ATI Mental Health Practice Exam A

ATI Mental Health Practice Exam A A nurse is interviewing a client at a temporary shelter after surviving the destruction of her home by a tornado. When assessing the client, the nurse should ask which of the following questions to determine the patient’s ability to cope with this situation? - "To whom do you talk when you feel overwhelmed?" - By asking this question, the nurse is assessing the client’s support system, which is an important factor in the client’s ability to cope with the situation. A nurse is caring for a patient who gave birth to a stillborn baby. Which of the following statements should the nurse make? - "I'll stay with you just in case you want to talk." - This response indicates the nurse’s interest in the client and a desire to understand the client’s feelings. A nurse on a medical-surgical unit is assessing a client who sustained injuries 12 hours ago following a motor-vehicle crash. The client’s admission blood alcohol level was 325 mg/dL. Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal? - BP 154/96 mm Hg - Physical manifestations of alcohol withdrawal occur in addition to psychological effects. A client who is experiencing alcohol withdrawal is expected to have hypertension, tachycardia, and fever greater than 38.3°C (101°F). It will be important for the nurse to rule out infection in the client who has fever. A nurse is teaching a family member and a client who has a sew diagnosis of Alzheimer’s disease and is to start taking donepezil. Which of the following statements should the nurse include in the teaching? - "Take this medication in the evening at bedtime." - The client should take this medication in the evening for optimal effectiveness. - A client should never double the dose after a missed dose due to adverse effects of the medication but should notify the provider. Chewing, crushing, or splitting the medication can affect the absorption of the medication. If the client has difficulty swallowing, the provider can prescribe orally disintegrating tablets. A nurse is discussing a 12-step program with a patient who has alcohol use disorder and is in an acute care facility undergoing detoxification. Which of the following information should the nurse include in the teaching? - The client should obtain a sponsor before discharge for an increased chance of recovery.- This is because the client-sponsor relationship has been shown to increase program attendance and the chances of recovery. During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in her bed. She reports that a bomb was placed in her room by a family member during visiting hours. Which of the following actions should the nurse take? - Assess the client for evidence of a perceptual disturbance. - The nurse should assess the situation to determine if the client is hallucinating or misperceiving external stimuli (experiencing illusions). A nurse is admitting a patient with major depression disorder and a new prescription for tranylcypromine. Which of the following OTC medications that the patient reports taking should alert the nurse to a potential adverse reaction? - Phenylephrine - Tranylcypromine is an MAOI antidepressant, which should not be taken with phenylephrine and other OTC medications for sinus congestions, colds, or allergies due to their actions on the sympathetic nervous system, which can result in severe hypertension. A nurse is assessing a patient with schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder? - Anhedonia - Negative symptoms of schizophrenia affect a person’s ability to interact with others and are less dominant than the positive symptoms. These symptoms develop over time. Examples are flat affect, anergia (lack of energy), anhedonia (inability to enjoy otherwise pleasurable activities), and thought blocking. A nurse emergency department is caring for a female adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Which of the following statements by the mother acknowledges her daughter's diagnosis? - "She won't let me take the trash from her room. I'm concerned about what she has in there." - The client might be binge eating and attempting to hide her food containers, which is a common behavior among clients who have bulimia nervosa. The mother’s statement indicates awareness of her daughter’s behavior. A nurse is assessing a client who has major depressive disorder and has been receiving amitriptyline for 1 week. Which of the following outcomes should the nurse expect? - Greater risk of attempting suicide as affect and energy improve.- An initial response to amitriptyline can develop in 1 week. For a client who has been severely depressed with suicidal ideation, the energy to carry out a plan is more possible after 1 week or treatment. A nurse in a community health center is teaching families of clients who have PTSD about expected clinical manifestations. Which of the following manifestations should the nurse include? - Experiences feelings of isolation - Clients who have PTSD often feel estranged and detached from others. A nurse is caring for a client who has anorexia nervosa. Which of the following criteria requires hospitalization? - Temperature 35.6°C (96.1°F) - Severe hypothermia, a temperature lower than 36°C (96.8°F) due to loss of subcutaneous tissue or dehydration requires hospitalization. A nurse is caring for a client who is experiencing alcohol withdrawals. Which of the following medications should the nurse administer first? - Diazepam 5 mg IV bolus - The greatest risk to the client experiencing alcohol withdrawal is seizures, an elevated heart rate, and elevated blood pressure. IV diazepam acts rapidly to prevent seizures, stabilize vital signs, and decrease the intensity of withdrawal manifestations. A patient with a diagnosis of depression is attending a group therapy. During the meeting, the nurse asks each member to identify one goal for the day. When it is the client’s turn, she does not respond. Which of the following actions should the nurse take before repeating the request to the patient? - Allow the client time to collect her thoughts. - Slowed response time is common in clients who have depression. The nurse should allow the client time to comprehend and formulate an answer to the question. A nurse observes a patient who has acute mania hit another patient first action to take? - Call for a team of staff members to help with the situation. - The greatest risk is injury to the client and others. Therefore, the first action the nurse should take is to call for assistance to prevent further injury to himself or others. A nurse is providing teaching to a patient who is to begin undergoing light therapy at home to treat seasonal affective disorder. Which of the following should the nurse include in the teaching?- Wear sunglasses when outdoors. - Light therapy, or phototherapy, can cause eye strain and sensitivity to light. A client who has bipolar disorder is to be discharged home with a prescription for lithium. Which of the following statements indicates that the client teaching regarding the medication has been effective? - "I should eat a regular diet with normal amounts of salt and fluids." - This statement indicates that the client understands the teaching because normal levels of sodium and fluid need to be maintained to ensure adequate excretion of lithium. If sodium levels are low, the body compensates by decreasing lithium excretion, which can lead to toxicity. A nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice? - Spending adequate time with a client who is verbally abusive. - By spending time with a client who is verbally abusive, the nurse is demonstrating the ethical principle of justice. When the nurse spends an appropriate amount of time with each client regardless of their behavior and in keeping with their individual needs, the nurse guarantees that all clients receive equal care. A nurse is working with a group of parents who recently lost a child. Which of the following actions should the nurse take? - Suggest forming a weekly support group for parents who have experienced the loss of a child. - Support groups are q positive resource in the process of recovery for parents who have lost a child. A nurse in a mental health clinic is planning care for a client who has a new prescription for olanzapine. Which of the following interventions should the nurse identify as the priority? - Instruct the client to avoid driving during initial therapy. - The greatest risk to client is injury resulting from drowsiness or dizziness. Therefore, the nurse’s priority intervention is to instruct the client to avoid activities that require mental alertness during initial medication therapy. A nurse is preparing to discharge an older adult client who attempted suicide to his home where he lives alone and has difficulty performing ADLs. Which of the following referrals should the nurse initiate? (select all) - Occupational therapy - Meal delivery services - Physical therapy- Home health services. - An occupational therapist can assist the client to perform ADL’s. Meal delivery services are necessary due to the client’s difficulty performing ADL’s. A physical therapist can assess the client’s mobility needs and assist with ADL’s. Home health services provide a nursing assessment of the client’s physical and mental status, as well as assistance with ADL’s. A nurse is reviewing laboratory results for a client who has schizophrenia and is taking clozapine. Which of the following values should the nurse identify as a contraindication for receiving clozapine? - WBC 2500/mm3 - This drug can cause agranulocytosis, which can be fatal due to overwhelming infection. The nurse should identify a WBC count below 3000/mm3 as a possible manifestation of agranulocytosis and should withhold the medication and notify the prescriber. A nurse in an outpatient mental health setting is collecting a health history from a patient who is taking paroxetine for depression. The client reports to the nurse that he is also taking herbal supplements. The nurse should advise the client that which of the following supplements has interacts adversely with paroxetine? - St. John's wort - This is an herbal supplement that decreases the reuptake of serotonin. The nurse should advise the client that taking St. John’s Wart with anther medication that also inhibits the reuptake of serotonin, such as paroxetine, places the client at risk for serotonin syndrome. A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? - "I will update the plan of care as a client's manifestations of depression change". - The nurse should update the plan of care as a client’s status and needs change. While observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors is consistent with this condition? - The client needs excessive external input to make everyday decisions. - Clients who have dependent personality disorder need excessive input from others to make everyday decisions. A nurse is caring for a child who is taking methylphenidate. The nurse should monitor the child for which of the following findings as an adverse effect of methylphenidate? - TachycardiaA nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following client behaviors indicates effectiveness of the therapy? - Refrains from manipulating others to earn dining-room privileges. - The goal of operant conditioning is to provide positive reinforcement in return for desired outcome. Refraining from manipulative behavior is a desired outcome. A nurse is planning care for a client with generalized anxiety disorder. At which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques? - Mild - This is when the client will be able to concentrate and process information A nurse is caring for a client in a mental health facility. The nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse take? - Report the occurrence to the charge nurse. - It is the charge nurse and nurse manager’s responsibility to confront the staff member about her behavior toward the client. A nurse is caring for a client who has attempted suicide and has alcohol use disorder. Which of the following statements indicates that the client is using a positive coping mechanism? - "I will attend daily group therapy sessions to practice relaxation techniques." - Relaxation techniques de crease the risk for self-harm by decreasing stress, anxiety, and depression. A nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. Which of the following interventions should the nurse include in the plan? - Renew the prescription for the client every 4 hours. - The nurse should assess the client’s behavior frequently during seclusion and should renew the prescription for seclusion every 4 hours, for a maximum of 24 hours. A nurse is planning care for a client who has depression and has made frequent suicide attempts. Which of the following statements indicates the client has a decreased risk for suicide. - "It is easier to talk about my feelings now. - When clients express their feelings, this indicates a positive treatment outcome.A nurse is reviewing routine laboratory values for several patients who are taking lithium carbonate. Which of the following clients should the nurse further assess for findings indicating lithium toxicity? - A client who has a sodium level of 128 mEq/L - This sodium level should alert the nurse that the client is at risk for lithium toxicity because renal excretion of lithium is decreased in the presence of a low sodium level. Expected findings for bulimia nervosa. - Tooth erosion. A nurse is planning care for a preschool-age child who has ADHD. Which of the following interventions should the nurse identify as the priority? - Remove unnecessary equipment from the child's surroundings. - The greatest risk for a child with ADHD is injury from impulsive behavior and the decreased ability to perceive self-harm. Therefore, the priority intervention is to remove unnecessary equipment from the child’s surroundings. A nurse is reviewing the chart of a client who has dissociative amnesia. Which of the following findings should the nurse expect? - The client was seriously injured while under the influence of alcohol - A traumatic event that causes severe stress is a trigger for dissociative amnesia. A nurse is caring for a client who has a recent diagnosis of Alzheimer's disease. The client’s partner asks the nurse about expected manifestations. The nurse should teach the partner to expect which of the following manifestations to occur first? - Frequently misplaces objects - According to EVB, the nurse should identify that mild cognitive impairment, such as frequently misplacing objects, is one of the first manifestations expected to occur for a client who has Alzheimer’s disease. As the disease progresses, other manifestations of moderate and severe cognitive impairment will occur. A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects and kicking others. Which of the following therapeutic nursing interventions is the priority? - Reduce environmental stimuli - The greatest risk to the child and others is harm. Therefore, the nurse’s priority intervention is to reduce environmental stimuli in an attempt to de-escalate the behavior and prevent injury.A nurse is assessing a client for risk factors for the development of depression. The nurse should identify that which of the following factors places the client at an increased risk for depression? - The client has COPD - Clients who have a medical illness are at an increased risk for the development of depression. A nurse is admitting a client who has anorexia nervosa and is at 60% of ideal body weight. Which of the following interventions should the nurse include in the plan of care? - Encourage the client to drink 125 mL of fluid each hour while awake. - This is to maintain hydration. A patient who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression. The client with depression reports, "That man in my room never sleeps and he keeps me up, too." Which of the following in an appropriate action for the nurse to take? - Move the client who bipolar disorder to a private room. - Clients who have bipolar disorder can disrupt the therapeutic milieu for other clients. Therefor, the nurse should move this client to a private room. - Clients who have severe depression are often at risk for self-harm and feel isolated. Therefore, the nurse should not move this client to a private room. A nurse is planning care for a client who is to undergo electroconvulsive therapy (ECT). Which of the following actions should the nurse include in the plan of care? - Monitor the client's cardiac rhythm during the procedure. - The seizure induced during ECT can stress that client’s heart. Therefore, the nurse should plan to monitor the client’s cardiac rhythm during ECT via an ECG. A nurse is obtaining a mental health history from an older adult client. Which of the following actions should the nurse plan to take? - Interview the client in a private setting. A nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and a fear of gaining weight. The client states, "I'm so fat I can't even stand to look at myself." Which of the following therapeutic responses demonstrates the nurse's use of summarizing? - "You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight."Planning prevention strategies for intimate partner abuse in the community. Which of the following strategies should the nurse include as a method of secondary prevention? - Establish screening programs to identify at-risk clients. A nurse in a mental health clinic is caring for a patient who has bipolar disorder and reports that she stopped taking lithium 2 weeks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the patient to stop taking the medication? - Hand tremors - Fine hand tremors are an expected effect of lithium and can interfere with the client’s ADL’s, causing the client to stop takin the medication A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who weighs 110 lbs. Available is chlorpromazine syrup 10mg/5mL. How many mL should the nurse administer? (Round to nearest whole #) - 14 mL A nurse is planning care for an adolescent who is being admitted to an acute care unit following a suicide attempt. Which of the following interventions should the nurse identify as the priority? - Arrange one-to-one observation of the client. - The greatest risk to the client is self-injury. Therefore, the priority nursing intervention is one-toone observation to promote safety. A nurse in a mental health facility is caring for a client with schizophrenia. Which of the following places the client at the greatest risk for self-directed injury or injuring others? - Command hallucinations. - A client with schizophrenia who experiences command hallucinations can hear voices telling him to hurt himself or others. Therefore, the client wo is experiencing command hallucinations is at the greatest risk for self-directed injury or injuring others. A nurse is facilitating a community meeting for acute care clients. One patient is constantly talking and using the majority of the group's time. Which of the following interventions should the nurse implement? - Ask group members to discuss their feelings about this client's monopolizing behavior.- This intervention will validate other members’ feelings toward the client who is dominating the meeting. It also should encourage group problem-solving. A home health nurse is assessing an older adult client whose sibling is the primary caregiver. Which of the following findings should the nurse identify as a possible indicator of neglect? - Inappropriate dress - Clothing that is soiled or clothing that is not appropriate for weather conditions is a possible indicator if neglect. A nurse is assessing a patient who has borderline personality disorder. Which of the following findings should the nurse expect? - Emotional lability - This is the rapid transition from one emotion to another and is a primary feature of borderline personality disorder. Clients who have borderline personality disorder react to situations with emotional responses that are out of proportion to the circumstances. A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the nurse’s suspicion of delirium? - Easily distracted. - Extreme distractibility is a hallmark manifestation of delirium. - Delirium has an acute onset. Dementia is a slow, progressive decline. Aphasia and confabulation are a manifestation of dementia. A nurse is caring for a client who has schizophrenia and was prescribed a conventional antipsychotic medication yesterday. Which of the following findings indicates the nurse should administer benztropine 2 mg IM? - Shuffling gait - Benztropine is used to treat parkinsonism manifestations, such as shuffling gait. A nurse is caring for a patient who has an anxiety disorder. Which of the following statement by the patient indicates successful use of guided imagery? - "I imagine myself lying on a quiet beach when I start to feel anxious" - Envisioning oneself in a peaceful, calm environment enhances relaxation and is an example of using guided imagery.A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following as an indication of a boundary issue? - Older children who are responsible for their younger siblings. - This is an example of enmeshed boundaries in which there are no distinctions between the roles of family members. A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? - Assist the client with deep-breathing exercises. - Relaxation techniques, such as deep, abdominal breathing exercises, help defuse manifestations of anxiety. A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which intervention should the nurse include in the plan of care? - Offer the client high-calorie finger foods frequently - The nurse should frequently offer the client high-calorie foods that can be eaten while the client is on the go. Clients experiencing mania might be unable to sit down for meals and can experience weight loss and dehydration. A nurse observes a client on a mental health unit pushing on the locked unit door. Which of the following statements should the nurse make? - "It appears as though you would like to open the door." - This is an example of the therapeutic technique of making observations. This technique encourages the client to notice the behavior so that she can describe thoughts and feelings related to that behavior. A charge nurse observes an assistive personnel (AP) slapping an older adult patient. After moving the patient to safety, which of the following is the charge nurse’s priority action? - Determine if the client has been physically harmed. - The greatest risk to client is injury. Therefore, the priority intervention the charge nurse should take is to determine if the client has injuries that need attention.