RN Mental Health Online Practice 2019 B with NGN w/ Rationales
1. A nurse is caring for a client who is in an abusive relationship and is assisting in the
development of a safety plan. Which of the following actions is the first component of a safety
plan?
a. Identify signs of escalation of violence
i. It is important for the client to be able to identify signs of escalation of violence,
which are the greatest risk to the client. Therefore, this is the first component of
the safety plan because it increases awareness of when danger is imminent and
it is time to leave.
2. 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?
a. Reduce environmental stimuli.
i. 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.
3. A nurse is updating the POC for a client who has bulimia nervosa and is 5% above their ideal
body weight. Which of the following interventions should the nurse include in the plan?
a. Identify the client's trigger foods.
i. The nurse should identify the trigger foods that initiate the client's binge and
assist the client to understand their thoughts and behavior that relate to the
food.
4. A nurse is assisting a client who has a terminal illness adjust to progressive loss of
independence. Which of the following statements made by the client indicates acceptance of
her illness?
a. "I am going to order a wheelchair for when I'm unable to walk."
i. The client is recognizing the reality of continued loss of independence and is
anticipating the need for assistive devices, which indicates the behavioral
response of acceptance.
5. A nurse is reviewing the medication administration for a client who is experiencing adverse
effects of chlorpromazine. The nurse should administer benztropine to relieve which of the
following adverse effects?
a. Acute dystonia
i. The nurse should administer benztropine, an anticholinergic agent, to relieve
acute dystonia, which is an extrapyramidal adverse effect of chlorpromazine
6. A nurse is caring for an older adult client who is experiencing delirium. Which of the following
interventions should the nurse include in the client's plan of care?
a. Permit the client to perform daily rituals to decrease anxiety.
i. The nurse should provide a client who has delirium with a plan of care that
decreases agitation and anxiety by permitting the client to perform daily rituals
7. A nurse is receiving change-of-shift report for four clients. Which of the following clients
should the nurse plan to see first?
a. A client who is taking clozapine and reports sore throat and chills.
i. When using the urgent vs. nonurgent approach to client care, the nurse should
determine to first see the client who is taking clozapine and reports a sore
throat and chills. Clozapine can cause agranulocytosis, a serious adverse effect
that causes neutropenia. The nurse should withhold the medication and notify
the provider of these findings
,RN Mental Health Online Practice 2019 B with NGN w/ Rationales
8. A nurse is planning care for a client who has made repeated physical threats toward others on
the unit. Although the client does not want to leave the unit, the nurse requests the provider
to transfer the client to another unit, the nurse request the provider to transfer the client to a
unit that is equipped to manage violent behavior. Which of the following ethical principles
should the nurse apply in the situation?
a. Nonmaleficence
i. It is the responsibility of the nurse to do no harm to clients. The nurse is
applying the ethical principle of nonmalecence by requesting to transfer this
client to a unit better able to manage their behavior and thereby prevent injury
to others on the unit.
9. 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?
a. Easily distracted.
i. Extreme distractibility is a hallmark manifestation of delirium.
10. 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?
a. Renew the prescription for the client every 4 hr.
i. The nurse should assess the client's behavior frequently during seclusion and
should renew the prescription for seclusion for an adult client every 4 hr, for a
maximum of 24 hr.
11. A client who has a recent diagnosis of bipolar disorder is placed in a room with a client who
has severe depression. The client who has depression reports to the nurse, "My roommate
never sleeps and keeps me up, too." Which of the following actions should the nurse take?
a. Move the client who has bipolar disorder to a private room.
i. Clients who have bipolar disorder can disrupt the therapeutic milieu for other
clients. Therefore, the nurse should move this client to a private room
12. A nurse is teaching the partner of a client who has bipolar disorder how to identify
manifestations of acute mania. Which of the following findings should the client' partner
report to the provider?
a. Inability to sleep
i. During acute mania, the client is extremely active and does not sleep, which can
lead to exhaustion. Therefore, the nurse should instruct the partner to report
this finding.
13. A nurse is teaching coping strategies to a client who is experiencing depression related to
partner violence. Which of the following statements by the client indicates an understanding
of the teaching?
a. "I will talk about my feelings with a close friend."
i. Discussing feelings, such as fear and depression, with a support person is an
effective coping strategy and can provide the client with emotional support and
other resources
,RN Mental Health Online Practice 2019 B with NGN w/ Rationales
14. A nurse is discussing a 12-step program with a client 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?
a. The client should obtain a sponsor before discharge for an increased chance of recovery.
i. The nurse should teach the client that peer support has been shown to increase
program attendance and the chances of recovery. If the client does not have a
sponsor, they can be assigned one when they begin attending the program.
15. 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?
a. The client has COPD.
i. The nurse should identify that client who have a chronic medical illness are at an
increased risk for the development of depression.
16. A nurse on a medical-surgical unit is assessing a client who sustained injuries 12 hr ago
following a MVC. 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?
a. Blood pressure 154/96 mm Hg
i. 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 a fever.
17. A nurse on a mental health unit observes a client who has acute mania hit another client.
Which of the following action should the nurse take first?
a. Call a team of staff members to help with the situation.
i. 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 themselves
or others.
18. A nurse is planning discharge teaching for a client who has severe schizoaffective disorder.
The nurse should identify that which of the following treatment options can offer
interdisciplinary services for the client at home?
a. Assertive community treatment
i. Assertive community treatment provides comprehensive, community-based
services to clients who have severe mental illness based upon individualized
needs. Services are available in any setting, including the client's home, 24 hr
per day and provide crisis intervention, medication services, and advocacy.
19. A nurse is planning care for a client who has generalized anxiety disorder. At which of the
following levels of anxiety should the nurse plan to teach the client relaxation techniques?
a. Mild
i. The nurse should plan to teach the client relaxation techniques during the mild
level of anxiety. This is when the client will be able to concentrate and process
information.
20. A nurse is education the parent of a child who has a new diagnosis of autism spectrum
disorder. Which of the following manifestations of this disorder should the nurse include in
the teaching?
a. Language delay
i. The nurse should identify that language delays are a manifestation of autism
spectrum disorder
, RN Mental Health Online Practice 2019 B with NGN w/ Rationales
21. A nurse in a mental health facility is caring for a client who has schizophrenia. Which of the
following findings places the client at the greatest risk for self-directed injury or injuring
others?
a. Command hallucinations
i. A client who has schizophrenia and is experiencing command hallucinations can
hear voices telling them to hurt themselves or others. Therefore, a client who is
experiencing command hallucinations is at the greatest risk for self-directed
injury or injuring others.
22. 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?
a. Spending adequate time with a client who is verbally abusive
i. By spending adequate 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.
23. A nurse is providing teaching to the partner of a client who is in a rehabilitation program for
alcohol use disorder. The nurse should identify that which of the following statements by the
client's partner indicates an understanding of the teaching?
a. "I will not take charge of my partner's work responsibilities."
i. The nurse should identify that it is important for the individual who has the
substance use disorder to take charge of personal responsibilities.
24. A nurse is talking with a group of parents who have recently experienced the death of a child.
Which of the following actions should the nurse take?
a. Suggest forming a weekly support group for parents who have experienced the death of
a child.
i. Support groups are a positive resource in the process of recovery for parents
following the death of a child.
25. A nurse is planning prevention strategies for partner violence in the community. Which of the
following strategies should the nurse include as a method of secondary prevention?
a. Establish screening programs to identify at-risk clients.
i. This is an example of secondary prevention. By establishing screening programs,
the nurse can identify individuals who are at risk for partner violence in the
community and can take the necessary steps to address individual client needs
26. A nurse is preparing to administer diazepam 7.5 mg IV bolus to a client for alcohol withdrawal.
Available is diazepam injection 5 mg/mL. How many mL should the nurse administer?
a. x mL= 1.5
27. A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the
following findings?
a. Tooth erosion
i. A client who has bulimia nervosa is likely to have dental caries and tooth erosion
caused by frequent exposure to gastric acid from vomiting.
28. A nurse on an acute mental health facility is receiving change-of-shift report for four clients.
Which of the following client should the nurse assess first?
a. A client who is experiencing delusions of persecution
i. The presence of delusions of persecution indicates that this client is at the
greatest risk for injury due to the client's belief that a person in power is out to
harm them. Therefore, the nurse should assess this client first.
1. A nurse is caring for a client who is in an abusive relationship and is assisting in the
development of a safety plan. Which of the following actions is the first component of a safety
plan?
a. Identify signs of escalation of violence
i. It is important for the client to be able to identify signs of escalation of violence,
which are the greatest risk to the client. Therefore, this is the first component of
the safety plan because it increases awareness of when danger is imminent and
it is time to leave.
2. 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?
a. Reduce environmental stimuli.
i. 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.
3. A nurse is updating the POC for a client who has bulimia nervosa and is 5% above their ideal
body weight. Which of the following interventions should the nurse include in the plan?
a. Identify the client's trigger foods.
i. The nurse should identify the trigger foods that initiate the client's binge and
assist the client to understand their thoughts and behavior that relate to the
food.
4. A nurse is assisting a client who has a terminal illness adjust to progressive loss of
independence. Which of the following statements made by the client indicates acceptance of
her illness?
a. "I am going to order a wheelchair for when I'm unable to walk."
i. The client is recognizing the reality of continued loss of independence and is
anticipating the need for assistive devices, which indicates the behavioral
response of acceptance.
5. A nurse is reviewing the medication administration for a client who is experiencing adverse
effects of chlorpromazine. The nurse should administer benztropine to relieve which of the
following adverse effects?
a. Acute dystonia
i. The nurse should administer benztropine, an anticholinergic agent, to relieve
acute dystonia, which is an extrapyramidal adverse effect of chlorpromazine
6. A nurse is caring for an older adult client who is experiencing delirium. Which of the following
interventions should the nurse include in the client's plan of care?
a. Permit the client to perform daily rituals to decrease anxiety.
i. The nurse should provide a client who has delirium with a plan of care that
decreases agitation and anxiety by permitting the client to perform daily rituals
7. A nurse is receiving change-of-shift report for four clients. Which of the following clients
should the nurse plan to see first?
a. A client who is taking clozapine and reports sore throat and chills.
i. When using the urgent vs. nonurgent approach to client care, the nurse should
determine to first see the client who is taking clozapine and reports a sore
throat and chills. Clozapine can cause agranulocytosis, a serious adverse effect
that causes neutropenia. The nurse should withhold the medication and notify
the provider of these findings
,RN Mental Health Online Practice 2019 B with NGN w/ Rationales
8. A nurse is planning care for a client who has made repeated physical threats toward others on
the unit. Although the client does not want to leave the unit, the nurse requests the provider
to transfer the client to another unit, the nurse request the provider to transfer the client to a
unit that is equipped to manage violent behavior. Which of the following ethical principles
should the nurse apply in the situation?
a. Nonmaleficence
i. It is the responsibility of the nurse to do no harm to clients. The nurse is
applying the ethical principle of nonmalecence by requesting to transfer this
client to a unit better able to manage their behavior and thereby prevent injury
to others on the unit.
9. 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?
a. Easily distracted.
i. Extreme distractibility is a hallmark manifestation of delirium.
10. 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?
a. Renew the prescription for the client every 4 hr.
i. The nurse should assess the client's behavior frequently during seclusion and
should renew the prescription for seclusion for an adult client every 4 hr, for a
maximum of 24 hr.
11. A client who has a recent diagnosis of bipolar disorder is placed in a room with a client who
has severe depression. The client who has depression reports to the nurse, "My roommate
never sleeps and keeps me up, too." Which of the following actions should the nurse take?
a. Move the client who has bipolar disorder to a private room.
i. Clients who have bipolar disorder can disrupt the therapeutic milieu for other
clients. Therefore, the nurse should move this client to a private room
12. A nurse is teaching the partner of a client who has bipolar disorder how to identify
manifestations of acute mania. Which of the following findings should the client' partner
report to the provider?
a. Inability to sleep
i. During acute mania, the client is extremely active and does not sleep, which can
lead to exhaustion. Therefore, the nurse should instruct the partner to report
this finding.
13. A nurse is teaching coping strategies to a client who is experiencing depression related to
partner violence. Which of the following statements by the client indicates an understanding
of the teaching?
a. "I will talk about my feelings with a close friend."
i. Discussing feelings, such as fear and depression, with a support person is an
effective coping strategy and can provide the client with emotional support and
other resources
,RN Mental Health Online Practice 2019 B with NGN w/ Rationales
14. A nurse is discussing a 12-step program with a client 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?
a. The client should obtain a sponsor before discharge for an increased chance of recovery.
i. The nurse should teach the client that peer support has been shown to increase
program attendance and the chances of recovery. If the client does not have a
sponsor, they can be assigned one when they begin attending the program.
15. 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?
a. The client has COPD.
i. The nurse should identify that client who have a chronic medical illness are at an
increased risk for the development of depression.
16. A nurse on a medical-surgical unit is assessing a client who sustained injuries 12 hr ago
following a MVC. 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?
a. Blood pressure 154/96 mm Hg
i. 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 a fever.
17. A nurse on a mental health unit observes a client who has acute mania hit another client.
Which of the following action should the nurse take first?
a. Call a team of staff members to help with the situation.
i. 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 themselves
or others.
18. A nurse is planning discharge teaching for a client who has severe schizoaffective disorder.
The nurse should identify that which of the following treatment options can offer
interdisciplinary services for the client at home?
a. Assertive community treatment
i. Assertive community treatment provides comprehensive, community-based
services to clients who have severe mental illness based upon individualized
needs. Services are available in any setting, including the client's home, 24 hr
per day and provide crisis intervention, medication services, and advocacy.
19. A nurse is planning care for a client who has generalized anxiety disorder. At which of the
following levels of anxiety should the nurse plan to teach the client relaxation techniques?
a. Mild
i. The nurse should plan to teach the client relaxation techniques during the mild
level of anxiety. This is when the client will be able to concentrate and process
information.
20. A nurse is education the parent of a child who has a new diagnosis of autism spectrum
disorder. Which of the following manifestations of this disorder should the nurse include in
the teaching?
a. Language delay
i. The nurse should identify that language delays are a manifestation of autism
spectrum disorder
, RN Mental Health Online Practice 2019 B with NGN w/ Rationales
21. A nurse in a mental health facility is caring for a client who has schizophrenia. Which of the
following findings places the client at the greatest risk for self-directed injury or injuring
others?
a. Command hallucinations
i. A client who has schizophrenia and is experiencing command hallucinations can
hear voices telling them to hurt themselves or others. Therefore, a client who is
experiencing command hallucinations is at the greatest risk for self-directed
injury or injuring others.
22. 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?
a. Spending adequate time with a client who is verbally abusive
i. By spending adequate 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.
23. A nurse is providing teaching to the partner of a client who is in a rehabilitation program for
alcohol use disorder. The nurse should identify that which of the following statements by the
client's partner indicates an understanding of the teaching?
a. "I will not take charge of my partner's work responsibilities."
i. The nurse should identify that it is important for the individual who has the
substance use disorder to take charge of personal responsibilities.
24. A nurse is talking with a group of parents who have recently experienced the death of a child.
Which of the following actions should the nurse take?
a. Suggest forming a weekly support group for parents who have experienced the death of
a child.
i. Support groups are a positive resource in the process of recovery for parents
following the death of a child.
25. A nurse is planning prevention strategies for partner violence in the community. Which of the
following strategies should the nurse include as a method of secondary prevention?
a. Establish screening programs to identify at-risk clients.
i. This is an example of secondary prevention. By establishing screening programs,
the nurse can identify individuals who are at risk for partner violence in the
community and can take the necessary steps to address individual client needs
26. A nurse is preparing to administer diazepam 7.5 mg IV bolus to a client for alcohol withdrawal.
Available is diazepam injection 5 mg/mL. How many mL should the nurse administer?
a. x mL= 1.5
27. A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the
following findings?
a. Tooth erosion
i. A client who has bulimia nervosa is likely to have dental caries and tooth erosion
caused by frequent exposure to gastric acid from vomiting.
28. A nurse on an acute mental health facility is receiving change-of-shift report for four clients.
Which of the following client should the nurse assess first?
a. A client who is experiencing delusions of persecution
i. The presence of delusions of persecution indicates that this client is at the
greatest risk for injury due to the client's belief that a person in power is out to
harm them. Therefore, the nurse should assess this client first.
