MENTAL HEALTH FINAL ATI 100%
ACCURATE SOLUTIONS 2025/2026
LATEST EDITION
A nurse is planning care for a client who has borderline personality disorder who self-mutilates. Which
of the following treatment approaches should the nurse plan to take? - ANS-a)Restrict participation in
group therapy sessions
b)Establish consequences for self-mutilation
c)Maintain close observation
d) Provide an unstructered environment
c is answer. 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
A nurse is caring for a client who has Alzheimer's disease and a new prescription for donepezil. What
action should the nurse take? - ANS-Administer the medication at bedtime.
A nurse is caring for a client who reports that the television set in the room is really a two-way radio and
states, "voices are coming from the TV and everything we say in this room is being recorded." What
response should the nurse make? - ANS-"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.
A nurse is caring for a client who has Wernicke-Korsakoff syndrome due to alcohol use disorder. What
finding should the nurse expect? - ANS-Confusion.
The nurse should expect the client who has Wernicke-Korsakoff syndrome to exhibit neurological and
cognitive manifestations due to thiamine deficiency. Confusion, stupor, diplopia, and memory loss are
expected findings of this disorder.
, A nurse is providing teaching to a client who has generalized anxiety disorder and a new prescription for
buspirone. The nurse should inform the client that which manifestations is a common adverse effect of
this medication? - ANS-Dizziness.
The nurse should inform the client that dizziness is a common adverse effect of buspirone. The nurse
should instruct the client to avoid driving and operating heavy machinery until the presence of adverse
effects is determined.
A nurse is reviewing the medical record of a client who has a new prescription for a benzodiazepine.
What finding should the nurse question the provider's prescription? - ANS-Hypotension.
The nurse should question the provider's prescription for a benzodiazepine for a client who has
hypotension. Benzodiazepines can cause severe hypotension and increase the client's risk for cardiac
arrest.
A nurse is assessing a client who takes phenelzine for the treatment of depression. What finding is the
priority for the nurse to report to the provider? - ANS-Elevated blood pressure.
The nurse should identify that the greatest risk to the client is an elevated blood pressure, which
increases the risk for a hypertensive crisis that can result from taking an MAOI, such as phenelzine. The
nurse should apply the safety and risk reduction priority-setting framework when assessing 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 frame-work, or nursing
knowledge to identify which risk poses the greatest risk.
A nurse is providing teaching to a client who has a new prescription for disulfiram for the management
of alcohol dependence. What dietary choices should the nurse instruct the client to avoid? - ANS-Pure
vanilla extract.
The nurse should instruct the client to avoid alcohol and alcohol-containing substances such as pure
vanilla extract. The ingestion of alcohol while taking this medication causes a disulfiram-alcohol reaction,
which is manifested by hyperventilation, dizziness, vomiting, and hypotension.
A nurse is providing teaching to the parents of a school-age child who has attention deficit hyperactivity
disorder (ADHD).What should the nurse include in her teaching? - ANS-Ignore your child's attention-
seeking behaviors that are not dangerous
A nurse is planning a staff education session about the administration of antidepressant medications to
older adult clients. What should the nurse include in the teaching? - ANS-Older adult clients require a
lower initial dose of antidepressant medication than adult clients
ACCURATE SOLUTIONS 2025/2026
LATEST EDITION
A nurse is planning care for a client who has borderline personality disorder who self-mutilates. Which
of the following treatment approaches should the nurse plan to take? - ANS-a)Restrict participation in
group therapy sessions
b)Establish consequences for self-mutilation
c)Maintain close observation
d) Provide an unstructered environment
c is answer. 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
A nurse is caring for a client who has Alzheimer's disease and a new prescription for donepezil. What
action should the nurse take? - ANS-Administer the medication at bedtime.
A nurse is caring for a client who reports that the television set in the room is really a two-way radio and
states, "voices are coming from the TV and everything we say in this room is being recorded." What
response should the nurse make? - ANS-"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.
A nurse is caring for a client who has Wernicke-Korsakoff syndrome due to alcohol use disorder. What
finding should the nurse expect? - ANS-Confusion.
The nurse should expect the client who has Wernicke-Korsakoff syndrome to exhibit neurological and
cognitive manifestations due to thiamine deficiency. Confusion, stupor, diplopia, and memory loss are
expected findings of this disorder.
, A nurse is providing teaching to a client who has generalized anxiety disorder and a new prescription for
buspirone. The nurse should inform the client that which manifestations is a common adverse effect of
this medication? - ANS-Dizziness.
The nurse should inform the client that dizziness is a common adverse effect of buspirone. The nurse
should instruct the client to avoid driving and operating heavy machinery until the presence of adverse
effects is determined.
A nurse is reviewing the medical record of a client who has a new prescription for a benzodiazepine.
What finding should the nurse question the provider's prescription? - ANS-Hypotension.
The nurse should question the provider's prescription for a benzodiazepine for a client who has
hypotension. Benzodiazepines can cause severe hypotension and increase the client's risk for cardiac
arrest.
A nurse is assessing a client who takes phenelzine for the treatment of depression. What finding is the
priority for the nurse to report to the provider? - ANS-Elevated blood pressure.
The nurse should identify that the greatest risk to the client is an elevated blood pressure, which
increases the risk for a hypertensive crisis that can result from taking an MAOI, such as phenelzine. The
nurse should apply the safety and risk reduction priority-setting framework when assessing 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 frame-work, or nursing
knowledge to identify which risk poses the greatest risk.
A nurse is providing teaching to a client who has a new prescription for disulfiram for the management
of alcohol dependence. What dietary choices should the nurse instruct the client to avoid? - ANS-Pure
vanilla extract.
The nurse should instruct the client to avoid alcohol and alcohol-containing substances such as pure
vanilla extract. The ingestion of alcohol while taking this medication causes a disulfiram-alcohol reaction,
which is manifested by hyperventilation, dizziness, vomiting, and hypotension.
A nurse is providing teaching to the parents of a school-age child who has attention deficit hyperactivity
disorder (ADHD).What should the nurse include in her teaching? - ANS-Ignore your child's attention-
seeking behaviors that are not dangerous
A nurse is planning a staff education session about the administration of antidepressant medications to
older adult clients. What should the nurse include in the teaching? - ANS-Older adult clients require a
lower initial dose of antidepressant medication than adult clients
