ATI Mental Health Practice A with NGN
A nurse is caring for a client who has a history of substance use disorder and was involuntarily
admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client
refuses to take the medication and becomes physically aggressive. Which of the following actions
should the nurse take?
A. Do not administer the lorazepam
B. Request a prescription for IV lorazepam
C. Request that another nurse attempt to administer the lorazepam
D. Place the lorazepam in the client's food
A. Do not administer the lorazepam.
Clients who are in a facility due to an involuntarily admission retain the right to refuse treatment.
Therefore, the nurse should hold the medication and document the client's refusal.
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?
A. "I'm relived now that my financial affairs are in order."
B. "It is easier to talk about my feelings now."
C. "Suddenly I have enough energy to do anything I want."
D. "Thank you for always taking such good care of me."
B. "It is easier to talk about my feelings now."
When clients express their feelings, this indicates a positive treatment outcome.
A nurse is caring for a client whose child has a terminal illness. The client requests information about
how to deal with the upcoming loss. Which of the following statements should the nurse make?
A. "It will be better for you to keep busy to avoid thinking about your child's death."
B. "You will complete the grieving process about a year after your child's death."
C. "The grief process will start once your child actually dies."
D. "It is not uncommon to feel angry toward yourself or others."
D. "It is not uncommon to feel angry toward yourself or others."
Feelings of blame and anger towards oneself or others are an expected reaction when a client is
experiencing a loss.
During a client's initial interview in a mental health inpatient setting, a nurse identifies that the client
is maintaining eye contact and leaning forward. Which of the following assumptions should the nurse
make based on the client's nonverbal behaviors?
A. The client is interested in what the nurse is saying
B. The client is attempting to manipulate the nurse
C. The client is physically attracted to the nurse
D. The client needs to feel accepted by the nurse
A. The client is interested in what the nurse is saying.
The client's posture and eye contact demonstrates an interest in the interview and what the nurse is
saying.
A nurse is reviewing the electronic medical record of a client who has schizophrenia and is taking
clozapine. Which of the following findings is the priority for the nurse to notify the provider?
A. The client's chart indicates a 1.36 kg (3 lb.) weight gain in 1 month.
B. The client reports an inability to breathe easily.
C. The client's laboratory results indicate a fasting blood glucose level of 130 mg/dL.
,D. The client reports having recently started smoking cigarettes.
B. The client reports an inability to breathe easily.
Serious adverse effects, such as heart failure, myocarditis, and pulmonary embolism are associated
with clozapine. When using the greatest risk framework, the nurse should identify that the greatest
risk to the client is dyspnea, which is a manifestation of respiratory or cardiac alterations, and should
be reported to the provider.
A nurse is reviewing routine laboratory values for several clients who are taking lithium carbonate.
Which of the following clients should the nurse assess further for findings indicating lithium toxicity?
A. A client who has a fasting blood glucose level of 80 mg/dL.
B. A client who has a sodium level of 128 mEq/L.
C. A client who has a BUN of 18 mg/dL.
D. A client who has a potassium level of 3.6 mEq/L.
B. A client who has a sodium level of 128 mEq/L.
A sodium level of 128 mEq/L 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.
A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder.
Which of the following strategies should the nurse use when communicating with this client?
A. Behave in a friendly manner toward the client.
B. Set realistic limits on the client's behavior.
C. Show respect for the client's need for isolation.
D. Act as a role model for assertiveness.
B. Set realistic limits on the client's behavior.
Clients who have antisocial personality disorder can seem to be in control of their behavior, but are
manipulative and impulsive and can suddenly become aggressive and assaultive. The nurse should
establish clear limits on specific aggressive and demanding behaviors.
A nurse in a provider's office is collecting a health history from the guardian of a school-age child who
has been taking atomoxetine. Which of the following adverse effects reported by the guardian is the
priority for the nurse to report to the provider?
A. Reduced appetite
B. Fatigue
C. Dark urine
D. Sweating
C. Dark urine
The greatest risk for the child is liver damage from atomoxetine, which can progress to liver failure
and death. Therefore, this is the nurse's priority finding.
A nurse is caring for a group of clients. For which of the following situations should the nurse
complete an incident report?
A. A client refuses electroconvulsive therapy after signing the consent form.
B. A client who was voluntarily admitted left the unit against medical advice.
C. A client was administered one-half of the prescribed dose of medication.
D. A client was placed in restraints after attempts to de-escalate aggressive behaviors failed.
C. A client was administered one-half of the prescribed dose of medication.
An incident report is a recording of any occurrence that does not meet the standard of care. The
nurse should report medication errors using the facility's incident or occurrence form.
, A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse
questions the client regarding their admission, the client states, "I'm red, in the head, and I'm going to
bed!" The nurse should document the client's speech pattern as which of the following?
A. Clang association
B. Word salad
C. Neologism
D. Echolalia
A. Clang association
The nurse should document that the client's speech uses clang associations, which often rhyme or
contain a string of words that can have a similar sound.
A nurse is communicating with a client in an inpatient mental health facility. Which of the following
actions by the nurse demonstrates the use of active listening?
A. Offering self
B. Use of silence
C. Attention to body language
D. Reflection of feelings
C. Attention to body language
Use of active listening involves identifying verbal and nonverbal communication by the client, which
includes attention to body language.
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?
A. Increased confusion
B. Sleep disturbances
C. Cluttered environment
D. Inappropriate dress
D. Inappropriate dress
Clothing that is soiled or clothing that is not appropriate for weather conditions is a possible indicator
of neglect.
A nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations
should the nurse expect during the admission assessment?
A. Diarrhea
B. Heavy menstrual bleeding
C. Tachycardia
D. Orthostatic hypotension
D. Orthostatic hypotension
Low weight, electrolyte imbalances, starvation, and dehydration cause orthostatic hypotension.
A 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 the
A. Controls anger outbursts to avoid being placed in seclusion.
B. No longer exhibits a fear of social or public situations.
C. Refrains from manipulating others to earn dining room privileges.
D. Imitates the therapist's use of a relaxation technique.
A nurse is caring for a client who has a history of substance use disorder and was involuntarily
admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client
refuses to take the medication and becomes physically aggressive. Which of the following actions
should the nurse take?
A. Do not administer the lorazepam
B. Request a prescription for IV lorazepam
C. Request that another nurse attempt to administer the lorazepam
D. Place the lorazepam in the client's food
A. Do not administer the lorazepam.
Clients who are in a facility due to an involuntarily admission retain the right to refuse treatment.
Therefore, the nurse should hold the medication and document the client's refusal.
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?
A. "I'm relived now that my financial affairs are in order."
B. "It is easier to talk about my feelings now."
C. "Suddenly I have enough energy to do anything I want."
D. "Thank you for always taking such good care of me."
B. "It is easier to talk about my feelings now."
When clients express their feelings, this indicates a positive treatment outcome.
A nurse is caring for a client whose child has a terminal illness. The client requests information about
how to deal with the upcoming loss. Which of the following statements should the nurse make?
A. "It will be better for you to keep busy to avoid thinking about your child's death."
B. "You will complete the grieving process about a year after your child's death."
C. "The grief process will start once your child actually dies."
D. "It is not uncommon to feel angry toward yourself or others."
D. "It is not uncommon to feel angry toward yourself or others."
Feelings of blame and anger towards oneself or others are an expected reaction when a client is
experiencing a loss.
During a client's initial interview in a mental health inpatient setting, a nurse identifies that the client
is maintaining eye contact and leaning forward. Which of the following assumptions should the nurse
make based on the client's nonverbal behaviors?
A. The client is interested in what the nurse is saying
B. The client is attempting to manipulate the nurse
C. The client is physically attracted to the nurse
D. The client needs to feel accepted by the nurse
A. The client is interested in what the nurse is saying.
The client's posture and eye contact demonstrates an interest in the interview and what the nurse is
saying.
A nurse is reviewing the electronic medical record of a client who has schizophrenia and is taking
clozapine. Which of the following findings is the priority for the nurse to notify the provider?
A. The client's chart indicates a 1.36 kg (3 lb.) weight gain in 1 month.
B. The client reports an inability to breathe easily.
C. The client's laboratory results indicate a fasting blood glucose level of 130 mg/dL.
,D. The client reports having recently started smoking cigarettes.
B. The client reports an inability to breathe easily.
Serious adverse effects, such as heart failure, myocarditis, and pulmonary embolism are associated
with clozapine. When using the greatest risk framework, the nurse should identify that the greatest
risk to the client is dyspnea, which is a manifestation of respiratory or cardiac alterations, and should
be reported to the provider.
A nurse is reviewing routine laboratory values for several clients who are taking lithium carbonate.
Which of the following clients should the nurse assess further for findings indicating lithium toxicity?
A. A client who has a fasting blood glucose level of 80 mg/dL.
B. A client who has a sodium level of 128 mEq/L.
C. A client who has a BUN of 18 mg/dL.
D. A client who has a potassium level of 3.6 mEq/L.
B. A client who has a sodium level of 128 mEq/L.
A sodium level of 128 mEq/L 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.
A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder.
Which of the following strategies should the nurse use when communicating with this client?
A. Behave in a friendly manner toward the client.
B. Set realistic limits on the client's behavior.
C. Show respect for the client's need for isolation.
D. Act as a role model for assertiveness.
B. Set realistic limits on the client's behavior.
Clients who have antisocial personality disorder can seem to be in control of their behavior, but are
manipulative and impulsive and can suddenly become aggressive and assaultive. The nurse should
establish clear limits on specific aggressive and demanding behaviors.
A nurse in a provider's office is collecting a health history from the guardian of a school-age child who
has been taking atomoxetine. Which of the following adverse effects reported by the guardian is the
priority for the nurse to report to the provider?
A. Reduced appetite
B. Fatigue
C. Dark urine
D. Sweating
C. Dark urine
The greatest risk for the child is liver damage from atomoxetine, which can progress to liver failure
and death. Therefore, this is the nurse's priority finding.
A nurse is caring for a group of clients. For which of the following situations should the nurse
complete an incident report?
A. A client refuses electroconvulsive therapy after signing the consent form.
B. A client who was voluntarily admitted left the unit against medical advice.
C. A client was administered one-half of the prescribed dose of medication.
D. A client was placed in restraints after attempts to de-escalate aggressive behaviors failed.
C. A client was administered one-half of the prescribed dose of medication.
An incident report is a recording of any occurrence that does not meet the standard of care. The
nurse should report medication errors using the facility's incident or occurrence form.
, A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse
questions the client regarding their admission, the client states, "I'm red, in the head, and I'm going to
bed!" The nurse should document the client's speech pattern as which of the following?
A. Clang association
B. Word salad
C. Neologism
D. Echolalia
A. Clang association
The nurse should document that the client's speech uses clang associations, which often rhyme or
contain a string of words that can have a similar sound.
A nurse is communicating with a client in an inpatient mental health facility. Which of the following
actions by the nurse demonstrates the use of active listening?
A. Offering self
B. Use of silence
C. Attention to body language
D. Reflection of feelings
C. Attention to body language
Use of active listening involves identifying verbal and nonverbal communication by the client, which
includes attention to body language.
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?
A. Increased confusion
B. Sleep disturbances
C. Cluttered environment
D. Inappropriate dress
D. Inappropriate dress
Clothing that is soiled or clothing that is not appropriate for weather conditions is a possible indicator
of neglect.
A nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations
should the nurse expect during the admission assessment?
A. Diarrhea
B. Heavy menstrual bleeding
C. Tachycardia
D. Orthostatic hypotension
D. Orthostatic hypotension
Low weight, electrolyte imbalances, starvation, and dehydration cause orthostatic hypotension.
A 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 the
A. Controls anger outbursts to avoid being placed in seclusion.
B. No longer exhibits a fear of social or public situations.
C. Refrains from manipulating others to earn dining room privileges.
D. Imitates the therapist's use of a relaxation technique.
