11/17/23, 6:34 PM ATI Mental Health Final Quiz aka Quiz 3 With Answers Explanations
ATI Mental Health Final Quiz
• A nurse is planning care for a client who has a borderline personality disorder and self-
mutilates. Which of the following test approaches should the nurse plan to take?
• Restrict participation in group therapy sessions.
The nurse should encourage the client who has borderline personality disorder to
participate in group therapy sessions to encourage appropriate interaction with other
clients.
• Establish consequences for self-mutilation.
The nurse should respond to self-mutilation with a neutral affect and encourage the
client to write down feelings that occurred leading up to the incident.
• Maintain close observation of the client.
Clients who have borderline personality disorder are at
risk for self-harm during times of increased anxiety. Maintaining close
observation reduces the client's risk of injury.
• Provide an unstructured environment.
Providing an unstructured environment for a client who has a borderline personality
disorder is not an effective treatment approach because it does not provide a safe
environment to protect the client from impulsive and self-injurious behavior.
• A nurse is assessing a client who has Stage 4 Alzheimer's disease. Which of the
following findings should the nurse expect?
• The client requires assistance with eating.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to still have the
ability to eat without assistance. Clients who have Alzheimer’s disease maintain this
ability until Stage 7.
• The client independently manages personal finances.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to have
difficulty performing complex tasks, such as managing personal finances.
• The client has bladder incontinence.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to be able to
use the toilet independently. Clients who have Alzheimer’s disease maintain
continence until Stage 6.
• The
client can identify the names of family members.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to recognize and
identify family members. Clients who have Alzheimer’s disease maintain this ability until Stage 6.
• A nurse is caring for a client who reports that the television set in the room is a two-way
radio and states, "voices are coming from the TV and everything we say in the room is being
recorded." Which of the following responses should the nurse make?
• "What we say is not being recorded."
The nurse should avoid negating the client’s beliefs about the delusion. This response can
promote a defensive client response and interfere with the development of trust in the
nurse-client relationship.
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,11/17/23, 6:34 PM ATI Mental Health Final Quiz aka Quiz 3 With Answers Explanations
• "Let's ignore the voices and talk about something else."
The nurse should ask the client directly about what the voices are saying to determine if
there is a safety risk. The nurse should also avoid validating that the voices are real,
which promotes the client’s beliefs about the delusion.
• "That
must be very frightening."
The nurse should respond to the client’s delusion in a calm and empathetic manner. By
acknowledging to the client that the delusion must be frightening, the nurse promotes
the nurse-client relationship.
• "Why do you think the TV is a two-way radio?"
The nurse should avoid asking the client a "why" question, which promotes a defensive
client response.
• A nurse is planning care for a newly admitted client who has bipolar disorder and is
experiencing acute mania. Which of the following client goals should the nurse identify as the
priority?
• Practicing problem-solving skills
The nurse should encourage the client to practice problem-solving skills during the
continuation phase of treatment; however, another intervention is the priority during the
acute phase of bipolar disorder.
• Understanding of medication regimen
The nurse should ensure that the client understands the medication regimen during the
continuation phase of treatment; however, another intervention is the priority during the
acute phase of bipolar disorder.
• Identifying indications of relapse
The nurse should teach the client to recognize indications of relapse during the
continuation phase of treatment; however, another intervention is the priority during the
acute phase of bipolar disorder.
• Maint
aining adequate hydration
The nurse should identify that the priority goal is to prevent physical exhaustion, maintain
health, and meet nutritional and rest needs during the acute phase of the client’s manic
episode. The nurse should consider Maslow’s hierarchy of needs, which includes five
levels of priority when planning care for this client. The first level consists of
physiological needs; the second level consists of safety and security needs; the third
level consists of love and belonging needs; the fourth level consists of personal
achievement and self-esteem needs, and the fifth level consists of achieving full
potential and the ability to problem solve and cope with life situations. When applying
Maslow’s hierarchy of needs priority-setting framework the nurse should review
physiological needs first. The nurse should then address the client’s needs by following
the remaining four hierarchical levels. It is important, however, for the nurse to consider
all contributing client factors, as higher levels of the pyramid can compete with those at
the lower levels, depending on the specific client situation. The fourth level of Maslow’s
hierarchy of needs includes usefulness, self-worth, and self-confidence in fulfilling self-
esteem needs.
about:blank 2/22
, 11/17/23, 6:34 PM ATI Mental Health Final Quiz aka Quiz 3 With Answers Explanations
• A nurse is preparing to administer benzodiazepine to a client with Generalized
Anxiety Disorder. The nurse should tell the client to expect the following adverse reactions?
• Tinnitus
Tinnitus is not an adverse effect of benzodiazepines.
• Bradycardia
Tachycardia, rather than bradycardia, is a potential adverse effect of benzodiazepines.
• Halitosis
Halitosis is not an adverse effect of benzodiazepines.
• Sedation
The nurse should tell the client to expect sedation as an adverse effect of benzodiazepines because of
the CNS depressive effects.
• A nurse in a mental health unit is planning care for a client who is receiving treatment
for self-inflicted injuries. The nurse should identify which of the following interventions is the priority
when planning care for this client.
• Promoting and maintaining client safety
The nurse should recognize that the client who has self-inflicted injuries is at risk for further
self-harm or suicide; therefore, the client’s safety is the priority. The nurse should apply
the safety and risk reduction priority-setting framework when planning care for this
client. This framework assigns priority to the factor or situation posing the greatest
safety risk to the client. When there are several risks to client safety, the one posing the
greatest threat is the highest priority. The nurse should use Maslow’s hierarchy of needs,
the ABC priority-setting framework, or nursing knowledge to identify which risk poses
the greatest threat to the client.
• Discussing reasons for the client's behavior
The nurse should communicate with the client to discuss reasons for the client’s
behavior; however, there is another action that is the priority.
• Assisting the client to recognize feelings
The nurse should assist the client to recognize feelings; however, there is another action
that is the priority.
• Teaching the client alternative coping strategies
The nurse should teach the client alternative coping strategies; however, there is another
action that is the priority.
• A nurse is providing teaching to a client who has a new prescription for disulfiram for
the management of alcohol dependence. Which of the following dietary choices should the nurse
instruct the client to avoid?
• Peppermint candy
The client doesn't need to avoid peppermint while taking disulfiram.
• Pure vanilla extract
The nurse should instruct the client to avoid alcohol and alcohol-
containing substances, such as pure vanilla extract while taking disulfiram. The
ingestion of alcohol while taking this medication causes a disulfiram-alcohol
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ATI Mental Health Final Quiz
• A nurse is planning care for a client who has a borderline personality disorder and self-
mutilates. Which of the following test approaches should the nurse plan to take?
• Restrict participation in group therapy sessions.
The nurse should encourage the client who has borderline personality disorder to
participate in group therapy sessions to encourage appropriate interaction with other
clients.
• Establish consequences for self-mutilation.
The nurse should respond to self-mutilation with a neutral affect and encourage the
client to write down feelings that occurred leading up to the incident.
• Maintain close observation of the client.
Clients who have borderline personality disorder are at
risk for self-harm during times of increased anxiety. Maintaining close
observation reduces the client's risk of injury.
• Provide an unstructured environment.
Providing an unstructured environment for a client who has a borderline personality
disorder is not an effective treatment approach because it does not provide a safe
environment to protect the client from impulsive and self-injurious behavior.
• A nurse is assessing a client who has Stage 4 Alzheimer's disease. Which of the
following findings should the nurse expect?
• The client requires assistance with eating.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to still have the
ability to eat without assistance. Clients who have Alzheimer’s disease maintain this
ability until Stage 7.
• The client independently manages personal finances.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to have
difficulty performing complex tasks, such as managing personal finances.
• The client has bladder incontinence.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to be able to
use the toilet independently. Clients who have Alzheimer’s disease maintain
continence until Stage 6.
• The
client can identify the names of family members.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to recognize and
identify family members. Clients who have Alzheimer’s disease maintain this ability until Stage 6.
• A nurse is caring for a client who reports that the television set in the room is a two-way
radio and states, "voices are coming from the TV and everything we say in the room is being
recorded." Which of the following responses should the nurse make?
• "What we say is not being recorded."
The nurse should avoid negating the client’s beliefs about the delusion. This response can
promote a defensive client response and interfere with the development of trust in the
nurse-client relationship.
about:blank 1/22
,11/17/23, 6:34 PM ATI Mental Health Final Quiz aka Quiz 3 With Answers Explanations
• "Let's ignore the voices and talk about something else."
The nurse should ask the client directly about what the voices are saying to determine if
there is a safety risk. The nurse should also avoid validating that the voices are real,
which promotes the client’s beliefs about the delusion.
• "That
must be very frightening."
The nurse should respond to the client’s delusion in a calm and empathetic manner. By
acknowledging to the client that the delusion must be frightening, the nurse promotes
the nurse-client relationship.
• "Why do you think the TV is a two-way radio?"
The nurse should avoid asking the client a "why" question, which promotes a defensive
client response.
• A nurse is planning care for a newly admitted client who has bipolar disorder and is
experiencing acute mania. Which of the following client goals should the nurse identify as the
priority?
• Practicing problem-solving skills
The nurse should encourage the client to practice problem-solving skills during the
continuation phase of treatment; however, another intervention is the priority during the
acute phase of bipolar disorder.
• Understanding of medication regimen
The nurse should ensure that the client understands the medication regimen during the
continuation phase of treatment; however, another intervention is the priority during the
acute phase of bipolar disorder.
• Identifying indications of relapse
The nurse should teach the client to recognize indications of relapse during the
continuation phase of treatment; however, another intervention is the priority during the
acute phase of bipolar disorder.
• Maint
aining adequate hydration
The nurse should identify that the priority goal is to prevent physical exhaustion, maintain
health, and meet nutritional and rest needs during the acute phase of the client’s manic
episode. The nurse should consider Maslow’s hierarchy of needs, which includes five
levels of priority when planning care for this client. The first level consists of
physiological needs; the second level consists of safety and security needs; the third
level consists of love and belonging needs; the fourth level consists of personal
achievement and self-esteem needs, and the fifth level consists of achieving full
potential and the ability to problem solve and cope with life situations. When applying
Maslow’s hierarchy of needs priority-setting framework the nurse should review
physiological needs first. The nurse should then address the client’s needs by following
the remaining four hierarchical levels. It is important, however, for the nurse to consider
all contributing client factors, as higher levels of the pyramid can compete with those at
the lower levels, depending on the specific client situation. The fourth level of Maslow’s
hierarchy of needs includes usefulness, self-worth, and self-confidence in fulfilling self-
esteem needs.
about:blank 2/22
, 11/17/23, 6:34 PM ATI Mental Health Final Quiz aka Quiz 3 With Answers Explanations
• A nurse is preparing to administer benzodiazepine to a client with Generalized
Anxiety Disorder. The nurse should tell the client to expect the following adverse reactions?
• Tinnitus
Tinnitus is not an adverse effect of benzodiazepines.
• Bradycardia
Tachycardia, rather than bradycardia, is a potential adverse effect of benzodiazepines.
• Halitosis
Halitosis is not an adverse effect of benzodiazepines.
• Sedation
The nurse should tell the client to expect sedation as an adverse effect of benzodiazepines because of
the CNS depressive effects.
• A nurse in a mental health unit is planning care for a client who is receiving treatment
for self-inflicted injuries. The nurse should identify which of the following interventions is the priority
when planning care for this client.
• Promoting and maintaining client safety
The nurse should recognize that the client who has self-inflicted injuries is at risk for further
self-harm or suicide; therefore, the client’s safety is the priority. The nurse should apply
the safety and risk reduction priority-setting framework when planning care for this
client. This framework assigns priority to the factor or situation posing the greatest
safety risk to the client. When there are several risks to client safety, the one posing the
greatest threat is the highest priority. The nurse should use Maslow’s hierarchy of needs,
the ABC priority-setting framework, or nursing knowledge to identify which risk poses
the greatest threat to the client.
• Discussing reasons for the client's behavior
The nurse should communicate with the client to discuss reasons for the client’s
behavior; however, there is another action that is the priority.
• Assisting the client to recognize feelings
The nurse should assist the client to recognize feelings; however, there is another action
that is the priority.
• Teaching the client alternative coping strategies
The nurse should teach the client alternative coping strategies; however, there is another
action that is the priority.
• A nurse is providing teaching to a client who has a new prescription for disulfiram for
the management of alcohol dependence. Which of the following dietary choices should the nurse
instruct the client to avoid?
• Peppermint candy
The client doesn't need to avoid peppermint while taking disulfiram.
• Pure vanilla extract
The nurse should instruct the client to avoid alcohol and alcohol-
containing substances, such as pure vanilla extract while taking disulfiram. The
ingestion of alcohol while taking this medication causes a disulfiram-alcohol
about:blank 3/22
