PN MENTAL HEALTH EXAM Q & A
WITH RATIONALES DOWNLOAD TO SCORE
A
A nurse is reinforcing teaching to a client who has a new prescription for phenelzine.
The nurse should instruct the client that eating foods high in tyramine can cause which
of the following adverse reactions with this medication?
A. Hypertensive crisis
B. Serotonin syndrome
C. Hearing loss
D. Urinary incontinence
A. Hypertensive crisis
RAT: Tyramine can cause severe hypertension in clients who are taking phenelzine, a
monoamine oxidase inhibitor. Manifestations include palpitations, stif f neck,
headache, nausea, vomiting, and elevated temperature.
A nurse is contributing to the plan of care for a client who has antisocial
personality disorder. Which of the following short-term goals should the nurse
recommend be included in the plan?
The client will participate in assertiveness training. The
client will discuss feelings that cause hostility.
The client will describe an activity they found enjoyable.
The client will dress in a manner appropriate for the setting and temperature. The client
will discuss feelings that cause hostility.
RAT: Clients who have antisocial personality disorder are frequently aggressive and
are at risk for injuring themselves or others. A short-term goal for these clients
should be to discuss feelings that precipitate aggression or hostility.
, PN MENTAL HEALTH EXAM Q & A
WITH RATIONALES DOWNLOAD TO SCORE
A
The nurse is assisting with an admission have a client who has eating disorder.
During data collection, which is the following to the nurse identify as manifestations
of bulimia nervosa? SOA
A. Tooth erosion
B. Hand calluses
C. Lanugo
D. Amenorrhea
E. Hypokalemia
A. Tooth erosion
B. Hand calluses
E. Hypokalemia
RAT: Tooth erosion is a manifestation of bulimia nervosa that results from self-
induced vomiting. Hand calluses are a manifestation of bulimia nervosa
that results from self-induced vomiting. Lanugo is a manifestation of anorexia nervosa
that results from starvation. Amenorrhea is a manifestation of anorexia nervosa that
results from extreme weight loss. Hypokalemia is a manifestation of bulimia nervosa
that results from volume depletion due to self-induced vomiting or excessive diuretic
and laxative use.
A nurse is caring for a client who is taking lithium and reports persistent nausea and
vomiting for 2 days. Which of the following laboratory values should the nurse
report to the provider?
A. Potassium 4.0 mEq/L
B. Lithium 0.9 mEq/L
C. BUN 12 mg/dL
, PN MENTAL HEALTH EXAM Q & A
WITH RATIONALES DOWNLOAD TO SCORE
A
D. Sodium 132 mEq/L
D. Sodium 132 mEq/L
RAT: The nurse should identify that a sodium level of 132 mEq/L is not within the
expected reference range of 136 to 145 mEq/L. This finding indicates hyponatremia,
which can lead to lithium accumulation and places the client at risk for lithium toxicity.
The nurse should report this finding to the provider.
, PN MENTAL HEALTH EXAM Q & A
WITH RATIONALES DOWNLOAD TO SCORE
A
A nurse in a mental health unit is assisting with the plan of care for a newly admitted
client who has anorexia nervosa. Which of the following actions should the nurse
include in the plan of care?
A. Weigh the client at night prior to bedtime.
B. Offer liquid supplements to the client.
C. Encourage the client to gain 2.3 kg (5 lb) per week.
D. Observe the client for up to 30 min after meals. B.
Offer liquid supplements to the client.
RAT: The nurse should offer liquid supplements to the client because the client might
be unable to eat solid foods when they are first admitted. The nurse should observe
the client for at least 1 hr after meals to prevent the client from throwing away,
hiding, or purging food.
A nurse is contributing to plan of care for a school-age child who has attention deficit
hyperactivity disorder. Which of the following interventions should the nurse
recommend?
A. Avoid the use of humor when managing the child's disruptive behaviors.
B. Instruct the child to apologize for behavior that negatively affects others.
C. Maintain a scheduled plan of activities regardless of the child's behavior.
D. Administer methylphenidate PRN when the child exhibits disruptive
behavior.
B. Instruct the child to apologize for behavior that negatively affects others.
RAT: The nurse should recommend performing simple techniques to manage the child's
behavior, including making amends. This technique includes apologizing to others when
WITH RATIONALES DOWNLOAD TO SCORE
A
A nurse is reinforcing teaching to a client who has a new prescription for phenelzine.
The nurse should instruct the client that eating foods high in tyramine can cause which
of the following adverse reactions with this medication?
A. Hypertensive crisis
B. Serotonin syndrome
C. Hearing loss
D. Urinary incontinence
A. Hypertensive crisis
RAT: Tyramine can cause severe hypertension in clients who are taking phenelzine, a
monoamine oxidase inhibitor. Manifestations include palpitations, stif f neck,
headache, nausea, vomiting, and elevated temperature.
A nurse is contributing to the plan of care for a client who has antisocial
personality disorder. Which of the following short-term goals should the nurse
recommend be included in the plan?
The client will participate in assertiveness training. The
client will discuss feelings that cause hostility.
The client will describe an activity they found enjoyable.
The client will dress in a manner appropriate for the setting and temperature. The client
will discuss feelings that cause hostility.
RAT: Clients who have antisocial personality disorder are frequently aggressive and
are at risk for injuring themselves or others. A short-term goal for these clients
should be to discuss feelings that precipitate aggression or hostility.
, PN MENTAL HEALTH EXAM Q & A
WITH RATIONALES DOWNLOAD TO SCORE
A
The nurse is assisting with an admission have a client who has eating disorder.
During data collection, which is the following to the nurse identify as manifestations
of bulimia nervosa? SOA
A. Tooth erosion
B. Hand calluses
C. Lanugo
D. Amenorrhea
E. Hypokalemia
A. Tooth erosion
B. Hand calluses
E. Hypokalemia
RAT: Tooth erosion is a manifestation of bulimia nervosa that results from self-
induced vomiting. Hand calluses are a manifestation of bulimia nervosa
that results from self-induced vomiting. Lanugo is a manifestation of anorexia nervosa
that results from starvation. Amenorrhea is a manifestation of anorexia nervosa that
results from extreme weight loss. Hypokalemia is a manifestation of bulimia nervosa
that results from volume depletion due to self-induced vomiting or excessive diuretic
and laxative use.
A nurse is caring for a client who is taking lithium and reports persistent nausea and
vomiting for 2 days. Which of the following laboratory values should the nurse
report to the provider?
A. Potassium 4.0 mEq/L
B. Lithium 0.9 mEq/L
C. BUN 12 mg/dL
, PN MENTAL HEALTH EXAM Q & A
WITH RATIONALES DOWNLOAD TO SCORE
A
D. Sodium 132 mEq/L
D. Sodium 132 mEq/L
RAT: The nurse should identify that a sodium level of 132 mEq/L is not within the
expected reference range of 136 to 145 mEq/L. This finding indicates hyponatremia,
which can lead to lithium accumulation and places the client at risk for lithium toxicity.
The nurse should report this finding to the provider.
, PN MENTAL HEALTH EXAM Q & A
WITH RATIONALES DOWNLOAD TO SCORE
A
A nurse in a mental health unit is assisting with the plan of care for a newly admitted
client who has anorexia nervosa. Which of the following actions should the nurse
include in the plan of care?
A. Weigh the client at night prior to bedtime.
B. Offer liquid supplements to the client.
C. Encourage the client to gain 2.3 kg (5 lb) per week.
D. Observe the client for up to 30 min after meals. B.
Offer liquid supplements to the client.
RAT: The nurse should offer liquid supplements to the client because the client might
be unable to eat solid foods when they are first admitted. The nurse should observe
the client for at least 1 hr after meals to prevent the client from throwing away,
hiding, or purging food.
A nurse is contributing to plan of care for a school-age child who has attention deficit
hyperactivity disorder. Which of the following interventions should the nurse
recommend?
A. Avoid the use of humor when managing the child's disruptive behaviors.
B. Instruct the child to apologize for behavior that negatively affects others.
C. Maintain a scheduled plan of activities regardless of the child's behavior.
D. Administer methylphenidate PRN when the child exhibits disruptive
behavior.
B. Instruct the child to apologize for behavior that negatively affects others.
RAT: The nurse should recommend performing simple techniques to manage the child's
behavior, including making amends. This technique includes apologizing to others when
