PN MENTAL HEALTH EXAM Q & A WITH
RATIONALES DOWNLOAD TO SCORE
A.2024
A nurse is reinforcing teaching to a client who has a new prescription forphenelzine. The nurse
should instruct the client that eating foods high intyramine can cause which of the following
adverse reactions with this medication?
• Hypertensive crisis
• Serotonin syndrome
• Hearing loss
• Urinary incontinence
• A. Hypertensive crisis
RAT: Tyramine can cause severe hypertension in clients who are takingphenelzine, 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-termgoal for these clients should be to
discuss feelings that precipitate aggression or hostility.
The nurse is assisting with an admission have a client who has eating disorder. During data
collection, which is the following to the nurse identifyas manifestations of bulimia nervosa?
SOA
• Tooth erosion
• Hand calluses
• Lanugo
• Amenorrhea
• Hypokalemia
• A. Tooth erosionB. Hand callusesE. 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 anorexianervosa 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 valuesshould the nurse report to the
provider?
• Potassium 4.0 mEq/L
• Lithium 0.9 mEq/L
• BUN 12 mg/dL
, • 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.
A nurse in a mental health unit is assisting with the plan of care for a newlyadmitted client who
has anorexia nervosa. Which of the following actions should the nurse include in the plan of
care?
• Weigh the client at night prior to bedtime.
• Offer liquid supplements to the client.
• Encourage the client to gain 2.3 kg (5 lb) per week.
• 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 theclient 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 interventionsshould the nurse recommend?
• Avoid the use of humor when managing the child's disruptive behaviors.
• Instruct the child to apologize for behavior that negatively affects others.
• Maintain a scheduled plan of activities regardless of the child's behavior.
• Administer methylphenidate PRN when the child exhibits disruptivebehavior.
B. Instruct the child to apologize for behavior that negatively affects others.
RATIONALES DOWNLOAD TO SCORE
A.2024
A nurse is reinforcing teaching to a client who has a new prescription forphenelzine. The nurse
should instruct the client that eating foods high intyramine can cause which of the following
adverse reactions with this medication?
• Hypertensive crisis
• Serotonin syndrome
• Hearing loss
• Urinary incontinence
• A. Hypertensive crisis
RAT: Tyramine can cause severe hypertension in clients who are takingphenelzine, 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-termgoal for these clients should be to
discuss feelings that precipitate aggression or hostility.
The nurse is assisting with an admission have a client who has eating disorder. During data
collection, which is the following to the nurse identifyas manifestations of bulimia nervosa?
SOA
• Tooth erosion
• Hand calluses
• Lanugo
• Amenorrhea
• Hypokalemia
• A. Tooth erosionB. Hand callusesE. 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 anorexianervosa 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 valuesshould the nurse report to the
provider?
• Potassium 4.0 mEq/L
• Lithium 0.9 mEq/L
• BUN 12 mg/dL
, • 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.
A nurse in a mental health unit is assisting with the plan of care for a newlyadmitted client who
has anorexia nervosa. Which of the following actions should the nurse include in the plan of
care?
• Weigh the client at night prior to bedtime.
• Offer liquid supplements to the client.
• Encourage the client to gain 2.3 kg (5 lb) per week.
• 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 theclient 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 interventionsshould the nurse recommend?
• Avoid the use of humor when managing the child's disruptive behaviors.
• Instruct the child to apologize for behavior that negatively affects others.
• Maintain a scheduled plan of activities regardless of the child's behavior.
• Administer methylphenidate PRN when the child exhibits disruptivebehavior.
B. Instruct the child to apologize for behavior that negatively affects others.
