ATI Mental Health Proctored Exam 8
2024 A+verified.
A nurse in a mental health clinic is caring for a client who has bipolar disorder and
reports that they stopped taking lithium 2 weeks ago. The nurse should recognize
which of the following as an expected adverse effect that might have caused the
client to spot taking the medication?
1. Sore throat
2. Photophobia
3. Hand tremors
4. Constipation - Correct = 3. Hand Tremors
- Fine hand tremors are an expected adverse effect of lithium and can interfere with
performance of ADLs, causing the client to stop taking the medication.
*Diarrhea is an early manifestation of lithium toxicity
A nurse is updating the plan of care for a client who has bulimia nervosa and is 5%
above their ideal body weight. Which of the following interventions should the nurse
include in the plan?
1. Include a liquid supplement with meals.
2. Identify the client's trigger foods.
3. Allow the client at least 1 hr for each meal.
4. Weigh the client at bedtime each day. - Correct = 2. Identify the client's trigger
foods.
- The nurse should identify the trigger foods that initiate the client's binge and assist
the client to understanding their thoughts and behavior that relate to the food.
The nurse should limit the client's meal times to about 30 min to prevent putting
excessive focus on food.
The nurse should weigh the client immediately after they wake up and void and prior
to oral intake. The nurse should weigh the client daily for the first week and then
three times per week.
*The nurse should include a liquid supplement for a client who is below their ideal
body weight and might not be able to eat solid foods at first or might need the
additional nutrition to gain weight.
A nurse is caring for a client whose child has a terminal illness. The client requests
information about how to deal with the upcoming loss. Which of the following
statements should the nurse make?
1. "It will be better for you to keep busy to avoid thinking about your child's death."
2. "You will complete the grieving process about a year after your child's death."
,3. "The grief process will start once your child actually dies."
4. "It is not uncommon to feel angry toward yourself or others." - Correct = 4. "It is
not uncommon to feel angry toward yourself or others."
- Feelings of blame and anger toward oneself or others are an expected reaction
when a client is experiencing a loss.
The grief process has no timeline. It varies for each individual.
The client can begin anticipatory grieving during the child's illness.
A nurse in a mental health clinic is planning care for a client who has a new
prescription for olanzapine. Which of the following interventions should the nurse
identify as the priority?
1. Advise the client to take frequent sips of water.
2. Recommend that the client exercise regularly.
3. Consult a dietitian for a calorie-controlled diet plan.
4. Instruct the client to avoid driving during initial therapy. - Correct = 4. Instruct the
client to avoid driving during initial therapy.
- The greatest risk to this client is injury resulting from drowsiness or dizziness.
Therefore, the nurse's priority intervention is to instruct the client to avoid activities
that require mental alertness during initial medication therapy.
The nurse should advise the client to take frequent sips of water due to the adverse
effect of dry mouth. However, this is not the nurse's priority intervention.
The nurse should advise the client to exercise regularly due to the adverse effects of
weight gain and constipation. However, this is not the nurse's priority intervention.
The nurse should consult a dietitian for a calorie-controlled diet plan due to the
adverse effect of weight gain. However, this is not the nurse's priority intervention.
A nurse is counseling an adolescent who has anorexia nervosa and reports
excessive laxative use and fear of gaining weight. The Client states, "I'm so fat I can't
even stand to look at myself.". Which of the following therapeutic responses
demonstrates the nurse's use of summarizing?
1. "You've discussed several concerns about your weight. Let's go back and talk
about your belief that you are fat."
2. "You're saying that you think you are fat and are using laxatives because you are
afraid of gaining weight."
3. "You don't want to look at yourself because you think you are fat."
4. "You and I can work together to overcome your fears of gaining weight." - Correct
= 2. "You're saying that you think you are fat and are using laxatives because you
are afraid of gaining weight."
- The nurse is using the therapeutic technique of summarizing to review the key
points of the discussion.
A nurse is admitting a client who has schizophrenia to an acute care setting. When
the nurse questions the client regarding their admission, the client states, "I'm red, in
, the head, and I'm going to bed!". The nurse should document the client's speech
pattern as which of the following?
1. Clang Association
2. Word Salad
3. Neologism
4. Echolalia - Correct = 1. Clang Association
- The nurse should document that the client's speech uses clang associations, which
often rhyme or contain a string of words that can have a similar sound.
NGN: A nurse is caring for a Client who has an alcohol use disorder.
Complete the following sentence by using the list of options...
Dropdown 1: "The Client is at greatest risk for
1. Dehydration
2. Violent Behavior
3. Ineffective Coping
Dropdown 2: "as evidenced by the Client's
4. Inability to Perform Simple Tasks
5. Loss of Appetite
6. Agitation - Correct =
Dropdown 1:
2. Violent Behavior
- The greatest risk for the client is engaging in violent behavior due to the withdrawal
of alcohol, which is causing them increasing agitation. The nurse should closely
monitor the client and be prepared to intervene to protect the client and others from
injury.
Dropdown 2:
6. Agitation
- The client is at greatest risk of engaging in violent behavior as evidenced by the
client's agitation, which can be indicated by pacing, restlessness, staring, silence,
rigid posture, and clenched jaw. The nurse should closely monitor the client and be
prepared to intervene to protect the client and others from injury.
NGN: A nurse on a mental health unit is caring for a recently admitted client.
For each potential assessment finding, click to specify if it is a positive or negative
symptom of schizophrenia.
Assessment Findings:
1. Delusions of Grandeur
2. Clang Associations
3. Alogia
4. Withdrawal from Social Activities
5. Catatonia
2024 A+verified.
A nurse in a mental health clinic is caring for a client who has bipolar disorder and
reports that they stopped taking lithium 2 weeks ago. The nurse should recognize
which of the following as an expected adverse effect that might have caused the
client to spot taking the medication?
1. Sore throat
2. Photophobia
3. Hand tremors
4. Constipation - Correct = 3. Hand Tremors
- Fine hand tremors are an expected adverse effect of lithium and can interfere with
performance of ADLs, causing the client to stop taking the medication.
*Diarrhea is an early manifestation of lithium toxicity
A nurse is updating the plan of care for a client who has bulimia nervosa and is 5%
above their ideal body weight. Which of the following interventions should the nurse
include in the plan?
1. Include a liquid supplement with meals.
2. Identify the client's trigger foods.
3. Allow the client at least 1 hr for each meal.
4. Weigh the client at bedtime each day. - Correct = 2. Identify the client's trigger
foods.
- The nurse should identify the trigger foods that initiate the client's binge and assist
the client to understanding their thoughts and behavior that relate to the food.
The nurse should limit the client's meal times to about 30 min to prevent putting
excessive focus on food.
The nurse should weigh the client immediately after they wake up and void and prior
to oral intake. The nurse should weigh the client daily for the first week and then
three times per week.
*The nurse should include a liquid supplement for a client who is below their ideal
body weight and might not be able to eat solid foods at first or might need the
additional nutrition to gain weight.
A nurse is caring for a client whose child has a terminal illness. The client requests
information about how to deal with the upcoming loss. Which of the following
statements should the nurse make?
1. "It will be better for you to keep busy to avoid thinking about your child's death."
2. "You will complete the grieving process about a year after your child's death."
,3. "The grief process will start once your child actually dies."
4. "It is not uncommon to feel angry toward yourself or others." - Correct = 4. "It is
not uncommon to feel angry toward yourself or others."
- Feelings of blame and anger toward oneself or others are an expected reaction
when a client is experiencing a loss.
The grief process has no timeline. It varies for each individual.
The client can begin anticipatory grieving during the child's illness.
A nurse in a mental health clinic is planning care for a client who has a new
prescription for olanzapine. Which of the following interventions should the nurse
identify as the priority?
1. Advise the client to take frequent sips of water.
2. Recommend that the client exercise regularly.
3. Consult a dietitian for a calorie-controlled diet plan.
4. Instruct the client to avoid driving during initial therapy. - Correct = 4. Instruct the
client to avoid driving during initial therapy.
- The greatest risk to this client is injury resulting from drowsiness or dizziness.
Therefore, the nurse's priority intervention is to instruct the client to avoid activities
that require mental alertness during initial medication therapy.
The nurse should advise the client to take frequent sips of water due to the adverse
effect of dry mouth. However, this is not the nurse's priority intervention.
The nurse should advise the client to exercise regularly due to the adverse effects of
weight gain and constipation. However, this is not the nurse's priority intervention.
The nurse should consult a dietitian for a calorie-controlled diet plan due to the
adverse effect of weight gain. However, this is not the nurse's priority intervention.
A nurse is counseling an adolescent who has anorexia nervosa and reports
excessive laxative use and fear of gaining weight. The Client states, "I'm so fat I can't
even stand to look at myself.". Which of the following therapeutic responses
demonstrates the nurse's use of summarizing?
1. "You've discussed several concerns about your weight. Let's go back and talk
about your belief that you are fat."
2. "You're saying that you think you are fat and are using laxatives because you are
afraid of gaining weight."
3. "You don't want to look at yourself because you think you are fat."
4. "You and I can work together to overcome your fears of gaining weight." - Correct
= 2. "You're saying that you think you are fat and are using laxatives because you
are afraid of gaining weight."
- The nurse is using the therapeutic technique of summarizing to review the key
points of the discussion.
A nurse is admitting a client who has schizophrenia to an acute care setting. When
the nurse questions the client regarding their admission, the client states, "I'm red, in
, the head, and I'm going to bed!". The nurse should document the client's speech
pattern as which of the following?
1. Clang Association
2. Word Salad
3. Neologism
4. Echolalia - Correct = 1. Clang Association
- The nurse should document that the client's speech uses clang associations, which
often rhyme or contain a string of words that can have a similar sound.
NGN: A nurse is caring for a Client who has an alcohol use disorder.
Complete the following sentence by using the list of options...
Dropdown 1: "The Client is at greatest risk for
1. Dehydration
2. Violent Behavior
3. Ineffective Coping
Dropdown 2: "as evidenced by the Client's
4. Inability to Perform Simple Tasks
5. Loss of Appetite
6. Agitation - Correct =
Dropdown 1:
2. Violent Behavior
- The greatest risk for the client is engaging in violent behavior due to the withdrawal
of alcohol, which is causing them increasing agitation. The nurse should closely
monitor the client and be prepared to intervene to protect the client and others from
injury.
Dropdown 2:
6. Agitation
- The client is at greatest risk of engaging in violent behavior as evidenced by the
client's agitation, which can be indicated by pacing, restlessness, staring, silence,
rigid posture, and clenched jaw. The nurse should closely monitor the client and be
prepared to intervene to protect the client and others from injury.
NGN: A nurse on a mental health unit is caring for a recently admitted client.
For each potential assessment finding, click to specify if it is a positive or negative
symptom of schizophrenia.
Assessment Findings:
1. Delusions of Grandeur
2. Clang Associations
3. Alogia
4. Withdrawal from Social Activities
5. Catatonia
