ATI RN Mental Health Proctored Exam 2023-2025
NGN (70 Questions) Latest 2025 Version, Answers
for Maximum Success
Section 1: Safety & Crisis Intervention
Question 1
A client with major depressive disorder states, "My family would be better off without me."
Which is the nurse's priority action?
A) Ask the client, "What makes you say that?"
B) Assess for suicidal ideation, plan, and means
C) Encourage the client to join a group activity
D) Reassure the client that things will get better
Rationale: The priority when a client expresses feelings of worthlessness or being a burden
is a direct safety assessment. Assessing for suicidal ideation, plan, and means is essential to
determine the level of risk and implement appropriate safety precautions. Reassurance (D) is
nontherapeutic and dismisses the client's feelings; activity (C) does not address the immediate
safety concern; asking "why" (A) is not the priority over a direct safety assessment .
Question 2
A nurse is caring for a client experiencing alcohol withdrawal. Which finding should the nurse
prioritize?
A) Tremors
B) Diaphoresis
C) Seizure activity
D) Nausea
Rationale: Seizures are life-threatening and can occur 6–48 hours after the last drink. The
nurse must prioritize seizure precautions, including padded side rails, oxygen, and suction
equipment at the bedside. Tremors, diaphoresis, and nausea are expected withdrawal
symptoms but are not immediately life-threatening .
,Question 3
A client says, "The FBI is following me and reading my thoughts." Which is the MOST
therapeutic response?
A) "That must be very frightening for you."
B) "There is no FBI following you."
C) "Why do you think the FBI would be interested in you?"
D) "You're safe here; no one can read your thoughts."
Rationale: This response acknowledges the client's feelings without reinforcing the
delusion. Direct confrontation (B) or questioning the delusion (C) is not therapeutic and can
increase anxiety. Option D gives false reassurance and does not validate the client's emotional
experience .
Question 4 (SATA)
A client with depression was admitted 3 days ago. Today, the nurse notes the client suddenly
appears calm, cheerful, and is giving away personal belongings. Which findings should the nurse
interpret as warning signs for suicide? Select all that apply.
A) Sudden mood improvement
B) Giving away personal belongings
C) Withdrawn behavior for 3 days
D) Verbalizing feelings of calmness after severe depression
Rationale: Sudden mood improvement and giving away possessions are classic warning
signs that a client has made a decision to complete suicide. The client may appear calm because
they have resolved the ambivalence about dying and made a plan. A withdrawn state (C) is a
sign of depression but not specifically an acute warning sign of imminent suicide .
Question 5
A nurse is caring for a client who is experiencing alcohol withdrawal. Which intervention should
the nurse implement first?
A) Administer a PRN dose of chlordiazepoxide
B) Place the client on seizure precautions
,C) Encourage oral fluid intake
D) Assess the client's withdrawal symptoms using a CIWA-Ar scale
Rationale: Seizure precautions are the priority to prevent injury. While assessment (D) and
medication (A) are important, safety measures must be in place first because seizures can occur
rapidly and without warning .
Question 6
A client tells the nurse, "Don't tell anyone, but I hid a sharp knife under my mattress to protect
myself from my roommate." Which action should the nurse take?
A) Keep the client's communication confidential
B) Watch the client and roommate closely without intervening
C) Tell the client this must be reported to the healthcare team
D) Report the incident without informing the client
Rationale: Safety threats must be reported. The nurse should use the ethical principle of
veracity (truthfulness) by informing the client that confidentiality must be breached due to
safety concerns. Keeping the information confidential (A) places both clients at risk; simply
watching (B) does not address the immediate danger; reporting without informing (D) violates
trust and the principle of veracity .
Question 7
A nurse decides to place a client with a psychotic disorder in seclusion overnight because the
unit is short-staffed. The nurse's actions are an example of which tort?
A) Invasion of privacy
B) False imprisonment
C) Assault
D) Battery
Rationale: False imprisonment is confining a client to a specific area for the convenience of
staff rather than for clinical necessity. Seclusion is only appropriate when the client poses an
immediate danger to self or others and less restrictive measures have failed. Assault is a threat;
battery is physical contact; invasion of privacy involves violation of confidentiality or personal
space .
, Question 8
A nurse is caring for a client who is in mechanical restraints. Which statement should the nurse
include in the documentation?
A) "Client ate most of his breakfast"
B) "Client was offered 8 oz of water every hour"
C) "Client is acting appropriately"
D) "Client is calm now"
Rationale: Documentation for a client in restraints must include specific objective data
regarding frequent monitoring, including offering fluids, toileting, range of motion exercises,
and assessment of circulation, skin integrity, and vital signs. "Client ate most of his breakfast"
and vague statements like "acting appropriately" or "calm now" do not meet documentation
standards for restraint monitoring .
Question 9
A nurse is planning care for a client who has a recent diagnosis of antisocial personality disorder.
Which outcome should the nurse include in the care plan?
A) The client recognizes the importance of others
B) The client conforms to social norms regarding clothing choices
C) The client reduces self-dramatization
D) The client treats others with respect
Rationale: The priority outcome for a client with antisocial personality disorder is to reduce
harmful behaviors toward others. Treating others with respect addresses the core issue of
disregard for the rights of others. Recognizing the importance of others (A) is overly broad;
clothing choices (B) are not the primary concern; reducing self-dramatization (C) is more
relevant to histrionic personality disorder .
Question 10
A nurse in an emergency department is caring for a female client who has ecchymosis of the
trunk and face. The client reports that her partner hit her. When offered information about
shelters, the client declines, stating, "I could never leave my husband because of my kids."
Which response should the nurse make?
NGN (70 Questions) Latest 2025 Version, Answers
for Maximum Success
Section 1: Safety & Crisis Intervention
Question 1
A client with major depressive disorder states, "My family would be better off without me."
Which is the nurse's priority action?
A) Ask the client, "What makes you say that?"
B) Assess for suicidal ideation, plan, and means
C) Encourage the client to join a group activity
D) Reassure the client that things will get better
Rationale: The priority when a client expresses feelings of worthlessness or being a burden
is a direct safety assessment. Assessing for suicidal ideation, plan, and means is essential to
determine the level of risk and implement appropriate safety precautions. Reassurance (D) is
nontherapeutic and dismisses the client's feelings; activity (C) does not address the immediate
safety concern; asking "why" (A) is not the priority over a direct safety assessment .
Question 2
A nurse is caring for a client experiencing alcohol withdrawal. Which finding should the nurse
prioritize?
A) Tremors
B) Diaphoresis
C) Seizure activity
D) Nausea
Rationale: Seizures are life-threatening and can occur 6–48 hours after the last drink. The
nurse must prioritize seizure precautions, including padded side rails, oxygen, and suction
equipment at the bedside. Tremors, diaphoresis, and nausea are expected withdrawal
symptoms but are not immediately life-threatening .
,Question 3
A client says, "The FBI is following me and reading my thoughts." Which is the MOST
therapeutic response?
A) "That must be very frightening for you."
B) "There is no FBI following you."
C) "Why do you think the FBI would be interested in you?"
D) "You're safe here; no one can read your thoughts."
Rationale: This response acknowledges the client's feelings without reinforcing the
delusion. Direct confrontation (B) or questioning the delusion (C) is not therapeutic and can
increase anxiety. Option D gives false reassurance and does not validate the client's emotional
experience .
Question 4 (SATA)
A client with depression was admitted 3 days ago. Today, the nurse notes the client suddenly
appears calm, cheerful, and is giving away personal belongings. Which findings should the nurse
interpret as warning signs for suicide? Select all that apply.
A) Sudden mood improvement
B) Giving away personal belongings
C) Withdrawn behavior for 3 days
D) Verbalizing feelings of calmness after severe depression
Rationale: Sudden mood improvement and giving away possessions are classic warning
signs that a client has made a decision to complete suicide. The client may appear calm because
they have resolved the ambivalence about dying and made a plan. A withdrawn state (C) is a
sign of depression but not specifically an acute warning sign of imminent suicide .
Question 5
A nurse is caring for a client who is experiencing alcohol withdrawal. Which intervention should
the nurse implement first?
A) Administer a PRN dose of chlordiazepoxide
B) Place the client on seizure precautions
,C) Encourage oral fluid intake
D) Assess the client's withdrawal symptoms using a CIWA-Ar scale
Rationale: Seizure precautions are the priority to prevent injury. While assessment (D) and
medication (A) are important, safety measures must be in place first because seizures can occur
rapidly and without warning .
Question 6
A client tells the nurse, "Don't tell anyone, but I hid a sharp knife under my mattress to protect
myself from my roommate." Which action should the nurse take?
A) Keep the client's communication confidential
B) Watch the client and roommate closely without intervening
C) Tell the client this must be reported to the healthcare team
D) Report the incident without informing the client
Rationale: Safety threats must be reported. The nurse should use the ethical principle of
veracity (truthfulness) by informing the client that confidentiality must be breached due to
safety concerns. Keeping the information confidential (A) places both clients at risk; simply
watching (B) does not address the immediate danger; reporting without informing (D) violates
trust and the principle of veracity .
Question 7
A nurse decides to place a client with a psychotic disorder in seclusion overnight because the
unit is short-staffed. The nurse's actions are an example of which tort?
A) Invasion of privacy
B) False imprisonment
C) Assault
D) Battery
Rationale: False imprisonment is confining a client to a specific area for the convenience of
staff rather than for clinical necessity. Seclusion is only appropriate when the client poses an
immediate danger to self or others and less restrictive measures have failed. Assault is a threat;
battery is physical contact; invasion of privacy involves violation of confidentiality or personal
space .
, Question 8
A nurse is caring for a client who is in mechanical restraints. Which statement should the nurse
include in the documentation?
A) "Client ate most of his breakfast"
B) "Client was offered 8 oz of water every hour"
C) "Client is acting appropriately"
D) "Client is calm now"
Rationale: Documentation for a client in restraints must include specific objective data
regarding frequent monitoring, including offering fluids, toileting, range of motion exercises,
and assessment of circulation, skin integrity, and vital signs. "Client ate most of his breakfast"
and vague statements like "acting appropriately" or "calm now" do not meet documentation
standards for restraint monitoring .
Question 9
A nurse is planning care for a client who has a recent diagnosis of antisocial personality disorder.
Which outcome should the nurse include in the care plan?
A) The client recognizes the importance of others
B) The client conforms to social norms regarding clothing choices
C) The client reduces self-dramatization
D) The client treats others with respect
Rationale: The priority outcome for a client with antisocial personality disorder is to reduce
harmful behaviors toward others. Treating others with respect addresses the core issue of
disregard for the rights of others. Recognizing the importance of others (A) is overly broad;
clothing choices (B) are not the primary concern; reducing self-dramatization (C) is more
relevant to histrionic personality disorder .
Question 10
A nurse in an emergency department is caring for a female client who has ecchymosis of the
trunk and face. The client reports that her partner hit her. When offered information about
shelters, the client declines, stating, "I could never leave my husband because of my kids."
Which response should the nurse make?
