost all his possessions in a house fire and states, "i have no idea what i
am going to do. I cannot even think right now". Which of the following actions should the nurse take?
Identify other housing options and sources of transportation.
Notify the facility chaplain to request scheduling an appointment.
Confirm that everything will be all right because belongings can be replaced.
Maintain eye contact with client and summarize the client's feelings. - CORRECT ANSWER Maintain eye
contact with client and summarize the client's feelings;
A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following actions
should the nurse take?
Avoid the use of nonverbal gestures to prevent miscommunication.
Overlook the client's frustration with communication.
Inform the client about scheduled daily activities.
Present the client with multiple choices to promote autonomy. - CORRECT ANSWER Inform the client
about scheduled daily activities;
Discussing scheduled daily activities assists in orienting the client to time and reality throughout the day.
A nurse is caring for a client who has an anxiety disorder. Which of the following statements by the client
indicates successful use of guided imagery?
"I imagine my negative emotions consuming my thoughts."
"I imagine solving my problems over and over again."
"I imagine myself being overwhelmed during difficult times."
"I imagine myself lying on a beach when I start to feel stressed." - CORRECT ANSWER "I imagine myself
lying on a beach when I start to feel stressed.";
1
,Envisioning oneself in a peaceful, calm environment enhances relaxation and is an example of using
guided imagery.
A nurse is assessing a toddler during a well child visit. Which of the following findings should the nurse
identify and report to the provider as an indication of physical maltreatment?
Several round burns on the soles of the feet
An abrasion on the elbow
Two bruises on the right shin in various stages of healing
A contusion on the forehead - CORRECT ANSWER Several round burns on the soles of the feet;
Although minor injuries are common in toddlers due to their general lack of coordination, the nurse
should identify that physical findings such as round burns on the soles of a child's feet can indicate
potential physical maltreatment. Burns such as these can be made with a cigarette or a cigar and should
alert the nurse to a potential instance of maltreatment that should be reported to the provider.
A nurse is caring for a client who becomes agitated while playing a game of cards with other clients. The
client stands up, throws the cards on the floor, and says, "I don't want to play anymore." Which of the
following actions should the nurse take?
Ignore the client's outburst.
Whisper reassuring comments in the client's ear.
Allow the client to choose another activity.
Ask the client to accompany the nurse to another area. - CORRECT ANSWER Ask the client to
accompany the nurse to another area;
The nurse should ask the client in a calm and nonthreatening manner to walk with them to another area,
away from the location of the outburst. Removing the client from the situation will ensure the safety of
the other clients as well as deescalate the situation.
A nurse is discussing types of crises with a newly licensed nurse. Which of the following experiences
should the nurse include as an example of maturational crisis?
2
, Assault
Retirement
House fire
Job change - CORRECT ANSWER Retirement;
The nurse should include retirement as an example of a maturational crisis. A maturational crisis is an
internal crisis that leads to psychosocial regression or growth. It is a naturally occurring event in a client's
life. Other examples of a maturational crisis include marriage, the birth of children, and the death of
parents.
A nurse is caring for a client whose partner died 1 year ago. The client states I feel so lonely. I don't go
out with my friends anymore. The nurse should identify that the client is isn which of the following
stages of grief?
Anger
Bargaining
Depression
Denial - CORRECT ANSWER Depression;
The nurse should identify that the client is in the depression stage of the grieving process. This stage
includes withdrawal, regression, and social isolation.
A nurse is caring for a client who has schizophrenia. Which of the following manifestations should the
nurse identify as negative symptoms of schizophrenia?
Auditory hallucinations
Delusions
Lack of emotion
Loose association of ideas - CORRECT ANSWER Lack of emotion;
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