MENTAL HEALTH FINAL EXAM1 ATI
QUESTIONS AND ANSWERS 2022
A nurse is planning care for a client who has borderline personality disorder who self-
mutilates. Which of the following treatment approaches should the nurse plan to take?
a)Restrict participation in group therapy sessions
b)Establish consequences for self-mutilation
c)Maintain close observation
d) Provide an unstructered environment
c)Maintain close observation
Clients who have borderline personality disorder are at risk for self-harm during times of
increased anxiety. Maintaining close observation reduces the client's risk of injury
A nurse is caring for a client who has Alzheimer's disease and a new prescription for
donepezil. What action should the nurse take?
Administer the medication at bedtime.
A nurse is caring for a client who reports that the television set in the room is really a
two-way radio and states, "voices are coming from the TV and everything we say in this
room is being recorded." What response should the nurse make?
"That must be very frightening."
The nurse should respond to the client's delusion in a calm and empathetic manner. By
acknowledging to the client that the delusion must be frightening, the nurse promotes
the nurse-client relationship.
A nurse is caring for a client who has Wernicke-Korsakoff syndrome due to alcohol use
disorder. What finding should the nurse expect?
Confusion.
The nurse should expect the client who has Wernicke-Korsakoff syndrome to exhibit
neurological and cognitive manifestations due to thiamine deficiency. Confusion, stupor,
diplopia, and memory loss are expected findings of this disorder.
A nurse is providing teaching to a client who has generalized anxiety disorder and a
new prescription for buspirone. The nurse should inform the client that which
manifestations is a common adverse effect of this medication?
Dizziness.
The nurse should inform the client that dizziness is a common adverse effect of
buspirone. The nurse should instruct the client to avoid driving and operating heavy
machinery until the presence of adverse effects is determined.
A nurse is reviewing the medical record of a client who has a new prescription for a
benzodiazepine. What finding should the nurse question the provider's prescription?
, Hypotension.
The nurse should question the provider's prescription for a benzodiazepine for a client
who has hypotension. Benzodiazepines can cause severe hypotension and increase
the client's risk for cardiac arrest.
A nurse is assessing a client who takes phenelzine for the treatment of depression.
What finding is the priority for the nurse to report to the provider?
Elevated blood pressure.
The nurse should identify that the greatest risk to the client is an elevated blood
pressure, which increases the risk for a hypertensive crisis that can result from taking
an MAOI, such as phenelzine. The nurse should apply the safety and risk reduction
priority-setting framework when assessing this client. This framework assigns priority to
the factor or situation posing the greatest safety risk to the client. When there are
several risks to client safety, the one posing the greatest threat is the highest priority.
The nurse should use Maslow's hierarchy of needs, the ABC priority-setting frame-work,
or nursing knowledge to identify which risk poses the greatest risk.
A nurse is providing teaching to a client who has a new prescription for disulfiram for the
management of alcohol dependence. What dietary choices should the nurse instruct the
client to avoid?
Pure vanilla extract.
The nurse should instruct the client to avoid alcohol and alcohol-containing substances
such as pure vanilla extract. The ingestion of alcohol while taking this medication
causes a disulfiram-alcohol reaction, which is manifested by hyperventilation, dizziness,
vomiting, and hypotension.
A nurse is providing teaching to the parents of a school-age child who has attention
deficit hyperactivity disorder (ADHD).What should the nurse include in her teaching?
Ignore your child's attention-seeking behaviors that are not dangerous
A nurse is planning a staff education session about the administration of antidepressant
medications to older adult clients. What should the nurse include in the teaching?
Older adult clients require a lower initial dose of antidepressant medication than adult
clients
A nurse is caring for a client who has major depressive disorder and is severely
withdrawn. What techniques should the nurse use to facilitate communication with the
client?
Speak to the client using simple and concrete terminology
A nurse in a substance use disorder treatment facility is reviewing the medication
records for a group of clients. The nurse should expect to administer methadone for a
client who has a substance use disorder for what substance?
QUESTIONS AND ANSWERS 2022
A nurse is planning care for a client who has borderline personality disorder who self-
mutilates. Which of the following treatment approaches should the nurse plan to take?
a)Restrict participation in group therapy sessions
b)Establish consequences for self-mutilation
c)Maintain close observation
d) Provide an unstructered environment
c)Maintain close observation
Clients who have borderline personality disorder are at risk for self-harm during times of
increased anxiety. Maintaining close observation reduces the client's risk of injury
A nurse is caring for a client who has Alzheimer's disease and a new prescription for
donepezil. What action should the nurse take?
Administer the medication at bedtime.
A nurse is caring for a client who reports that the television set in the room is really a
two-way radio and states, "voices are coming from the TV and everything we say in this
room is being recorded." What response should the nurse make?
"That must be very frightening."
The nurse should respond to the client's delusion in a calm and empathetic manner. By
acknowledging to the client that the delusion must be frightening, the nurse promotes
the nurse-client relationship.
A nurse is caring for a client who has Wernicke-Korsakoff syndrome due to alcohol use
disorder. What finding should the nurse expect?
Confusion.
The nurse should expect the client who has Wernicke-Korsakoff syndrome to exhibit
neurological and cognitive manifestations due to thiamine deficiency. Confusion, stupor,
diplopia, and memory loss are expected findings of this disorder.
A nurse is providing teaching to a client who has generalized anxiety disorder and a
new prescription for buspirone. The nurse should inform the client that which
manifestations is a common adverse effect of this medication?
Dizziness.
The nurse should inform the client that dizziness is a common adverse effect of
buspirone. The nurse should instruct the client to avoid driving and operating heavy
machinery until the presence of adverse effects is determined.
A nurse is reviewing the medical record of a client who has a new prescription for a
benzodiazepine. What finding should the nurse question the provider's prescription?
, Hypotension.
The nurse should question the provider's prescription for a benzodiazepine for a client
who has hypotension. Benzodiazepines can cause severe hypotension and increase
the client's risk for cardiac arrest.
A nurse is assessing a client who takes phenelzine for the treatment of depression.
What finding is the priority for the nurse to report to the provider?
Elevated blood pressure.
The nurse should identify that the greatest risk to the client is an elevated blood
pressure, which increases the risk for a hypertensive crisis that can result from taking
an MAOI, such as phenelzine. The nurse should apply the safety and risk reduction
priority-setting framework when assessing this client. This framework assigns priority to
the factor or situation posing the greatest safety risk to the client. When there are
several risks to client safety, the one posing the greatest threat is the highest priority.
The nurse should use Maslow's hierarchy of needs, the ABC priority-setting frame-work,
or nursing knowledge to identify which risk poses the greatest risk.
A nurse is providing teaching to a client who has a new prescription for disulfiram for the
management of alcohol dependence. What dietary choices should the nurse instruct the
client to avoid?
Pure vanilla extract.
The nurse should instruct the client to avoid alcohol and alcohol-containing substances
such as pure vanilla extract. The ingestion of alcohol while taking this medication
causes a disulfiram-alcohol reaction, which is manifested by hyperventilation, dizziness,
vomiting, and hypotension.
A nurse is providing teaching to the parents of a school-age child who has attention
deficit hyperactivity disorder (ADHD).What should the nurse include in her teaching?
Ignore your child's attention-seeking behaviors that are not dangerous
A nurse is planning a staff education session about the administration of antidepressant
medications to older adult clients. What should the nurse include in the teaching?
Older adult clients require a lower initial dose of antidepressant medication than adult
clients
A nurse is caring for a client who has major depressive disorder and is severely
withdrawn. What techniques should the nurse use to facilitate communication with the
client?
Speak to the client using simple and concrete terminology
A nurse in a substance use disorder treatment facility is reviewing the medication
records for a group of clients. The nurse should expect to administer methadone for a
client who has a substance use disorder for what substance?
