ATI RN
Behavioral Health Nursing Care Plans Questions
Question 1 of 5
A nurse asks a patient, If you had fever and vomiting for 3 days, what would you do? Which aspect of the mental status examination is the nurse assessing?
Correct Answer: B
Rationale: Assessing cognition involves evaluating a patient’s judgment and decision-making abilities. This question tests the patient’s ability to reason and respond appropriately to a hypothetical health scenario. A rational response like 'Call my doctor' indicates intact cognition, while poor judgment (e.g., 'I’d wait and see') suggests impairment. Options A, C, and D assess different aspects: behavior (observable actions), affect/mood (emotional state), and perceptual disturbances (hallucinations), none of which are directly tested by this question.
Question 2 of 5
The patient states that he is 14 trillion years old and created the world. The nurse documents this statement as an example of which type of thinking displayed by the patient?
Correct Answer: A
Rationale: A delusion is a fixed false belief not based in reality. Ideas of reference are client's inaccurate interpretation that general events are personally directed to him or her, such as hearing a speech on the news and believing the message had personal meaning. Word salad is flow of unconnected words that convey no meaning to the listener. Hallucinations are false sensory perceptions or perceptual experiences that do not really exist.
Question 3 of 5
A nurse assesses that a depressed patient is lethargic during the day and does not actively participate in unit activities. The notes from the night shift document that the patient did not sleep well. The most probable interpretation of these data is
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 4 of 5
A client made threats to harm his parents if they come too close to him. The parents called 911, and the client is now held involuntarily for a psychiatric evaluation. During this time of involuntary admission, the client retains all client rights except for which of the following?
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 5 of 5
When is a nurse legally obligated to breach confidentiality?
Correct Answer: B
Rationale: The duty to warn a third party exists when a client threatens harm to that identifiable third party; the client's confidentiality is overridden. Answer choices A, C, and D are not situations in which confidentiality may be breached. Decisions about the duty to warn third parties usually are made by psychiatrists or by qualified mental health therapists in outpatient settings. It is not permissible for a nurse to breach confidentiality at any time a client is threatening, or becomes aggressive or violates the nurse's boundaries.