ATI PN MENTAL HEALTH
•
PROCTORED EXAM_2022/2023 |
PN MENTAL HEALTH
PROCTORED EXAM_Graded A
• 1. A nurse is assessing a client who has generalized anxiety disorder
(GAD). Which of the following findings should the nurse expect?
o A. Episodes of acute, intense fear
o B. Persistent, excessive worry for at least 6 months
o C. Fear of being in open, crowded spaces
o D. Repetitive, ritualistic behaviors
o Rationale: GAD is characterized by chronic, persistent, and
excessive worry about a variety of events or activities, lasting for at
least 6 months. Episodes of acute fear (A) describe panic attacks. Fear
of open spaces (C) describes agoraphobia. Ritualistic behaviors (D)
describe obsessive-compulsive disorder.
• 2. A nurse is caring for a client who is experiencing a panic attack. Which
of the following actions should the nurse take first?
o A. Administer an anti-anxiety medication as prescribed.
o B. Stay with the client and remain calm.
o C. Teach the client deep breathing techniques.
o D. Move the client to a quiet, less stimulating environment.
o Rationale: The first priority during a panic attack is safety and
reducing the client's anxiety. Staying with the client and remaining
calm provides reassurance and a sense of safety. Medication (A) and
teaching techniques (C) may be appropriate later, but the immediate
, intervention is to provide a calm, supportive presence. Moving the
client (D) is helpful but does not supersede the nurse's presence.
• 3. A client is prescribed lithium carbonate. Which of the following
instructions should the nurse include in the teaching?
o A. "Increase your fluid intake to 2 to 3 liters per day."
o B. "Follow a low-sodium diet."
o C. "Take the medication on an empty stomach."
o D. "You can stop taking the medication once your mood stabilizes."
o Rationale: Lithium is a salt; maintaining adequate fluid intake (2-3
L/day) and a normal sodium diet is crucial to prevent toxicity. A low-
sodium diet (B) can lead to lithium retention and toxicity. The
medication should be taken with food (C) to reduce GI upset. The
medication must be taken consistently, even when the mood is
stable, to prevent relapse (D).
• 4. A nurse is evaluating the effectiveness of a client's new prescription for
fluoxetine. Which of the following statements by the client indicates the
medication is effective?
o A. "I am sleeping better at night."
o B. "I have more energy than I know what to do with."
o C. "I no longer feel like I want to harm myself."
o D. "I have gained 5 pounds since I started taking it."
o Rationale: A primary goal for a client with depression is safety. A
statement indicating a cessation of suicidal ideation ("no longer feel
like I want to harm myself") is the strongest indicator of effectiveness.
Improved sleep (A) and increased energy (B) are also positive signs,
but safety is the priority. Weight gain (D) is a common adverse effect,
not a therapeutic effect.
,• 5. A nurse is planning care for a client who has anorexia nervosa. Which of
the following is the priority nursing intervention?
o A. Establish a contract with the client regarding food intake.
o B. Monitor the client's vital signs and weight.
o C. Encourage the client to discuss feelings about body image.
o D. Provide a highly structured mealtime environment.
o Rationale: The priority for a client with anorexia nervosa is
physiological stability. Monitoring vital signs and weight helps assess
the severity of malnutrition and the effectiveness of refeeding.
Establishing a contract (A), discussing feelings (C), and providing
structure (D) are all important, but physiological safety comes first.
• 6. A client who has been diagnosed with schizophrenia is experiencing
auditory hallucinations. Which of the following responses by the nurse is
appropriate?
o A. "What are the voices saying to you?"
o B. "You know those voices aren't real."
o C. "Try to ignore the voices."
o D. "Why do you think you are hearing voices?"
o Rationale: Asking what the voices are saying helps the nurse
assess the content of the hallucination and determine if the client is
at risk for self-harm or harm to others. Directly challenging the
hallucination (B) or telling the client to ignore it (C) is not therapeutic.
Asking "why" (D) can be threatening and is not helpful.
• 7. A nurse is assessing a client who is withdrawing from alcohol. Which of
the following findings should the nurse expect?
o A. Bradycardia
, o B. Hypotension
o C. Tremors
o D. Constricted pupils
o Rationale: Alcohol withdrawal causes central nervous system
excitation. Expected findings include tremors, tachycardia,
hypertension, and diaphoresis. Bradycardia (A), hypotension (B), and
constricted pupils (D) are signs of opioid overdose or other
conditions, not alcohol withdrawal.
• 8. A client is taking clozapine. The nurse should monitor the client for
which of the following serious adverse effects?
o A. Agranulocytosis
o B. Hypertension
o C. Weight loss
o D. Insomnia
o Rationale: Clozapine is an atypical antipsychotic that carries a risk
of severe neutropenia/agranulocytosis. Clients must have regular
blood tests to monitor their white blood cell count. Hypotension (B)
and weight gain (C) are more common side effects. Insomnia (D) is
not a primary concern.
• 9. A nurse is teaching a client about the adverse effects of sertraline.
Which of the following should the nurse include?
o A. Increased risk for bleeding
o B. Bradycardia
o C. Constipation
o D. Weight loss
•
PROCTORED EXAM_2022/2023 |
PN MENTAL HEALTH
PROCTORED EXAM_Graded A
• 1. A nurse is assessing a client who has generalized anxiety disorder
(GAD). Which of the following findings should the nurse expect?
o A. Episodes of acute, intense fear
o B. Persistent, excessive worry for at least 6 months
o C. Fear of being in open, crowded spaces
o D. Repetitive, ritualistic behaviors
o Rationale: GAD is characterized by chronic, persistent, and
excessive worry about a variety of events or activities, lasting for at
least 6 months. Episodes of acute fear (A) describe panic attacks. Fear
of open spaces (C) describes agoraphobia. Ritualistic behaviors (D)
describe obsessive-compulsive disorder.
• 2. A nurse is caring for a client who is experiencing a panic attack. Which
of the following actions should the nurse take first?
o A. Administer an anti-anxiety medication as prescribed.
o B. Stay with the client and remain calm.
o C. Teach the client deep breathing techniques.
o D. Move the client to a quiet, less stimulating environment.
o Rationale: The first priority during a panic attack is safety and
reducing the client's anxiety. Staying with the client and remaining
calm provides reassurance and a sense of safety. Medication (A) and
teaching techniques (C) may be appropriate later, but the immediate
, intervention is to provide a calm, supportive presence. Moving the
client (D) is helpful but does not supersede the nurse's presence.
• 3. A client is prescribed lithium carbonate. Which of the following
instructions should the nurse include in the teaching?
o A. "Increase your fluid intake to 2 to 3 liters per day."
o B. "Follow a low-sodium diet."
o C. "Take the medication on an empty stomach."
o D. "You can stop taking the medication once your mood stabilizes."
o Rationale: Lithium is a salt; maintaining adequate fluid intake (2-3
L/day) and a normal sodium diet is crucial to prevent toxicity. A low-
sodium diet (B) can lead to lithium retention and toxicity. The
medication should be taken with food (C) to reduce GI upset. The
medication must be taken consistently, even when the mood is
stable, to prevent relapse (D).
• 4. A nurse is evaluating the effectiveness of a client's new prescription for
fluoxetine. Which of the following statements by the client indicates the
medication is effective?
o A. "I am sleeping better at night."
o B. "I have more energy than I know what to do with."
o C. "I no longer feel like I want to harm myself."
o D. "I have gained 5 pounds since I started taking it."
o Rationale: A primary goal for a client with depression is safety. A
statement indicating a cessation of suicidal ideation ("no longer feel
like I want to harm myself") is the strongest indicator of effectiveness.
Improved sleep (A) and increased energy (B) are also positive signs,
but safety is the priority. Weight gain (D) is a common adverse effect,
not a therapeutic effect.
,• 5. A nurse is planning care for a client who has anorexia nervosa. Which of
the following is the priority nursing intervention?
o A. Establish a contract with the client regarding food intake.
o B. Monitor the client's vital signs and weight.
o C. Encourage the client to discuss feelings about body image.
o D. Provide a highly structured mealtime environment.
o Rationale: The priority for a client with anorexia nervosa is
physiological stability. Monitoring vital signs and weight helps assess
the severity of malnutrition and the effectiveness of refeeding.
Establishing a contract (A), discussing feelings (C), and providing
structure (D) are all important, but physiological safety comes first.
• 6. A client who has been diagnosed with schizophrenia is experiencing
auditory hallucinations. Which of the following responses by the nurse is
appropriate?
o A. "What are the voices saying to you?"
o B. "You know those voices aren't real."
o C. "Try to ignore the voices."
o D. "Why do you think you are hearing voices?"
o Rationale: Asking what the voices are saying helps the nurse
assess the content of the hallucination and determine if the client is
at risk for self-harm or harm to others. Directly challenging the
hallucination (B) or telling the client to ignore it (C) is not therapeutic.
Asking "why" (D) can be threatening and is not helpful.
• 7. A nurse is assessing a client who is withdrawing from alcohol. Which of
the following findings should the nurse expect?
o A. Bradycardia
, o B. Hypotension
o C. Tremors
o D. Constricted pupils
o Rationale: Alcohol withdrawal causes central nervous system
excitation. Expected findings include tremors, tachycardia,
hypertension, and diaphoresis. Bradycardia (A), hypotension (B), and
constricted pupils (D) are signs of opioid overdose or other
conditions, not alcohol withdrawal.
• 8. A client is taking clozapine. The nurse should monitor the client for
which of the following serious adverse effects?
o A. Agranulocytosis
o B. Hypertension
o C. Weight loss
o D. Insomnia
o Rationale: Clozapine is an atypical antipsychotic that carries a risk
of severe neutropenia/agranulocytosis. Clients must have regular
blood tests to monitor their white blood cell count. Hypotension (B)
and weight gain (C) are more common side effects. Insomnia (D) is
not a primary concern.
• 9. A nurse is teaching a client about the adverse effects of sertraline.
Which of the following should the nurse include?
o A. Increased risk for bleeding
o B. Bradycardia
o C. Constipation
o D. Weight loss
