ATI PN MENTAL HEALTH PROCTORED EXAM 2023 WITH VERIFIED SOLUTIONS
AND RATIONALE/A+ SCORE ASSURED
Question 1
A nurse is caring for a client with schizophrenia who reports hearing voices telling them that the
food is poisoned. Which of the following is the priority nursing action?
A) Tell the client that the voices are not real.
B) Inquire about the content of the hallucinations to assess for safety.
C) Suggest the client listen to music through headphones.
D) Administer a PRN dose of lorazepam.
E) Provide a different meal to prove the food is safe.
Correct Answer: B) Inquire about the content of the hallucinations to assess for safety.
Rationale: The priority is to assess for "command hallucinations" which might instruct the
client to harm themselves or others. Understanding the content allows the nurse to
implement appropriate safety measures.
Question 2
A nurse is teaching a client about a new prescription for lithium carbonate for bipolar disorder.
Which of the following instructions should the nurse include?
A) Limit your sodium intake to less than 1,500 mg per day.
B) Stop taking the medication if you experience a fine hand tremor.
C) Maintain consistent fluid intake of 2 to 3 liters per day.
D) Take the medication on an empty stomach for better absorption.
E) Use ibuprofen for headaches while on this medication.
Correct Answer: C) Maintain consistent fluid intake of 2 to 3 liters per day.
Rationale: Lithium is a salt, and dehydration can lead to toxic lithium levels. Consistently
high fluid intake helps maintain stable serum levels and prevents toxicity.
Question 3
A nurse is assessing a client with anorexia nervosa. Which of the following physical findings
should the nurse expect?
A) Hypertension
B) Tachycardia
C) Hyperthermia
D) Bradycardia
E) Diarrhea
Correct Answer: D) Bradycardia
Rationale: Severe malnutrition and starvation in anorexia nervosa lead to physiological
slowing, resulting in bradycardia, hypotension, and hypothermia.
Question 4
A nurse is caring for a client who is experiencing a panic attack. Which of the following actions
should the nurse take first?
, 2
A) Teach the client how to use abdominal breathing.
B) Stay with the client and remain calm.
C) Administer a dose of buspirone.
D) Ask the client to identify the trigger of the attack.
E) Encourage the client to join a group therapy session.
Correct Answer: B) Stay with the client and remain calm.
Rationale: During a panic attack, the client's safety and immediate reassurance are the
priorities. The nurse’s presence provides a sense of security until the physical symptoms
subside.
Question 5
A nurse is teaching a client who has a new prescription for clozapine. Which of the following
laboratory tests should the nurse emphasize the need for regular monitoring?
A) Serum potassium
B) Liver function tests
C) White blood cell (WBC) count
D) Blood urea nitrogen (BUN)
E) Fasting blood glucose
Correct Answer: C) White blood cell (WBC) count
Rationale: Clozapine carries a high risk of agranulocytosis, a severe drop in the WBC count.
Regular monitoring (usually weekly) is mandatory to detect this life-threatening side effect.
Question 6
A client with obsessive-compulsive disorder (OCD) spends 45 minutes washing their hands after
every meal. Which of the following is an appropriate intervention for the nurse to implement?
A) Lock the bathroom doors to prevent the ritual.
B) Gradually set time limits for the ritualistic behavior.
C) Inform the client that their hands are already clean.
D) Assign the client to a different task during mealtimes.
E) Give the client a "no-harm" contract to sign.
Correct Answer: B) Gradually set time limits for the ritualistic behavior.
Rationale: Completely stopping the ritual immediately can cause extreme anxiety.
Gradually decreasing the time allowed for the behavior helps the client gain control
without overwhelming them.
Question 7
A nurse is assessing a client for anhedonia. Which of the following statements by the client
indicates this finding?
A) "I hear voices that no one else can hear."
B) "I feel like everyone is out to get me."
C) "I don't find joy in gardening anymore, even though I used to love it."
, 3
D) "I can't remember what I ate for breakfast this morning."
E) "I feel like my heart is racing and I can't catch my breath."
Correct Answer: C) "I don't find joy in gardening anymore, even though I used to love it."
Rationale: Anhedonia is the inability to feel pleasure or a loss of interest in activities that
were previously enjoyable, a common symptom of depression.
Question 8
A client is being admitted for alcohol withdrawal. Which of the following medications should the
nurse expect to administer to manage acute withdrawal symptoms?
A) Disulfiram
B) Lorazepam
C) Methadone
D) Sertraline
E) Bupropion
Correct Answer: B) Lorazepam
Rationale: Benzodiazepines like lorazepam are the gold standard for alcohol withdrawal to
prevent seizures, tremors, and delirium tremens due to their sedative effects on the CNS.
Question 9
A nurse is caring for a client with borderline personality disorder. Which of the following is the
priority nursing intervention?
A) Encouraging the client to participate in group therapy.
B) Identifying the client's use of "splitting."
C) Setting clear and consistent boundaries.
D) Monitoring the client for self-mutilation or self-harm.
E) Teaching the client social skills.
Correct Answer: D) Monitoring the client for self-mutilation or self-harm.
Rationale: Clients with borderline personality disorder are at high risk for self-harm and
suicidal behaviors. Safety is always the priority in the hierarchy of needs.
Question 10
A nurse is teaching a client who has a new prescription for sertraline. Which of the following
side effects should the nurse include in the teaching?
A) Excessive salivation
B) Sexual dysfunction
C) Weight loss
D) Urinary retention
E) Orthostatic hypotension
Correct Answer: B) Sexual dysfunction
Rationale: Sexual dysfunction, including decreased libido and delayed orgasm, is a common
and often distressing side effect of SSRIs like sertraline.
AND RATIONALE/A+ SCORE ASSURED
Question 1
A nurse is caring for a client with schizophrenia who reports hearing voices telling them that the
food is poisoned. Which of the following is the priority nursing action?
A) Tell the client that the voices are not real.
B) Inquire about the content of the hallucinations to assess for safety.
C) Suggest the client listen to music through headphones.
D) Administer a PRN dose of lorazepam.
E) Provide a different meal to prove the food is safe.
Correct Answer: B) Inquire about the content of the hallucinations to assess for safety.
Rationale: The priority is to assess for "command hallucinations" which might instruct the
client to harm themselves or others. Understanding the content allows the nurse to
implement appropriate safety measures.
Question 2
A nurse is teaching a client about a new prescription for lithium carbonate for bipolar disorder.
Which of the following instructions should the nurse include?
A) Limit your sodium intake to less than 1,500 mg per day.
B) Stop taking the medication if you experience a fine hand tremor.
C) Maintain consistent fluid intake of 2 to 3 liters per day.
D) Take the medication on an empty stomach for better absorption.
E) Use ibuprofen for headaches while on this medication.
Correct Answer: C) Maintain consistent fluid intake of 2 to 3 liters per day.
Rationale: Lithium is a salt, and dehydration can lead to toxic lithium levels. Consistently
high fluid intake helps maintain stable serum levels and prevents toxicity.
Question 3
A nurse is assessing a client with anorexia nervosa. Which of the following physical findings
should the nurse expect?
A) Hypertension
B) Tachycardia
C) Hyperthermia
D) Bradycardia
E) Diarrhea
Correct Answer: D) Bradycardia
Rationale: Severe malnutrition and starvation in anorexia nervosa lead to physiological
slowing, resulting in bradycardia, hypotension, and hypothermia.
Question 4
A nurse is caring for a client who is experiencing a panic attack. Which of the following actions
should the nurse take first?
, 2
A) Teach the client how to use abdominal breathing.
B) Stay with the client and remain calm.
C) Administer a dose of buspirone.
D) Ask the client to identify the trigger of the attack.
E) Encourage the client to join a group therapy session.
Correct Answer: B) Stay with the client and remain calm.
Rationale: During a panic attack, the client's safety and immediate reassurance are the
priorities. The nurse’s presence provides a sense of security until the physical symptoms
subside.
Question 5
A nurse is teaching a client who has a new prescription for clozapine. Which of the following
laboratory tests should the nurse emphasize the need for regular monitoring?
A) Serum potassium
B) Liver function tests
C) White blood cell (WBC) count
D) Blood urea nitrogen (BUN)
E) Fasting blood glucose
Correct Answer: C) White blood cell (WBC) count
Rationale: Clozapine carries a high risk of agranulocytosis, a severe drop in the WBC count.
Regular monitoring (usually weekly) is mandatory to detect this life-threatening side effect.
Question 6
A client with obsessive-compulsive disorder (OCD) spends 45 minutes washing their hands after
every meal. Which of the following is an appropriate intervention for the nurse to implement?
A) Lock the bathroom doors to prevent the ritual.
B) Gradually set time limits for the ritualistic behavior.
C) Inform the client that their hands are already clean.
D) Assign the client to a different task during mealtimes.
E) Give the client a "no-harm" contract to sign.
Correct Answer: B) Gradually set time limits for the ritualistic behavior.
Rationale: Completely stopping the ritual immediately can cause extreme anxiety.
Gradually decreasing the time allowed for the behavior helps the client gain control
without overwhelming them.
Question 7
A nurse is assessing a client for anhedonia. Which of the following statements by the client
indicates this finding?
A) "I hear voices that no one else can hear."
B) "I feel like everyone is out to get me."
C) "I don't find joy in gardening anymore, even though I used to love it."
, 3
D) "I can't remember what I ate for breakfast this morning."
E) "I feel like my heart is racing and I can't catch my breath."
Correct Answer: C) "I don't find joy in gardening anymore, even though I used to love it."
Rationale: Anhedonia is the inability to feel pleasure or a loss of interest in activities that
were previously enjoyable, a common symptom of depression.
Question 8
A client is being admitted for alcohol withdrawal. Which of the following medications should the
nurse expect to administer to manage acute withdrawal symptoms?
A) Disulfiram
B) Lorazepam
C) Methadone
D) Sertraline
E) Bupropion
Correct Answer: B) Lorazepam
Rationale: Benzodiazepines like lorazepam are the gold standard for alcohol withdrawal to
prevent seizures, tremors, and delirium tremens due to their sedative effects on the CNS.
Question 9
A nurse is caring for a client with borderline personality disorder. Which of the following is the
priority nursing intervention?
A) Encouraging the client to participate in group therapy.
B) Identifying the client's use of "splitting."
C) Setting clear and consistent boundaries.
D) Monitoring the client for self-mutilation or self-harm.
E) Teaching the client social skills.
Correct Answer: D) Monitoring the client for self-mutilation or self-harm.
Rationale: Clients with borderline personality disorder are at high risk for self-harm and
suicidal behaviors. Safety is always the priority in the hierarchy of needs.
Question 10
A nurse is teaching a client who has a new prescription for sertraline. Which of the following
side effects should the nurse include in the teaching?
A) Excessive salivation
B) Sexual dysfunction
C) Weight loss
D) Urinary retention
E) Orthostatic hypotension
Correct Answer: B) Sexual dysfunction
Rationale: Sexual dysfunction, including decreased libido and delayed orgasm, is a common
and often distressing side effect of SSRIs like sertraline.
