ATI RN Mental Health Online Practice 2019 A - 60 Correct Questions
& Answers
1. When admitting a client to an inpatient mental health facility, a nurse notices that the client
seems withdrawn and appears fearful. To establish a trusting nurse-client relationship, the
nurse should first
a. Introduce the client to other clients in the day room (working phase)
b. Inform the client that her admission will be confidential (orientation phase)
c. Assist the client in facilitating behavioral change (working phase)
d. Determine coping strategies that the client has used in the past (working phase)
2. A nurse is reviewing the potential adverse effects of lithium with a client who began the
medication 2 weeks ago. For which of the following should the nurse instruct the client
to monitor and report to the provider?
a. Hearing loss
b. Dry persistent cough
c. Bruising
d. Coarse hand tremor (indication toxicity )
3. 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 highest priority?
a. Encourage expression of feelings (acknowledge them)
b. Promote attendance at an assertiveness training group (how to be assertive rather
than aggressive)
c. Assist the client to perform relaxation breathing (assist the child to calm down)
d. Use a therapeutic holding technique (the greatest risk to this child and others is harm?
Therefore, the nurse’s priority intervention is to use a therapeutic holding technique
to de-escalate the behavior and prevent injury)
4. A nurse in a mental health facility observes a client who is experiencing panic level of anxiety.
Which of the following actions should the nurse take first?
a. Teach the client a relaxation technique (after the attack has subsided to prevent
further escalations of anxiety)
b. Establish an exercise routine for the client (after the attack has subsided to prevent
further escalations anxiety)
c. Assist the client to identify anxiety triggers
d. Accompany the client to a quiet room
5. A nurse is caring for a client who is taking chlorpromazine for schizophrenia. Which of the
following assessment findings indicates that the client is experiencing extrapyramidal
adverse effects?
a. Fever and sore throat (indicate agranulocytosis)
b. Urinary retention (Anticholinergic side effect)
c. Postural hypotension (cardiovascular side effect)
d. Lip smacking and tongue rolling (indicate long-term extrapyramidal side
effects associated with typical antipsychotic medications)
6. 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? (round the
answer to the nearest tenth. Use a leading zero if applicable. Do not use a trailing zero.)
, 1.5 mL
7. A nurse is assessing a client in the emergency department. The client appears agitated, his
blood pressure is 152/94 mm Hg, his heart rate is 104/min, and his pupils are dilated. The nurse
should suspect intoxication with which of the following substances?
a. Heroin (intoxication constricted pupils, decrease blood pressure)
b. Cocaine (intoxication cause tachycardia, elevated blood pressure, dilated pupils
and agitation)
c. Benzodiazepines (decreased blood pressure)
d. Inhalants (central nervous system depression)
8. A nurse is educating the parent of a child who has a new diagnosis of autism spectrum
disorder. Which of the following characteristics of this disorder should the nurse include in the
teaching?
a. Fear of abandonment (separation anxiety disorder)
b. Language delay (autism spectrum disorder)
c. Hostile behavior (oppositional defiant disorder)
d. Motor and verbal tics (Tourette’s disorder)
9. A nurse is leading a group therapy session when a client becomes agitated and yells,
“Listening to all of you is making me worse!” which of the following is an appropriate
response?
a. “You sound angry and frustrated. Tell us more about how you are feeling?” ( the nurse
is making observations and exploring the client’s feelings to demonstrate caring)
b. “Maybe you would like to go to another group from now on.” (nurse’s response
is showing disapproval of the client and can make all of the clients defensive)
c. “Let’s not talk about this now. We will talk more about this in our individual session.”
(minimizing the client’s immediate concerns and feelings)
d. “Do any of the other group members feel this way?”(showing disapproval of the
client and can make all of the clients defensive)
10. A home health nurse is assessing an older adult client who lives alone. Which of the following
finding should indicate to the nurse that the client is experiencing delirium?
a. Sudden onset (suddenly over hours to days)
b. Euthymic mood ( clients who have delirium have rapid mood swings)
c. Flat affect (demonstrate expressions of feelings)
d. Slow speech (raid, inappropriate speech and language)
11. A nurse is caring for a client who has schizophrenia. The treatment plan is for the client
to increase his autonomy from his parents. Prior to discharge, the nurse should plan to
a. Stress to the client that he need to be more independent (does not give him skills to gain
autonomy. The nurse must assist the client to learn these skills)
b. Schedule a family conference (Allows the nurse to work with both the client and
his family to make an action plan for increased autonomy. This is a positive step for
the client prior to discharge)
c. Tell the client not to visit his family so often (The client needs emotional support from
his family. Decreasing family visits could be obstructive to his emotional well-being and
would not necessarily increase autonomy)
d. Arrange housing placement for the client in another town (The client needs emotional
support from his family. Moving him to another city could isolate him from this support
an d would not necessarily increase autonomy)
& Answers
1. When admitting a client to an inpatient mental health facility, a nurse notices that the client
seems withdrawn and appears fearful. To establish a trusting nurse-client relationship, the
nurse should first
a. Introduce the client to other clients in the day room (working phase)
b. Inform the client that her admission will be confidential (orientation phase)
c. Assist the client in facilitating behavioral change (working phase)
d. Determine coping strategies that the client has used in the past (working phase)
2. A nurse is reviewing the potential adverse effects of lithium with a client who began the
medication 2 weeks ago. For which of the following should the nurse instruct the client
to monitor and report to the provider?
a. Hearing loss
b. Dry persistent cough
c. Bruising
d. Coarse hand tremor (indication toxicity )
3. 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 highest priority?
a. Encourage expression of feelings (acknowledge them)
b. Promote attendance at an assertiveness training group (how to be assertive rather
than aggressive)
c. Assist the client to perform relaxation breathing (assist the child to calm down)
d. Use a therapeutic holding technique (the greatest risk to this child and others is harm?
Therefore, the nurse’s priority intervention is to use a therapeutic holding technique
to de-escalate the behavior and prevent injury)
4. A nurse in a mental health facility observes a client who is experiencing panic level of anxiety.
Which of the following actions should the nurse take first?
a. Teach the client a relaxation technique (after the attack has subsided to prevent
further escalations of anxiety)
b. Establish an exercise routine for the client (after the attack has subsided to prevent
further escalations anxiety)
c. Assist the client to identify anxiety triggers
d. Accompany the client to a quiet room
5. A nurse is caring for a client who is taking chlorpromazine for schizophrenia. Which of the
following assessment findings indicates that the client is experiencing extrapyramidal
adverse effects?
a. Fever and sore throat (indicate agranulocytosis)
b. Urinary retention (Anticholinergic side effect)
c. Postural hypotension (cardiovascular side effect)
d. Lip smacking and tongue rolling (indicate long-term extrapyramidal side
effects associated with typical antipsychotic medications)
6. 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? (round the
answer to the nearest tenth. Use a leading zero if applicable. Do not use a trailing zero.)
, 1.5 mL
7. A nurse is assessing a client in the emergency department. The client appears agitated, his
blood pressure is 152/94 mm Hg, his heart rate is 104/min, and his pupils are dilated. The nurse
should suspect intoxication with which of the following substances?
a. Heroin (intoxication constricted pupils, decrease blood pressure)
b. Cocaine (intoxication cause tachycardia, elevated blood pressure, dilated pupils
and agitation)
c. Benzodiazepines (decreased blood pressure)
d. Inhalants (central nervous system depression)
8. A nurse is educating the parent of a child who has a new diagnosis of autism spectrum
disorder. Which of the following characteristics of this disorder should the nurse include in the
teaching?
a. Fear of abandonment (separation anxiety disorder)
b. Language delay (autism spectrum disorder)
c. Hostile behavior (oppositional defiant disorder)
d. Motor and verbal tics (Tourette’s disorder)
9. A nurse is leading a group therapy session when a client becomes agitated and yells,
“Listening to all of you is making me worse!” which of the following is an appropriate
response?
a. “You sound angry and frustrated. Tell us more about how you are feeling?” ( the nurse
is making observations and exploring the client’s feelings to demonstrate caring)
b. “Maybe you would like to go to another group from now on.” (nurse’s response
is showing disapproval of the client and can make all of the clients defensive)
c. “Let’s not talk about this now. We will talk more about this in our individual session.”
(minimizing the client’s immediate concerns and feelings)
d. “Do any of the other group members feel this way?”(showing disapproval of the
client and can make all of the clients defensive)
10. A home health nurse is assessing an older adult client who lives alone. Which of the following
finding should indicate to the nurse that the client is experiencing delirium?
a. Sudden onset (suddenly over hours to days)
b. Euthymic mood ( clients who have delirium have rapid mood swings)
c. Flat affect (demonstrate expressions of feelings)
d. Slow speech (raid, inappropriate speech and language)
11. A nurse is caring for a client who has schizophrenia. The treatment plan is for the client
to increase his autonomy from his parents. Prior to discharge, the nurse should plan to
a. Stress to the client that he need to be more independent (does not give him skills to gain
autonomy. The nurse must assist the client to learn these skills)
b. Schedule a family conference (Allows the nurse to work with both the client and
his family to make an action plan for increased autonomy. This is a positive step for
the client prior to discharge)
c. Tell the client not to visit his family so often (The client needs emotional support from
his family. Decreasing family visits could be obstructive to his emotional well-being and
would not necessarily increase autonomy)
d. Arrange housing placement for the client in another town (The client needs emotional
support from his family. Moving him to another city could isolate him from this support
an d would not necessarily increase autonomy)
