ATI RN Mental Health Online Practice 2023 A
Study online at https://quizlet.com/_ello20
1. A school nurse is assessing a school aged child who experienced the trau-
matic loss of a parent 8 months ago. Which of the following findings should
the nurse identify as an indication that the child is experiencing post traumatic
stress disorder (PTSD)
1. Clinging behaviors directed toward a teacher
2. Increased time spent sleeping
3. Intense focus on school work
4. Lack of interest in an upcoming holiday: Correct = 4. Lack of interest in an upcoming holiday
The child who has PTSD will have negative moods and difficulty remembering aspects of the traumatic event. The child
can also have a loss of interest or lack of participation in significant activities and events (e.g., Holidays)
*PTSD manifestations seen in children include detachment or estrangement from others, difficulty sleeping/distressing
dreams, difficulty concentrating on tasks
2. A nurse is caring for a group of clients. Which of the following finding should
the nurse report?
1. A client who is taking clozapine and has a WBC count of 7,500
2. A client who is taking lamotrigine and has developed a rash
3. A client who is taking valproate and has a platelet count of 150,000
4. A client who is taking lithium and has a lithium level of 1.2: Correct = 2. A client who
is taking lamotrigine and has developed a rash
Lamotrigine is an anticonvulsant medication that is used as a mood stabilizer. The nurse should identify that a rash is
a potentially life threatening adverse effect of the medication and report the finding immediately
3. A nurse is reviewing laboratory results for a client who has schizophrenia and
is taking clozapine. Which of the following values should the nurse identify as
contraindication for receiving clozapine?
1. WBC count 2,500
2. Hgb 11.5
3. Platelets 150,000
, ATI RN Mental Health Online Practice 2023 A
Study online at https://quizlet.com/_ello20
4. RBC count 3.5: Correct - 1. WBC count 2,500
Clozapine can cause agranulocytosis, which can be fatal due to overwhelming infection. The nurse should identify a
WBC count of less than 3,000 as a possible manifestation of agranulocytosis and should withhold the medication and
notify the provider
4. 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?
1. "I'm relieved now that my financial affairs are in order."
2. "It is easier to talk about my feelings now."
3. "Suddenly I have enough energy to do anything I want."
4. "Thank you for always taking such good care of me.": Correct - 2. "It is easier to talk about
my feelings now."
When clients express their feelings, this indicates a positive treatment outcome
*When clients who have depression verbalize getting their affairs in order, or suddenly have more energy are at
an increased risk of suicide. Clients who have depression often show an appreciation for loved ones when they are
contemplating suicide
5. During a client's initial interview in a mental health inpatient setting, a nurse
identifies that the client is maintaining eye contact and leaning forward. Which
of the following assumptions should the nurse make based on the client's
nonverbal behaviors?
1. The client is interested in what the nurse is saying
2. The client is attempting to manipulate the nurse
3. The client is physically attracted to the nurse
4. The client is seeking acceptance by the nurse: Correct - 1. The client is interested in what
the nurse is saying
The client's posture and eye contact demonstrate an interest in the interview and what the nurse is saying
, ATI RN Mental Health Online Practice 2023 A
Study online at https://quizlet.com/_ello20
6. A nurse is planning care for a client who has schizophrenia and reports
auditory hallucinations. Which of the following interventions should the nurse
include in the plan?
1. Promote use of music to compete with the client's auditory hallucination
2. Inform the client that the auditory hallucinations are not real
3. Avoid asking the client if they are experiencing auditory hallucinations
4. Instruct the client on the use of voice recognition regarding the auditory
hallucinations: Correct = 1. Promote the use of music to compete with the client's auditory hallucinations
Competing reality based stimulating such as the use of music or television during auditory hallucinations can assist in
limiting the effect the hallucinations have on the client's stress level
*The nurse should acknowledge that the client is hearing auditory hallucinations, but should tell the client that others
cannot hear anything to reinforce reality. The nurse should ask the client if they are hearing voices to evaluate whether
these are command hallucinations, which can place the client or others at risk for harm. The nurse should assist the
client to develop the skill of voice dismissal when auditory hallucinations occur. This involves commanding the voices to
stop, which gives the client a sense of control
7. A nurse is caring for a client who has impaired cognition
A nurse is updating the client's plan of care. For each of the following potential
nursing interventions, click to specify if the potential intervention is anticipated,
nonessential, or contraindicated for the client
Potential Intervention:
1. When addressing the client, approach them from the front when possible
2. Use a vest restrain to keep the client in a medical recliner
3. Ensure the bed is kept at a working height for the nurse
4. Provide the client with high-calorie protein drinks hourly
5. Give directions to the client slowly and in a moderate tone of voice
6. Decrease the sensory stimulation
7. Keep the lights off in the client's bedroom and bathroom at night
8. Assign the client to a room near the nurses' station
, ATI RN Mental Health Online Practice 2023 A
Study online at https://quizlet.com/_ello20
Exhibit 1:
Medical History
Day 1, 0800: Client treated for UTI 8 months ago
Day 3, 0830: Client fell getting out of bed to go to the ba: Correct =
1. When addressing the client, approach them from the front when possible = Anticipated.
*A client who is unexpectantly approached or touched from someone out of view is easily startled, which can promote
aggressive behavior in the client.
2. Use a vest restraint to keep the client in a medical recliner = Contraindicated.
*The client has the right to be free from the use of restraints except in the case of an emergency.
3. Ensure the bed is kept at a working height for the nurse = Contraindicated.
*The client's bed should be placed in the lowest position to decrease the risk for falls, or lessen injury severity if the
client does fall.
4. Provide the client with high-calorie protein drinks hourly = Nonessential.
*This is nonessential for this client because they are taking in nutrition. The nurse should provide the client who has
mania with this type of dietary supplement.
5. Give directions to the client slowly and in a moderate tone of voice = Anticipated.
*Providing directions slowly and in a moderate tone of voice will increase client comprehension. Loud voices can cause
the client to feel uncomfortable and can even cause feelings of anger.
6. Decrease sensory stimulation = Anticipated.
*A highly stimulating environment can cause the client to become anxious and further disoriented, which can impair
client safety.
7. Keep the lights off in the client's bedroom and bathroom at night = Contraindicated.
*This can increase the client's risk for falls. Keeping a light on can decrease wandering.
8. Assign the client to a room near the nurses' station = Anticipated.
*This promotes client safety by allowing staff to observe the client frequently.
8. A nurse is planning discharge teaching with a family member of a client who
has a new diagnosis of depression. Which of the following information about
relapse should the nurse include?
1. Additional acute episodes of depression are unlikely following inpatient
Study online at https://quizlet.com/_ello20
1. A school nurse is assessing a school aged child who experienced the trau-
matic loss of a parent 8 months ago. Which of the following findings should
the nurse identify as an indication that the child is experiencing post traumatic
stress disorder (PTSD)
1. Clinging behaviors directed toward a teacher
2. Increased time spent sleeping
3. Intense focus on school work
4. Lack of interest in an upcoming holiday: Correct = 4. Lack of interest in an upcoming holiday
The child who has PTSD will have negative moods and difficulty remembering aspects of the traumatic event. The child
can also have a loss of interest or lack of participation in significant activities and events (e.g., Holidays)
*PTSD manifestations seen in children include detachment or estrangement from others, difficulty sleeping/distressing
dreams, difficulty concentrating on tasks
2. A nurse is caring for a group of clients. Which of the following finding should
the nurse report?
1. A client who is taking clozapine and has a WBC count of 7,500
2. A client who is taking lamotrigine and has developed a rash
3. A client who is taking valproate and has a platelet count of 150,000
4. A client who is taking lithium and has a lithium level of 1.2: Correct = 2. A client who
is taking lamotrigine and has developed a rash
Lamotrigine is an anticonvulsant medication that is used as a mood stabilizer. The nurse should identify that a rash is
a potentially life threatening adverse effect of the medication and report the finding immediately
3. A nurse is reviewing laboratory results for a client who has schizophrenia and
is taking clozapine. Which of the following values should the nurse identify as
contraindication for receiving clozapine?
1. WBC count 2,500
2. Hgb 11.5
3. Platelets 150,000
, ATI RN Mental Health Online Practice 2023 A
Study online at https://quizlet.com/_ello20
4. RBC count 3.5: Correct - 1. WBC count 2,500
Clozapine can cause agranulocytosis, which can be fatal due to overwhelming infection. The nurse should identify a
WBC count of less than 3,000 as a possible manifestation of agranulocytosis and should withhold the medication and
notify the provider
4. 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?
1. "I'm relieved now that my financial affairs are in order."
2. "It is easier to talk about my feelings now."
3. "Suddenly I have enough energy to do anything I want."
4. "Thank you for always taking such good care of me.": Correct - 2. "It is easier to talk about
my feelings now."
When clients express their feelings, this indicates a positive treatment outcome
*When clients who have depression verbalize getting their affairs in order, or suddenly have more energy are at
an increased risk of suicide. Clients who have depression often show an appreciation for loved ones when they are
contemplating suicide
5. During a client's initial interview in a mental health inpatient setting, a nurse
identifies that the client is maintaining eye contact and leaning forward. Which
of the following assumptions should the nurse make based on the client's
nonverbal behaviors?
1. The client is interested in what the nurse is saying
2. The client is attempting to manipulate the nurse
3. The client is physically attracted to the nurse
4. The client is seeking acceptance by the nurse: Correct - 1. The client is interested in what
the nurse is saying
The client's posture and eye contact demonstrate an interest in the interview and what the nurse is saying
, ATI RN Mental Health Online Practice 2023 A
Study online at https://quizlet.com/_ello20
6. A nurse is planning care for a client who has schizophrenia and reports
auditory hallucinations. Which of the following interventions should the nurse
include in the plan?
1. Promote use of music to compete with the client's auditory hallucination
2. Inform the client that the auditory hallucinations are not real
3. Avoid asking the client if they are experiencing auditory hallucinations
4. Instruct the client on the use of voice recognition regarding the auditory
hallucinations: Correct = 1. Promote the use of music to compete with the client's auditory hallucinations
Competing reality based stimulating such as the use of music or television during auditory hallucinations can assist in
limiting the effect the hallucinations have on the client's stress level
*The nurse should acknowledge that the client is hearing auditory hallucinations, but should tell the client that others
cannot hear anything to reinforce reality. The nurse should ask the client if they are hearing voices to evaluate whether
these are command hallucinations, which can place the client or others at risk for harm. The nurse should assist the
client to develop the skill of voice dismissal when auditory hallucinations occur. This involves commanding the voices to
stop, which gives the client a sense of control
7. A nurse is caring for a client who has impaired cognition
A nurse is updating the client's plan of care. For each of the following potential
nursing interventions, click to specify if the potential intervention is anticipated,
nonessential, or contraindicated for the client
Potential Intervention:
1. When addressing the client, approach them from the front when possible
2. Use a vest restrain to keep the client in a medical recliner
3. Ensure the bed is kept at a working height for the nurse
4. Provide the client with high-calorie protein drinks hourly
5. Give directions to the client slowly and in a moderate tone of voice
6. Decrease the sensory stimulation
7. Keep the lights off in the client's bedroom and bathroom at night
8. Assign the client to a room near the nurses' station
, ATI RN Mental Health Online Practice 2023 A
Study online at https://quizlet.com/_ello20
Exhibit 1:
Medical History
Day 1, 0800: Client treated for UTI 8 months ago
Day 3, 0830: Client fell getting out of bed to go to the ba: Correct =
1. When addressing the client, approach them from the front when possible = Anticipated.
*A client who is unexpectantly approached or touched from someone out of view is easily startled, which can promote
aggressive behavior in the client.
2. Use a vest restraint to keep the client in a medical recliner = Contraindicated.
*The client has the right to be free from the use of restraints except in the case of an emergency.
3. Ensure the bed is kept at a working height for the nurse = Contraindicated.
*The client's bed should be placed in the lowest position to decrease the risk for falls, or lessen injury severity if the
client does fall.
4. Provide the client with high-calorie protein drinks hourly = Nonessential.
*This is nonessential for this client because they are taking in nutrition. The nurse should provide the client who has
mania with this type of dietary supplement.
5. Give directions to the client slowly and in a moderate tone of voice = Anticipated.
*Providing directions slowly and in a moderate tone of voice will increase client comprehension. Loud voices can cause
the client to feel uncomfortable and can even cause feelings of anger.
6. Decrease sensory stimulation = Anticipated.
*A highly stimulating environment can cause the client to become anxious and further disoriented, which can impair
client safety.
7. Keep the lights off in the client's bedroom and bathroom at night = Contraindicated.
*This can increase the client's risk for falls. Keeping a light on can decrease wandering.
8. Assign the client to a room near the nurses' station = Anticipated.
*This promotes client safety by allowing staff to observe the client frequently.
8. A nurse is planning discharge teaching with a family member of a client who
has a new diagnosis of depression. Which of the following information about
relapse should the nurse include?
1. Additional acute episodes of depression are unlikely following inpatient
