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ATI MENTAL HEALTH PROCTORED EXAM
LATEST REAL QUESTIONS AND CORRECT
ANSWERS GRADE A
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 A nurse is preparing to assess an infant who has shaken baby syndrome. Which of the following is an expected finding? (Select all that apply) A. Sunken fontanels B. Respiratory distress C. Retinal hemorrhage D. Altered LOC E. Increase in head circumference - CORRECT ANSWER B, C, D, & E. Respiratory distress, retinal hemorrhage, altered LOS, and increased head circumference are expected findings of shaken baby syndrome. Bulging, rather than sunken, fontanels are an expected finding of shaken baby syndrome. A nurse working in an emergency department is assessing a preschool-age child who reports abdominal pain. When conducting a head-to-toe assessment, which of the following findings should alert the nurse to possible abuse?
A. Abrasions on knees B. Round burn marks on forearms C. Mismatched clothing D. Abdominal rebound tenderness E. Areas of ecchymosis on torso - CORRECT ANSWER B & E. Round burn marks anywhere on the child's body can indicate cigarette burns and should alert the nurse to possible abuse. Areas of ecchymosis on the torso, back, or buttocks should alert the nurse to possible abuse. Minor injuries on the arms and legs and mismatched clothing are common in this age group. Abdominal rebound tenderness is a possible indication or appendicitis rather than abuse. A nurse is preparing a community education seminar about family violence. When discussing types of violence, the nurse should include which of the following? A. Refusing to pay bills for a dependent, even when funds are available, is neglect. B. Intentionally causing an older adult to fall is an example of physical violence. C. Striking an intimate partner is an example of sexual violence. D. Failure to provide a stimulating environment for normal development is emotional abuse. - CORRECT ANSWER B. Physical violence occurs when physical pain or harm is directed toward another individual. A is economic maltreatment. C is physical violence. D is neglect.
interview, marked changes in sexual behavior, sudden onset of phobic reactions, no verbalization of the occurrence of sexual assault A nurse is discussing silent rape reaction with a newly licensed nurse. The nurse should identify which of the following characteristics as expected for this type of reaction? (Select all that apply) A. Sudden development of phobias B. Development of substance use disorder C. Increased level of anxiety during interview D. Reactivation of a prior physical disorder E. Unwillingness to discuss the sexual assault - CORRECT ANSWER A, C, & E. Sudden onset of phobic reactions, increased anxiety during interview, and not verbalizing the sexual assault are characteristics of a silent rape reaction. B and D are characteristics of a compound rape reaction. A nurse is assessing a client who experienced sexual assault. Which of the following findings indicate the client is experiencing an emotional reaction of rape-trauma syndrome? (Select all that apply) A. Genitourinary soreness B. Difficulties with low self-esteem C. Sleep disturbances D. Emotional outburst E. Difficulty making decisions - CORRECT ANSWER D & E. Emotional outbursts indicate an expressed initial reaction of rapetrauma syndrome. Difficulty making decisions indicates a controlled initial reaction of rape-trauma syndrome.
A and C are somatic reactions. B is a sustained and maladaptive emotional response beyond the initial reaction. A nurse is discussing the care of a client following a sexual assault with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "I will administer prophylactic treatment for sexually transmitted infections." B. "I am not required to obtain informed consent before the sexual assault nurse examiner collects forensic evidence." C. "I can expect manifestations of rape-trauma syndrome to be similar to bipolar disorder." D. "I should use narrative documentation when documenting subjective data." - CORRECT ANSWER A. The nurse should administer prophylactic treatment for STIs. Informed consent is required before collecting forensic evidence. Manifestations of rape-trauma syndrome are similar to PTSD. The nurse should document subjective data using the client's verbatim statements. A nurse is caring for a client who was recently raped. The client states, "I never should have been out on the street alone at night." Which of the following responses should the nurse make? A. "Your actions had nothing to do with what happened." B. "You should focus on recovery rather than blaming yourself for what happened."
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 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
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." E. "Client acted out after lunch." - CORRECT ANSWER B, C, & D. Documentation must include how much water was offered and how often, a description of the client's verbal communication, and the dosage and time of medication administration. Intake and behavior should be documented in the client's medical
record. A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first? A. Notify the nurse manager. B. Tell the nurse to stop discussing the behavior. C. Provide an in-service program about confidentiality. D. Complete an incident report. - CORRECT ANSWER B. The greatest risk to this client is invasion of privacy through the sharing of confidential information in a public place. The first action the nurse should take is to tell the newly licensed nurse to stop discussing the client's hallucinations in a public location. A nurse is caring for the parents of a child who has demonstrated changes in behavior and mood. When the mother of the child asks the nurse for reassurance about her son's condition, which of the following responses should the nurse make? A. "I think your son is getting better. What have you noticed." B. "I'm sure everything will be okay. It just takes time to heal." C. "I'm not sure whats wrong. Have you asked the doctor about your concerns?" D. "I understand you're concerned. Let's discuss what concerns you specifically." - CORRECT ANSWER D. This reflects upon and accepts the parents' feelings and allows them to clarify what they are feeling.
Rationalization - CORRECT ANSWER Creating reasonable and acceptable explanations for unacceptable behavior Dissociation - CORRECT ANSWER Creating a temporary compartmentalization or lack of connection between the person's identity, memory, or how they perceive the environment Denial - CORRECT ANSWER Pretending the truth is not reality to manage the anxiety of acknowledging what is real Compensation - CORRECT ANSWER Emphasizing strengths to make up for weaknesses Identification - CORRECT ANSWER Conscious or unconscious assumption of the characteristics of another individual or group Intellectualization - CORRECT ANSWER Separation of emotional and logical facts when analyzing or coping with a situation or event Conversion - CORRECT ANSWER Responding to stress through the unconscious development of physical manifestations not caused by a physical illness Splitting - CORRECT ANSWER Demonstrating an inability to reconcile negative and positive attributes of self or others Projection - CORRECT ANSWER Attributing one's unacceptable thoughts and feelings onto another who does not have them
Mild anxiety - CORRECT ANSWER Occurs in normal experience of everyday living, increases one's ability to perceive reality, has an identifiable cause Moderate anxiety - CORRECT ANSWER Slightly reduced perception and processing of information occurs and selective inattention can occur, ability to think clearly is hampered but learning and problem solving can still occur, may show increased HR and RR Severe anxiety - CORRECT ANSWER Perceptual field is greatly reduced with distorted perceptions, learning and problem solving do not occur, may cause increased HR and RR Panic level anxiety - CORRECT ANSWER Characterized by markedly disturbed behavior, cannot process what is occurring in the environment and can lose touch with reality, experiences extreme fight and horror A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm coughing because I have that cold that everyone has been getting." The nurse should identify that the client is using which of the following defense mechanisms? A. Reaction formation B. Denial C. Displacement D. Sublimation - CORRECT ANSWER B. This is an example of denial, which is pretending the truth is not reality to manage the anxiety of acknowledging what is real. A nurse is providing preoperative teaching for a client who was just informed that she requires emergency surgery. The client has
of another person who has been significant to the client's personal life Countertransference - CORRECT ANSWER Occurs when a health care team member displaces characteristics of people in her past onto a client A nurse is talking with a client who is at risk for suicide following the death of his spouse. Which of the following statements should the nurse make? A. "I feel very sorry for the loneliness you must be experiencing." B. "Suicide is not the appropriate way to cope with loss." C. "Losing someone close to you must be very upsetting." D. "I know how difficult it is to lose a loved one." - CORRECT ANSWER C. This statement is an empathetic response that attempts to understand the client's feelings. A focuses on the nurse's feelings. B implies judgment. D focuses on the nurse's experiences. A charge nurse is discussing the characteristics of a nurse-client relationship with a newly licensed nurse. Which of the following characteristics should the nurse include in the discussion? (Select all that apply) A. The needs of both participants are met. B. An emotional commitment exists between the participants. C. It is goal-directed. D. Behavioral change is encouraged. E. A termination date is established. - CORRECT ANSWER C, D, & E. A therapeutic nurse-client relationship is goal-directed,
encourages positive behavioral change, and has an established termination date. It should focus on the client only. An emotional commitment is a characteristic of an intimate or social relationship rather than a therapeutic relationship. A nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine use disorder. Which of the following actions indicates transference behavior? A. The client asks the nurse whether she will go out to dinner with him. B. The client accuses the nurses of telling him what to do just like his ex-girlfriend. C. The client reminds the nurse of a friend who died from a substance overdose. D. The client becomes angry and threatens to harm himself. - CORRECT ANSWER B. When a client views the nurse as having characteristics of another person who has been significant to his personal life, such as his ex-girlfriend, this indicates transference. A nurse is planning care for the termination phase of a nurseclient relationship. Which of the following actions should the nurse include in the plan of care? A. Discussing ways to use new behaviors B. Practicing new problem-solving skills C. Developing goals
