ATI RN Mental Health Proctored Form C |
Questions and Answers | LATEST 2020 /
2021
Section 1: Foundations of Psychiatric-Mental Health Nursing
1. A nurse is assessing a client who states, "I feel like I'm outside my body watching myself."
The nurse should document this as:
A. Depersonalization
B. Derealization
C. Illusion
D. Hallucination
Correct: A
Depersonalization is a feeling of detachment from oneself (feeling unreal or outside one's
body). Derealization (B) is detachment from the environment. An illusion (C) is a misperception
of a real stimulus. A hallucination (D) is a sensory perception without an external stimulus.
2. Which nursing action best demonstrates the mental health principle of "least restrictive
environment"?
A. Placing a newly admitted client in seclusion for verbal aggression
B. Offering a quiet room and PRN medication before considering restraints
C. Applying wrist restraints at the first sign of agitation
D. Restricting all unit privileges until the client complies with treatment
Correct: B
The least restrictive alternative is attempted first; de-escalation, environmental
modification, and PRN medication precede restraints/seclusion. A, C, and D escalate restriction
before trying less invasive measures.
3. A nurse is reviewing the medical record of a client prescribed clozapine. Which laboratory
value requires immediate follow-up?
A. WBC 3,200/mm³
B. Hemoglobin 13 g/dL
,C. Potassium 4.0 mEq/L
D. Platelets 250,000/mm³
Correct: A
Clozapine carries a risk of severe neutropenia/agranulocytosis. A WBC below 3,500/mm³ (or
ANC <1,500) requires holding the drug and notifying the provider. The other values are within
normal limits.
4. Which statement by a nurse reflects a nonjudgmental attitude?
A. "Why did you stop taking your medication again?"
B. "You seem upset. Tell me what's happening."
C. "You should know better than to skip your meds."
D. "If you loved your family, you'd stay on treatment."
Correct: B
A nonjudgmental response is open, accepting, and exploratory. "Why" questions (A) can
sound accusatory, and C and D impose values and guilt.
5. A nurse is caring for a client with a new prescription for haloperidol. Which finding
indicates acute dystonia?
A. Involuntary neck twisting and upward eye deviation
B. Lip smacking and tongue rolling
C. Tremor and pill-rolling of the fingers
D. Fever and muscle rigidity
Correct: A
Acute dystonia presents within hours to days as muscle spasms — torticollis, oculogyric
crisis, opisthotonus. B is tardive dyskinesia. C is parkinsonism. D suggests neuroleptic malignant
syndrome.
6. The nurse should recognize which client as being at highest risk for neuroleptic malignant
syndrome (NMS)?
A. A client on lithium with a sodium level of 140
B. A client on haloperidol who is dehydrated and agitated
C. A client on sertraline who reports insomnia
D. A client on lorazepam who reports drowsiness
, Correct: B
NMS risk is increased with high-potency antipsychotics, dehydration, agitation, and rapid
dose escalation. Presentation includes hyperthermia, rigidity, autonomic instability, and
elevated CK.
7. Which intervention is priority for a client experiencing NMS?
A. Administer another dose of the antipsychotic
B. Hold the antipsychotic and prepare to administer dantrolene
C. Encourage a high-protein diet
D. Apply cold compresses to the forehead only
Correct: B
NMS is a medical emergency: stop the offending agent, provide cooling, hydrate, and give
dantrolene (or bromocriptine). Restarting the antipsychotic (A) would worsen it.
8. A nurse is teaching a client about a new prescription for lithium. Which statement indicates
understanding?
A. "I should maintain a consistent sodium intake."
B. "I should double my dose if I miss one."
C. "I can take NSAIDs for headaches without concern."
D. "I should restrict fluids to 1 liter per day."
Correct: A
Consistent sodium and fluid intake prevent lithium toxicity. Missing doses should not be
doubled (B). NSAIDs (C) increase lithium levels. Fluid restriction (D) increases lithium
concentration.
9. A client on lithium reports coarse hand tremor, vomiting, and blurred vision. The lithium
level is 2.3 mEq/L. The nurse should:
A. Administer the next scheduled dose
B. Hold the dose and notify the provider immediately
C. Encourage increased oral fluids and reassess in 8 hours
D. Document and continue to monitor
Correct: B
Therapeutic lithium range is 0.6–1.2 mEq/L. A level of 2.3 indicates moderate-to-severe
, toxicity (tremor, GI symptoms, visual changes). Hold the drug and notify the provider;
hemodialysis may be needed.
10. Which action by the nurse best supports a client's autonomy?
A. Deciding the client's discharge date without input
B. Offering the client a choice between two unit activities
C. Telling the client which coping skill to use
D. Scheduling the client's therapy appointments without discussion
Correct: B
Autonomy is supported by offering meaningful choices within safe limits. The other options
make decisions for the client.
11. A nurse is assessing a client for akathisia. Which finding is expected?
A. Continuous, involuntary movement of the lips
B. Intense inner restlessness and inability to sit still
C. High fever with muscle rigidity
D. Excessive salivation and sweating
Correct: B
Akathisia is a subjective feeling of motor restlessness, often with pacing and shifting. It can
be mistaken for anxiety and increases suicide risk. A is tardive dyskinesia; C is NMS; D is
cholinergic effects.
12. Which nursing diagnosis has priority for a client with severe anorexia nervosa and a BMI
of 13?
A. Disturbed body image
B. Imbalanced nutrition: less than body requirements
C. Chronic low self-esteem
D. Impaired social interaction
Correct: B
Maslow's hierarchy and ABCs prioritize physiological needs. Severe malnutrition is life-
threatening and must be addressed first.
Questions and Answers | LATEST 2020 /
2021
Section 1: Foundations of Psychiatric-Mental Health Nursing
1. A nurse is assessing a client who states, "I feel like I'm outside my body watching myself."
The nurse should document this as:
A. Depersonalization
B. Derealization
C. Illusion
D. Hallucination
Correct: A
Depersonalization is a feeling of detachment from oneself (feeling unreal or outside one's
body). Derealization (B) is detachment from the environment. An illusion (C) is a misperception
of a real stimulus. A hallucination (D) is a sensory perception without an external stimulus.
2. Which nursing action best demonstrates the mental health principle of "least restrictive
environment"?
A. Placing a newly admitted client in seclusion for verbal aggression
B. Offering a quiet room and PRN medication before considering restraints
C. Applying wrist restraints at the first sign of agitation
D. Restricting all unit privileges until the client complies with treatment
Correct: B
The least restrictive alternative is attempted first; de-escalation, environmental
modification, and PRN medication precede restraints/seclusion. A, C, and D escalate restriction
before trying less invasive measures.
3. A nurse is reviewing the medical record of a client prescribed clozapine. Which laboratory
value requires immediate follow-up?
A. WBC 3,200/mm³
B. Hemoglobin 13 g/dL
,C. Potassium 4.0 mEq/L
D. Platelets 250,000/mm³
Correct: A
Clozapine carries a risk of severe neutropenia/agranulocytosis. A WBC below 3,500/mm³ (or
ANC <1,500) requires holding the drug and notifying the provider. The other values are within
normal limits.
4. Which statement by a nurse reflects a nonjudgmental attitude?
A. "Why did you stop taking your medication again?"
B. "You seem upset. Tell me what's happening."
C. "You should know better than to skip your meds."
D. "If you loved your family, you'd stay on treatment."
Correct: B
A nonjudgmental response is open, accepting, and exploratory. "Why" questions (A) can
sound accusatory, and C and D impose values and guilt.
5. A nurse is caring for a client with a new prescription for haloperidol. Which finding
indicates acute dystonia?
A. Involuntary neck twisting and upward eye deviation
B. Lip smacking and tongue rolling
C. Tremor and pill-rolling of the fingers
D. Fever and muscle rigidity
Correct: A
Acute dystonia presents within hours to days as muscle spasms — torticollis, oculogyric
crisis, opisthotonus. B is tardive dyskinesia. C is parkinsonism. D suggests neuroleptic malignant
syndrome.
6. The nurse should recognize which client as being at highest risk for neuroleptic malignant
syndrome (NMS)?
A. A client on lithium with a sodium level of 140
B. A client on haloperidol who is dehydrated and agitated
C. A client on sertraline who reports insomnia
D. A client on lorazepam who reports drowsiness
, Correct: B
NMS risk is increased with high-potency antipsychotics, dehydration, agitation, and rapid
dose escalation. Presentation includes hyperthermia, rigidity, autonomic instability, and
elevated CK.
7. Which intervention is priority for a client experiencing NMS?
A. Administer another dose of the antipsychotic
B. Hold the antipsychotic and prepare to administer dantrolene
C. Encourage a high-protein diet
D. Apply cold compresses to the forehead only
Correct: B
NMS is a medical emergency: stop the offending agent, provide cooling, hydrate, and give
dantrolene (or bromocriptine). Restarting the antipsychotic (A) would worsen it.
8. A nurse is teaching a client about a new prescription for lithium. Which statement indicates
understanding?
A. "I should maintain a consistent sodium intake."
B. "I should double my dose if I miss one."
C. "I can take NSAIDs for headaches without concern."
D. "I should restrict fluids to 1 liter per day."
Correct: A
Consistent sodium and fluid intake prevent lithium toxicity. Missing doses should not be
doubled (B). NSAIDs (C) increase lithium levels. Fluid restriction (D) increases lithium
concentration.
9. A client on lithium reports coarse hand tremor, vomiting, and blurred vision. The lithium
level is 2.3 mEq/L. The nurse should:
A. Administer the next scheduled dose
B. Hold the dose and notify the provider immediately
C. Encourage increased oral fluids and reassess in 8 hours
D. Document and continue to monitor
Correct: B
Therapeutic lithium range is 0.6–1.2 mEq/L. A level of 2.3 indicates moderate-to-severe
, toxicity (tremor, GI symptoms, visual changes). Hold the drug and notify the provider;
hemodialysis may be needed.
10. Which action by the nurse best supports a client's autonomy?
A. Deciding the client's discharge date without input
B. Offering the client a choice between two unit activities
C. Telling the client which coping skill to use
D. Scheduling the client's therapy appointments without discussion
Correct: B
Autonomy is supported by offering meaningful choices within safe limits. The other options
make decisions for the client.
11. A nurse is assessing a client for akathisia. Which finding is expected?
A. Continuous, involuntary movement of the lips
B. Intense inner restlessness and inability to sit still
C. High fever with muscle rigidity
D. Excessive salivation and sweating
Correct: B
Akathisia is a subjective feeling of motor restlessness, often with pacing and shifting. It can
be mistaken for anxiety and increases suicide risk. A is tardive dyskinesia; C is NMS; D is
cholinergic effects.
12. Which nursing diagnosis has priority for a client with severe anorexia nervosa and a BMI
of 13?
A. Disturbed body image
B. Imbalanced nutrition: less than body requirements
C. Chronic low self-esteem
D. Impaired social interaction
Correct: B
Maslow's hierarchy and ABCs prioritize physiological needs. Severe malnutrition is life-
threatening and must be addressed first.
