ATI CMS MENTAL HEALTH REVIEW EXAM WITH
CORRECT ANSWERS LATEST UPDATED 2023
LOC - ALERT (Correct Answer) - patient is responsive
opens eyes
... [Show More] spontaneously
answers questions appropriately
LOC - LETHARGIC (Correct Answer) - patient can open eyesand
respond to questions
falls asleep easily
LOC - OBTUNDED (Correct Answer) - patient responds to light
shaking
is confused
slow to respond
LOC - STUPOROUS (Correct Answer) - patient barely respondsto
painful stimuli
*example*
rubbing sternum
LOC - COMATOSE (Correct Answer) - patient is unresponsive
abnormal posturing may be present
DECORTICATE POSTURING (Correct Answer) - arms
flexed/internally rotated
legs extended/internally rotated
DECEREBRATE POSTURING (Correct Answer) - head arched back
arms/legs extended
AUTONOMY (Correct Answer) - patient has the right to make
their own decisions even if not in their best interest
BENEFICENCE (Correct Answer) - do what is best for the
patient
*do good*
FIDELITY (Correct Answer) - keep your promises
loyalty/faithfulness
JUSTICE (Correct Answer) - provide fairness in care and
allocation of resources
NONMALEFICENCE (Correct Answer) - do no harm
VERACITY (Correct Answer) - tell the truth
PATIENT RIGHTS - REFUSAL OF TREATMENT (Correct Answer) -
even patients who are involuntarily admitted have the right to
refuse treatment
PATIENT RIGHTS - CONFIDENTIALITY (Correct Answer) - HIPAA
states that health information cannot be released without
patient's permission
client's right to privacy continues even after death
CONFIDENTIALITY - NURSING ACTIONS (Correct Answer) - if
someone calls to get an update, suggest they reach out to the
patient's family
if you overhear a conversation in a public space, take action to
stop the violation
PATIENT RIGHTS - MANDATORY REPORTING (Correct Answer) -
nurses are required to report suspicion of abuse
warn/protect third parties who are at risk for harm
INFORMED CONSENT - PROVIDER RESPONSIBILITIES (Correct Answer) -
communicate purpose of procedure
provide a complete description of procedure in patient's primary
language (use interpreter if needed)
explain risks vs. benefits
describe other options to treat condition
INFORMED CONSENT - NURSE/RN RESPONSIBILITIES (Correct Answer) -
make sure provider gave patient appropriate informationregarding
procedure
ensure that patient is competent to give informed consent
have patient sign consent document
notify provider if patient has more questions or doesn't
understand information provided
RESTRAINTS - TYPES (Correct Answer) - *Physical*
- vest
- belt
- mitten
Chemical
- sedative Rx
- antipsychotic Rx
RESTRAINTS - ALTERNATIVES (Correct Answer) - provide verbal
interventions
diversions
calm/quiet environment
RESTRAINTS - PRESCRIPTIONS (Correct Answer) - MUST BE IN
WRITING
prescription must be rewritten every 24 hours
in an emergency situation, a nurse may use restraints, but must
obtain a written prescription per facility policy (usually within
15-30 minutes)
RESTRAINTS - TIME LIMITS (Correct Answer) - Adults
4 hours
Ages 9 - 17
2 hours
*Ages 8 and Under*
1 hour
RESTRAINTS - DOCUMENTATION (Correct Answer) - complete
every 15-30 minutes
*include the following:*
- precipitating event
- alternative interventions attempted
- time treatment began
- medication(s) administered
- patient assessment (current behavior, VS, pain)
- patient care provided (food, toileting [Show Less]