ATI Mental Health Practice A
A nurse is assessing a school-age child who experienced the traumatic loss of a parent 8 months ago.
Which of the following findings should the nurse identify as an indication that the child is experiencing
post-traumatic stress disorder (PTSD)?
Clinging behaviors directed towards a teacher
Increasing time spent sleeping
Intense focus on school work
Lack of interest in an upcoming holiday ANS: Lack of interest in an upcoming holiday
The child who has PTSD will have negative moods and difficulty remembering aspects of the traumatic
event. The child can also have a loss of interest or lack of participation in significant activities and events
such as holidays.
A nurse is caring for a group of clients. Which of the following findings should the nurse report?
A client who is taking clozapine and has a WBC count of 7500 (5000-10000)
A client who is taking lamotrigine and has developed a rash
A client who is taking valproate and has a platelet count of 200000 (150k-400k)
,A client who is taking lithium and has increased thirst ANS: A client who is taking lamotrigine and has
developed a rash
Lamotrigine is an anticonvulsant medication that is used as a mood stabilizer. The nurse should identify
that a rash is a potentially life-threatening adverse effect of the medication and report this finding
immediately.
A nurse is caring for a male client who has schizophrenia and is taking clozapine. Which of the following
client findings should the nurse identify as a contraindication for receiving clozapine?
WBC count 2500
Hgb 11.5
Alogia
Client reports having a dry mouth ANS: WBC 2500
Clozapine can cause agranulocytosis which can be fatal due to overwhelming infection.
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?
"I'm relieved now that my financial affairs are in order."
"It is easier to talk about my feelings now."
,"Suddenly I have enough energy to do anything I want."
"Thank you for always taking such good care of me." ANS: It is easier to talk about my feelings now.
When clients express their feelings, this indicates a positive treatment outcome.
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
The client is interested in what the nurse is saying.
The client is attempting to manipulate the nurse.
The client is physically attracted to the nurse.
The client is seeking acceptance by the nurse. ANS: The client is interested in what the nurse is saying.
A nurse is planning care for a client who has schizophrenia and reports auditory hallucinations. Which of
the following interventions should the nurse include in the plan?
Promote the use of music to compete with the clients auditory hallucinations.
Inform the client that the auditory hallucinations are not real.
Avoid asking the client if they are experiencing auditory hallucinations.
, Instruct the client on the use of voice recognition regarding the auditory hallucinations. ANS: Promote
the use of music to compete with the client's auditory hallucinations.
Competing reality-based stimulation such as the use of music or tv during auditory hallucinations can
assist in limiting the effect the hallucinations have on the client's stress level.
A nurse is caring for a client who has impaired cognition.
A nurse is updating the c clients plan of care. For each of the following potential nursing interventions,
click to specify if the potential intervention is anticipated, nonessential or contraindicated for the client.
ANS: Anticipated: Approach from front, give directions slowly and moderate tone, decrease sensory
stimulation, assign the client to a room near nurses' station
Nonessential: High calorie hourly protein
Contraindicated: vest to restrain, bed is kept at working height, lights in bedroom and bathroom off at
night.
A nurse is planning discharge teaching with a family member of a client who has a new diagnosis of
depression. Which of the following information about relapse should the nurse include?
Additional acute episodes of depression are unlikely following inpatient care.
Early identification of changes, such as decreased social involvement, is important.
Medication compliance will prevent further need for inpatient hospitalization.
It is helpful to regularly reinforce to the client that things will get better. ANS: Early identification of
changes, such as decreased social involvement is important.
A nurse is assessing a school-age child who experienced the traumatic loss of a parent 8 months ago.
Which of the following findings should the nurse identify as an indication that the child is experiencing
post-traumatic stress disorder (PTSD)?
Clinging behaviors directed towards a teacher
Increasing time spent sleeping
Intense focus on school work
Lack of interest in an upcoming holiday ANS: Lack of interest in an upcoming holiday
The child who has PTSD will have negative moods and difficulty remembering aspects of the traumatic
event. The child can also have a loss of interest or lack of participation in significant activities and events
such as holidays.
A nurse is caring for a group of clients. Which of the following findings should the nurse report?
A client who is taking clozapine and has a WBC count of 7500 (5000-10000)
A client who is taking lamotrigine and has developed a rash
A client who is taking valproate and has a platelet count of 200000 (150k-400k)
,A client who is taking lithium and has increased thirst ANS: A client who is taking lamotrigine and has
developed a rash
Lamotrigine is an anticonvulsant medication that is used as a mood stabilizer. The nurse should identify
that a rash is a potentially life-threatening adverse effect of the medication and report this finding
immediately.
A nurse is caring for a male client who has schizophrenia and is taking clozapine. Which of the following
client findings should the nurse identify as a contraindication for receiving clozapine?
WBC count 2500
Hgb 11.5
Alogia
Client reports having a dry mouth ANS: WBC 2500
Clozapine can cause agranulocytosis which can be fatal due to overwhelming infection.
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?
"I'm relieved now that my financial affairs are in order."
"It is easier to talk about my feelings now."
,"Suddenly I have enough energy to do anything I want."
"Thank you for always taking such good care of me." ANS: It is easier to talk about my feelings now.
When clients express their feelings, this indicates a positive treatment outcome.
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
The client is interested in what the nurse is saying.
The client is attempting to manipulate the nurse.
The client is physically attracted to the nurse.
The client is seeking acceptance by the nurse. ANS: The client is interested in what the nurse is saying.
A nurse is planning care for a client who has schizophrenia and reports auditory hallucinations. Which of
the following interventions should the nurse include in the plan?
Promote the use of music to compete with the clients auditory hallucinations.
Inform the client that the auditory hallucinations are not real.
Avoid asking the client if they are experiencing auditory hallucinations.
, Instruct the client on the use of voice recognition regarding the auditory hallucinations. ANS: Promote
the use of music to compete with the client's auditory hallucinations.
Competing reality-based stimulation such as the use of music or tv during auditory hallucinations can
assist in limiting the effect the hallucinations have on the client's stress level.
A nurse is caring for a client who has impaired cognition.
A nurse is updating the c clients plan of care. For each of the following potential nursing interventions,
click to specify if the potential intervention is anticipated, nonessential or contraindicated for the client.
ANS: Anticipated: Approach from front, give directions slowly and moderate tone, decrease sensory
stimulation, assign the client to a room near nurses' station
Nonessential: High calorie hourly protein
Contraindicated: vest to restrain, bed is kept at working height, lights in bedroom and bathroom off at
night.
A nurse is planning discharge teaching with a family member of a client who has a new diagnosis of
depression. Which of the following information about relapse should the nurse include?
Additional acute episodes of depression are unlikely following inpatient care.
Early identification of changes, such as decreased social involvement, is important.
Medication compliance will prevent further need for inpatient hospitalization.
It is helpful to regularly reinforce to the client that things will get better. ANS: Early identification of
changes, such as decreased social involvement is important.
