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Mental Health Nursing - ATI questions and answers verified answers||Latest 2024/2025
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Mental Health Nursing - ATIUnit1 Ch1: Basic Concepts
List the three foundations that set the standards for client care in the mental health setting - 1.
American Nurses Association
2. American Psychiatric Nurses Association
3. International Society of Psychiatric-Mental Health Nurses
Mental health nurses should use the _________ process, as well as a ___________ approach,
which includes ____, _____, ______, & _____ aspects. in client care. - a) Nursing process
b) holistic approach
c) biological
d) social
e) psychological
f) and spiritual aspects
Describe the levels of consciousness:
1. Alert
2. Lethargy
3. Obtundation
4. Stupor
5. Coma - 1. Alert- client is responsive, eyes open, fully able to respond, answer questions
normally, appropriately
2. Lethargy- can open eyes & respond but easily falls asleep
3. Obtundation- needs to be lightly shaken, may be confused and slow to respond
4. Stupor- requires painful stimuli to elicit brief response, may not be able to respond verbally
5. Coma- no response achieved via painful stimuli, abnormal posturing may be present
-->*A-L-O-S-C - (all alphabetical except C)*
1. Decorticate rigidity
2. Decerebrate rigidity - 1. Decorticate rigidity - flexion and internal rotation of upper extremity &
joints
2. Decerebrate rigidity - neck & elbow extension, wrist & finger flexion --> Sounds like vertebrae
- which is straight, whereas decorticate is all flexed up and twisted in
Difference between a client's mood and affect - Mood is the subjective information supplied
about their emotions while affect is an objective expression of their mood
--> "He says he is in a good mood, but he seems to have such a flat affect all the time"
The Glasgow Coma Scale evaluates what?
a) And a score of 3 would represent?
, b) A score of 15? - The GCS obtains a baseline assessment of a client's consciousness for
ongoing assessment
a) Score of 3 = coma
b) Score of 15 = alert, awake, oriented
What is a good assessment for assessing psychosocial risk factors in an adolescent? - The
psychosocial assessment tool: HEADSS - Home, Education/employment, peer group, Activities,
Drugs, Sexuality, and Suicide/depression
What are some assessment scales that would be used with the older adult patient? - 1. Geriatric
Depression Scale
2. Michigan Alcoholism Screening Test
3. MMSE (all age groups)
4. Wong-Baker FACES pain scale, McGill Pain Questionnaire MPQ, or Pain Assessment in
Advanced Dementia scale PAINAD
DSMV-IV Multiaxial system for assessment
Axis I
Axis II
Axis III
Axis IV
Axis V - Axis I - All disorders except for axis II disorders
Axis II - Personality disorders and mental retardation
Axis III - Any General medical diagnosis (ie asthma)
Axis IV - Psychosocial problems that may affect dx, tx, prog
Axis V - Global Assessment of Functioning (GAF)
--> *A-P-A-P-G*
Global Assessment of Functioning
1. Score 80-100
2. Score 60-80
3. Score 40 and below
4. GAF of 50/80 means what? - 1. Score 80-100 = normal, near normal fxn
2. Score 60-80 = moderate problems
3. Score 40 and below = serious mental/functional disability
4. GAF of 50/80 means what? Patient has gone from near normal fxn of 80 the previous year,
down to moderately severe functional disabilities this year
Milieu Therapy - Type of therapy in which a substantial change in the client's immediate
environment is made to enhance other forms of therapy
--> Inpatient therapy in psych setting with prescription of social interactions & activities to meet
client's specific needs
Difference between the objective noticing of:
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