Prof. Exams ATI Mental Health Online Practice 201 9 A &B 1. A nurse is caring for a client who has an anxiety disorder. Which of the following statements by the c lient indicates successful use of guided imagery? >> The nurse should teach the client to secure a sponsor because the client -
sponsor relationship has been shown to increase program attendance and the chances of recovery. 2. A nurse is facilitatin g a community meeting for acute care clients. One client is constantly talking and using the majority of the group's time. Which of the following interventions should the nurse implement? >> "I imagine myself lying on a quiet beach when I start to feel anxious." - Envisioning oneself in a peaceful, calm environment enhances relaxation and is an example of using guided imagery. 3. A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? >> "I will update the plan of care as a client's manifestations of depression change." - The nurse should update the plan of care as a client's status and needs change. 4. A nurse is caring for a client who gave birth to a stillborn baby. Which of the following statements should the nurse make? >> "I'll stay with you just in case you want to talk." - This response indicates the nurse's interes t in the client and a desire to understand the client's feelings. 5. 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? >> "It is easier to talk about my feelings now." - When clients express their feelings, this indicates a positive treatment outcome. 6. . A client who has bipolar disorder is to be discharged home with a prescription for lithium. Which of the foll owing statements indicates that client teaching regarding the medication has been effective? >> “ I should eat a regular diet with normal amounts of salt and fluids” - This statement indicates that the client understands the teaching because normal levels of sodium and fluid need to be maintained to ensure adequate excretion Prof. Exams of lithium. If sodium levels are low, the body compensates by decreasing lithium excretion, which can lead to toxicity. 7. A nurse is caring for a client who has attempted sui cide and has alcohol use disorder. Which of the following statements indicates that the client is using a positive coping mechanism? >> “ I will attend daily group therapy sessions to practice relaxation techniques” -Relaxation techniques decrease the risk for self -harm by decreasing stress, anxiety, and depression. 8. A nurse observes a client on a mental health unit pushing on the locked unit door. Which of the following statements should the nurse make? >> “ It appears as though you wou ld like to open the door.” - This statement is an example of the therapeutic technique of making observations. This technique encourages the client to notice the behavior so that she can describe thoughts and feelings related to that behavior. 9. A nurse in an emergency department is caring for a female adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Which of the following statements by the mother acknowledges her daughter's diagnosis? >> “She won’t let me take the trash from her room. I’m concerned about what she has in there.” - The client might be binge eating and attempting to hide her food containers, which is a common behavior among clients who have bulimia nervosa. The mother's statem ent indicates awareness of her daughter's behavior. 10. A nurse is teaching a family member and a client who has a new diagnosis of Alzheimer's disease and is to start taking donepezil. Which of the following statements should the nurse include in the teaching? >> “Take this medication in the eveni ng at bedtime” -The client should take this medication in the evening at bedtime for optimal effectiveness. 11. A nurse is interviewing a client at a temporary shelter after surviving the destruction of her home by a tornado. When assessing the client, the nurse should ask which of the following questions to determine the client's ability to cope with this situation? >> “To whom do you talk when you feel overwhelmed?” - By asking this question, the nurse is assessing the client's support systems, whi ch is an important factor in the client's ability to cope with the situation. 12. A nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and a fear of gaining weight. The client states, "I'm so fat I can't even sta nd Prof. Exams to look at myself." Which of the following therapeutic responses demonstrates the nurse's use of summarizing? >> “You’re saying that you think you are fat and are using laxatives because you are afraid of gaining weight” - The nurse is using the therapeutic technique of summarizing to review the key points of the discussion. 13. 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 fi ndings indicating lithium toxicity? >> 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. 14. A client who has a diagnosis of depression is attending group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. When it is the client's turn, she does not respond. Which of the follo wing actions should the nurse take before repeating the request to the client? >> Allow the client time to collect her thoughts. - Slowed response time is common in clients who have depression. The nurse should allow the client time to comprehend a nd formulate an answer to the question. 15. A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder? >> Anhedonia - Negative symptoms of schizophrenia af fect a person's ability to interact with others and are less dominant than positive symptoms. These symptoms develop over time. Examples of negative symptoms include flat affect, anergia (lack of energy), anhedonia (inability to enjoy otherwise pleasurable activities), and thought blocking. 16. A nurse is planning care for an adolescent who is being admitted to an acute care unit following a suicide attempt. Which of the following interventions should the nurse identify as the priority? >> Arrange one-to-one observation of the client. - The greatest risk to the client is self -injury. Therefore, the priority nursing intervention is one -to-one observation to promote client safety. 17. A charge nurse enters a client's room and observes an assistive pe rsonnel (AP) slapping an older adult client. After moving the client to safety, which of the following actions is the charge nurse's priority? Prof. Exams >> Ask group members to discuss their feelings about this client's monopolizing behavior. - This interven tion will validate other members' feelings toward the client who is dominating the meeting. It also should encourage group problem -solving. 18. During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in her bed. The clien t reports that a bomb was placed in her room by a family member during visiting hours. Which of the following actions should the nurse take? >>Assess the client for evidence of a perceptual disturbance. - The nurse should assess the situation to d etermine if the client is hallucinating or misperceiving external stimuli (experiencing illusions). 19. A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? >> Assist the client w ith deep -breathing exercises - Relaxation techniques, such as deep, abdominal breathing exercises, help defuse manifestations of anxiety. 20. A nurse on a medical -surgical unit is assessing a client who sustained injuries 12 hr ago following a motor -vehic le crash. The client's admission blood alcohol level was 325 mg/dL. Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal? >>Blood pressure 154/96 mm Hg - Physical manifestations of alcohol withdrawal occur in addition to psychological effects. A client who is experiencing alcohol withdrawal is expected to have hypertension, tachycardia, and fever greater than 38.3° C (101° F). It will be important for the nurse to rule out infection in the client who has a fever . 21. A nurse in a mental health unit observes a client who has acute mania hit another client. Which fo the following actions should the nurse take first? ○ Call for a team of staff members to help with the situation - The greatest risk is injury to the client and others. Therefore, the first action the nurse should take is to call for assistance to prevent further injury to himself or others. 22. A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adole scent who weighs 110 lb. Available is chlorpromazine syrup 10 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ○ Client has COPD - This response indicates the nurse's interest in the client and a desire to understand the client's feelings.
sponsor relationship has been shown to increase program attendance and the chances of recovery. 2. A nurse is facilitatin g a community meeting for acute care clients. One client is constantly talking and using the majority of the group's time. Which of the following interventions should the nurse implement? >> "I imagine myself lying on a quiet beach when I start to feel anxious." - Envisioning oneself in a peaceful, calm environment enhances relaxation and is an example of using guided imagery. 3. A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? >> "I will update the plan of care as a client's manifestations of depression change." - The nurse should update the plan of care as a client's status and needs change. 4. A nurse is caring for a client who gave birth to a stillborn baby. Which of the following statements should the nurse make? >> "I'll stay with you just in case you want to talk." - This response indicates the nurse's interes t in the client and a desire to understand the client's feelings. 5. 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? >> "It is easier to talk about my feelings now." - When clients express their feelings, this indicates a positive treatment outcome. 6. . A client who has bipolar disorder is to be discharged home with a prescription for lithium. Which of the foll owing statements indicates that client teaching regarding the medication has been effective? >> “ I should eat a regular diet with normal amounts of salt and fluids” - This statement indicates that the client understands the teaching because normal levels of sodium and fluid need to be maintained to ensure adequate excretion Prof. Exams of lithium. If sodium levels are low, the body compensates by decreasing lithium excretion, which can lead to toxicity. 7. A nurse is caring for a client who has attempted sui cide and has alcohol use disorder. Which of the following statements indicates that the client is using a positive coping mechanism? >> “ I will attend daily group therapy sessions to practice relaxation techniques” -Relaxation techniques decrease the risk for self -harm by decreasing stress, anxiety, and depression. 8. A nurse observes a client on a mental health unit pushing on the locked unit door. Which of the following statements should the nurse make? >> “ It appears as though you wou ld like to open the door.” - This statement is an example of the therapeutic technique of making observations. This technique encourages the client to notice the behavior so that she can describe thoughts and feelings related to that behavior. 9. A nurse in an emergency department is caring for a female adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Which of the following statements by the mother acknowledges her daughter's diagnosis? >> “She won’t let me take the trash from her room. I’m concerned about what she has in there.” - The client might be binge eating and attempting to hide her food containers, which is a common behavior among clients who have bulimia nervosa. The mother's statem ent indicates awareness of her daughter's behavior. 10. A nurse is teaching a family member and a client who has a new diagnosis of Alzheimer's disease and is to start taking donepezil. Which of the following statements should the nurse include in the teaching? >> “Take this medication in the eveni ng at bedtime” -The client should take this medication in the evening at bedtime for optimal effectiveness. 11. A nurse is interviewing a client at a temporary shelter after surviving the destruction of her home by a tornado. When assessing the client, the nurse should ask which of the following questions to determine the client's ability to cope with this situation? >> “To whom do you talk when you feel overwhelmed?” - By asking this question, the nurse is assessing the client's support systems, whi ch is an important factor in the client's ability to cope with the situation. 12. A nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and a fear of gaining weight. The client states, "I'm so fat I can't even sta nd Prof. Exams to look at myself." Which of the following therapeutic responses demonstrates the nurse's use of summarizing? >> “You’re saying that you think you are fat and are using laxatives because you are afraid of gaining weight” - The nurse is using the therapeutic technique of summarizing to review the key points of the discussion. 13. 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 fi ndings indicating lithium toxicity? >> 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. 14. A client who has a diagnosis of depression is attending group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. When it is the client's turn, she does not respond. Which of the follo wing actions should the nurse take before repeating the request to the client? >> Allow the client time to collect her thoughts. - Slowed response time is common in clients who have depression. The nurse should allow the client time to comprehend a nd formulate an answer to the question. 15. A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder? >> Anhedonia - Negative symptoms of schizophrenia af fect a person's ability to interact with others and are less dominant than positive symptoms. These symptoms develop over time. Examples of negative symptoms include flat affect, anergia (lack of energy), anhedonia (inability to enjoy otherwise pleasurable activities), and thought blocking. 16. A nurse is planning care for an adolescent who is being admitted to an acute care unit following a suicide attempt. Which of the following interventions should the nurse identify as the priority? >> Arrange one-to-one observation of the client. - The greatest risk to the client is self -injury. Therefore, the priority nursing intervention is one -to-one observation to promote client safety. 17. A charge nurse enters a client's room and observes an assistive pe rsonnel (AP) slapping an older adult client. After moving the client to safety, which of the following actions is the charge nurse's priority? Prof. Exams >> Ask group members to discuss their feelings about this client's monopolizing behavior. - This interven tion will validate other members' feelings toward the client who is dominating the meeting. It also should encourage group problem -solving. 18. During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in her bed. The clien t reports that a bomb was placed in her room by a family member during visiting hours. Which of the following actions should the nurse take? >>Assess the client for evidence of a perceptual disturbance. - The nurse should assess the situation to d etermine if the client is hallucinating or misperceiving external stimuli (experiencing illusions). 19. A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? >> Assist the client w ith deep -breathing exercises - Relaxation techniques, such as deep, abdominal breathing exercises, help defuse manifestations of anxiety. 20. A nurse on a medical -surgical unit is assessing a client who sustained injuries 12 hr ago following a motor -vehic le crash. The client's admission blood alcohol level was 325 mg/dL. Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal? >>Blood pressure 154/96 mm Hg - Physical manifestations of alcohol withdrawal occur in addition to psychological effects. A client who is experiencing alcohol withdrawal is expected to have hypertension, tachycardia, and fever greater than 38.3° C (101° F). It will be important for the nurse to rule out infection in the client who has a fever . 21. A nurse in a mental health unit observes a client who has acute mania hit another client. Which fo the following actions should the nurse take first? ○ Call for a team of staff members to help with the situation - The greatest risk is injury to the client and others. Therefore, the first action the nurse should take is to call for assistance to prevent further injury to himself or others. 22. A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adole scent who weighs 110 lb. Available is chlorpromazine syrup 10 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ○ Client has COPD - This response indicates the nurse's interest in the client and a desire to understand the client's feelings.
