ATI Ch 1

Question 1

Assessment

Answer 1

Use touch to communicate caring as appropriate.
Include questions related to difficulty sleeping, incontinence, falls or other injuries, depression, dizziness, loss of energy.

Question 2

Psychosocial history assess for…..

Answer 2

Assess the client’s perception of own health, beliefs about illness and wellness.
Use of substances
Stress levels, coping abilities

Question 3

Cultural beliefs and practices

Answer 3

The nurses awareness of culture alleviates stereotyping and stigmatizing.

Question 4

Alert

Answer 4

The client is responsive and able to fully respond by opening their eye and responding to a normal tone of voice and speech. The client answers questions spontaneously and appropriately.

Question 5

Lethargic

Answer 5

The client is able to open their eyes and respond but is drowsy and falls asleep readily.

Question 6

Stuporous

Answer 6

The client requires vigorous or painful stimuli to elicit a brief response. Might not be able to respond verbally.

Question 7

Comatose

Answer 7

The client is unconscious and does not respond to painful stimuli.

Question 8

Decorticate rigidity

Answer 8

Flexion and internal rotation of upper-extremity joints and legs

Question 9

Decerebrate rigidity

Answer 9

Neck and elbow extension, wrist and finger flexion.

Question 10

Mental Status Examination (MSE)

Answer 10

Cognitive Level

Mood, appearance, physical behavior, speech, nonverbal communication, thought processes

Question 11

Affect

Answer 11

is an objective expression of mood (a flat affect or a lack of facial expression.)

Question 12

mini mental state examination (MMSE)

Answer 12

This examination is used to objectively assess a client’s cognitive status:
Orientation to time and place
Attention span and ability to calculate backward by seven
Registration and recalling of objects
Language, including naming of objects, following of commands, and ability to write.

Question 13

HEADSS assessment tool

Answer 13

Home environment 
Education employment
Activities
Drug and Substance abuse
Sexuality
Suicide/depression
safety

Question 14

DSM-5

Answer 14

used to diagnose mental health disorders

Establishes diagnostic criteria for individual mental health disorders.
Indicates recommended pharmacological tx for MHD.
Indicates expected assessment findings of MHD’s.

Question 15

Therapeutic strategies

Answer 15

Counseling

Milieu Therapy - Orienting the client to the physical setting. Identifying rules and boundaries of the setting. Ensuring a safe environment for the client. Assisting the client to participate in appropriate activities.

Promotion of self care activities
Psychobiological interventions 
Cognitive and behavioral therapies
Health Teaching
Health promotion and health maintenance
Case management

Question 16

A charge nurse is discussing mental status examinations with a newly licensed nurse. Which of the following statements NLN indicates an understanding of the teaching?

Answer 16

To assess cognitive ability, I should ask the client to count backwards by sevens.
To assess affect, I should observe the client’s facial expression.
To assess language ability I should instruct the client to write a sentence.

Question 17

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 psychological intervention?

Answer 17

Monitor the client for adverse effects of medications.

Question 18

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 a priority?

Answer 18

Identify the client’s perception of their mental status.