ATI RN Mental Health Online Practice 2023
A questions and Correct answers with
explanations
1.A school nurse is assessing a school aged child who experienced the traumatic 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 answerCorrect = 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 answerCorrect = 2. A client who
taking lamotrigine and has developed a rash
Lamotrigine is an anticonvulsant medication that is used as a mood stabilizer. The nurse should identi
that a rash is a potentially life threatening adverse effect of the medication and report the finding
immediately
,3. Platelets 150,000
4. RBC count 3.5 - Correct answerCorrect - 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 answerCorrect - 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
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 answerCorrect - 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
6.A nurse is planning care for a client who has schizophrenia and reports auditory hallucinations. Whi
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
answerCorrect = 1. Promote the use of music to compete with the client's auditory hallucinations
, *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
A nurse is caring for a client who has impaired cognition
7.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 clien
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
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 answerCorrect =
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,
A questions and Correct answers with
explanations
1.A school nurse is assessing a school aged child who experienced the traumatic 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 answerCorrect = 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 answerCorrect = 2. A client who
taking lamotrigine and has developed a rash
Lamotrigine is an anticonvulsant medication that is used as a mood stabilizer. The nurse should identi
that a rash is a potentially life threatening adverse effect of the medication and report the finding
immediately
,3. Platelets 150,000
4. RBC count 3.5 - Correct answerCorrect - 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 answerCorrect - 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
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 answerCorrect - 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
6.A nurse is planning care for a client who has schizophrenia and reports auditory hallucinations. Whi
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
answerCorrect = 1. Promote the use of music to compete with the client's auditory hallucinations
, *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
A nurse is caring for a client who has impaired cognition
7.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 clien
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
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 answerCorrect =
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,
