ATI MENTAL HEALTH B---70QA, Verified,
And Correct Answers, Secure HIGHSCORE
SECTION I — FOUNDATIONS OF PSYCHIATRIC-MENTAL HEALTH NURSING
1. A nurse is assessing a client who reports feeling "numb" and detached from reality after a
traumatic event. The client states, "It's like I'm watching myself from outside my body."
Which of the following terms best describes this experience?
A. Depersonalization
B. Derealization
C. Dissociative amnesia
D. Conversion disorder
Correct Answer: A. Depersonalization
Rationale: Depersonalization is a feeling of being detached from one's own self or body
(e.g., "watching myself from outside"). Derealization (B) is detachment from the environment
("things seem unreal"). Dissociative amnesia (C) involves inability to recall important personal
information. Conversion disorder (D) involves neurologic symptoms without organic cause. Both
depersonalization and derealization can occur in dissociative disorders and PTSD.
2. A nurse is reviewing the medical record of a client with a new diagnosis of major depressive
disorder. Which of the following findings should the nurse identify as a priority risk factor?
A. Report of insomnia for 3 weeks
B. Previous suicide attempt
C. Flat affect during interview
D. Weight loss of 5 lb (2.3 kg)
Correct Answer: B. Previous suicide attempt
Rationale: A previous suicide attempt is the single strongest predictor of completed suicide
and takes priority over other assessment findings. Insomnia, flat affect, and weight loss (A, C, D)
are important depressive symptoms but are not immediate lethality risks. Safety is always the
priority.
,3. A nurse is caring for a client prescribed haloperidol. Which of the following findings
indicates the client is experiencing an extrapyramidal side effect?
A. Blood glucose 210 mg/dL
B. Involuntary facial grimacing
C. Dry mucous membranes
D. Blood pressure 150/90 mm Hg
Correct Answer: B. Involuntary facial grimacing
Rationale: Involuntary facial grimacing is a sign of acute dystonia, an extrapyramidal
symptom (EPS) caused by dopamine blockade. Hyperglycemia (A) is associated with atypical
antipsychotics. Dry mucous membranes (C) reflect anticholinergic effects. Hypertension (D) is
not a classic EPS.
4. A nurse is teaching a client about the mechanism of action of selective serotonin reuptake
inhibitors (SSRIs). Which of the following statements by the client indicates understanding?
A. "They block dopamine receptors in my brain."
B. "They increase serotonin available at the synapse."
C. "They decrease norepinephrine production."
D. "They act on GABA receptors to calm me."
Correct Answer: B. "They increase serotonin available at the synapse."
Rationale: SSRIs block the reuptake of serotonin, increasing its availability in the synaptic
cleft. Dopamine blockade (A) describes antipsychotics. Decreased norepinephrine (C) is not the
SSRI mechanism. GABA activity (D) describes benzodiazepines.
5. A nurse is assessing a client for manifestations of serotonin syndrome. Which of the
following findings should the nurse expect? (Select all that apply.)
A. Hyperreflexia
B. Clonus
C. Bradycardia
D. Agitation
E. Hypothermia
Correct Answers: A, B, D
Rationale: Serotonin syndrome manifests with neuromuscular excitation (hyperreflexia,
,clonus), autonomic instability (tachycardia, hyperthermia), and altered mental status (agitation).
Bradycardia (C) and hypothermia (E) are not expected; tachycardia and hyperthermia are.
6. A nurse is reviewing the laboratory results of a client taking lithium. Which of the following
values should the nurse report immediately?
A. Lithium level 0.8 mEq/L
B. Lithium level 1.9 mEq/L
C. TSH 2.0 mIU/L
D. Sodium 138 mEq/L
Correct Answer: B. Lithium level 1.9 mEq/L
Rationale: Therapeutic lithium range is 0.6–1.2 mEq/L. A level of 1.9 mEq/L indicates toxicity
and requires immediate intervention. 0.8 mEq/L (A) is therapeutic. TSH and sodium (C, D) are
within normal limits.
7. A nurse is assessing a client who has been taking clozapine for 6 weeks. Which of the
following findings requires immediate follow-up?
A. Weight gain of 3 lb
B. Sore throat and fever
C. Increased salivation at night
D. Drowsiness after morning dose
Correct Answer: B. Sore throat and fever
Rationale: Clozapine can cause agranulocytosis. Sore throat and fever may indicate severe
neutropenia/infection and require immediate CBC evaluation. Weight gain, sialorrhea, and
sedation (A, C, D) are common, expected side effects.
8. A nurse is caring for a client experiencing acute alcohol withdrawal. Which of the following
findings indicates the greatest risk?
A. HR 110/min
B. Tremors
C. Visual hallucinations
D. Seizure activity
, Correct Answer: D. Seizure activity
Rationale: Seizures during alcohol withdrawal are life-threatening and indicate severe
withdrawal. Tachycardia, tremors, and hallucinations (A, B, C) are concerning but less
immediately lethal. Benzodiazepines are first-line for withdrawal seizures.
9. A nurse is teaching a client about the adverse effects of monoamine oxidase inhibitors
(MAOIs). Which of the following foods should the client avoid?
A. Bananas
B. Aged cheese
C. White rice
D. Applesauce
Correct Answer: B. Aged cheese
Rationale: Aged cheese is high in tyramine; combined with MAOIs it can precipitate a
hypertensive crisis. Bananas (A) contain tyramine in the peel but overripe bananas are more
concerning; aged cheese is the classic correct answer. Rice and applesauce (C, D) are safe.
10. A nurse is assessing a client with generalized anxiety disorder. Which of the following
findings should the nurse expect?
A. Episodic panic attacks
B. Excessive worry for at least 6 months
C. Fear of social situations
D. Compulsive rituals
Correct Answer: B. Excessive worry for at least 6 months
Rationale: GAD is characterized by excessive, uncontrollable worry about multiple areas for
≥6 months. Episodic panic (A) describes panic disorder. Social fear (C) describes social anxiety.
Compulsions (D) describe OCD.
11. A nurse is evaluating a client's understanding of the therapeutic relationship. Which of the
following phases involves establishing trust and defining goals?
A. Preinteraction
B. Orientation
And Correct Answers, Secure HIGHSCORE
SECTION I — FOUNDATIONS OF PSYCHIATRIC-MENTAL HEALTH NURSING
1. A nurse is assessing a client who reports feeling "numb" and detached from reality after a
traumatic event. The client states, "It's like I'm watching myself from outside my body."
Which of the following terms best describes this experience?
A. Depersonalization
B. Derealization
C. Dissociative amnesia
D. Conversion disorder
Correct Answer: A. Depersonalization
Rationale: Depersonalization is a feeling of being detached from one's own self or body
(e.g., "watching myself from outside"). Derealization (B) is detachment from the environment
("things seem unreal"). Dissociative amnesia (C) involves inability to recall important personal
information. Conversion disorder (D) involves neurologic symptoms without organic cause. Both
depersonalization and derealization can occur in dissociative disorders and PTSD.
2. A nurse is reviewing the medical record of a client with a new diagnosis of major depressive
disorder. Which of the following findings should the nurse identify as a priority risk factor?
A. Report of insomnia for 3 weeks
B. Previous suicide attempt
C. Flat affect during interview
D. Weight loss of 5 lb (2.3 kg)
Correct Answer: B. Previous suicide attempt
Rationale: A previous suicide attempt is the single strongest predictor of completed suicide
and takes priority over other assessment findings. Insomnia, flat affect, and weight loss (A, C, D)
are important depressive symptoms but are not immediate lethality risks. Safety is always the
priority.
,3. A nurse is caring for a client prescribed haloperidol. Which of the following findings
indicates the client is experiencing an extrapyramidal side effect?
A. Blood glucose 210 mg/dL
B. Involuntary facial grimacing
C. Dry mucous membranes
D. Blood pressure 150/90 mm Hg
Correct Answer: B. Involuntary facial grimacing
Rationale: Involuntary facial grimacing is a sign of acute dystonia, an extrapyramidal
symptom (EPS) caused by dopamine blockade. Hyperglycemia (A) is associated with atypical
antipsychotics. Dry mucous membranes (C) reflect anticholinergic effects. Hypertension (D) is
not a classic EPS.
4. A nurse is teaching a client about the mechanism of action of selective serotonin reuptake
inhibitors (SSRIs). Which of the following statements by the client indicates understanding?
A. "They block dopamine receptors in my brain."
B. "They increase serotonin available at the synapse."
C. "They decrease norepinephrine production."
D. "They act on GABA receptors to calm me."
Correct Answer: B. "They increase serotonin available at the synapse."
Rationale: SSRIs block the reuptake of serotonin, increasing its availability in the synaptic
cleft. Dopamine blockade (A) describes antipsychotics. Decreased norepinephrine (C) is not the
SSRI mechanism. GABA activity (D) describes benzodiazepines.
5. A nurse is assessing a client for manifestations of serotonin syndrome. Which of the
following findings should the nurse expect? (Select all that apply.)
A. Hyperreflexia
B. Clonus
C. Bradycardia
D. Agitation
E. Hypothermia
Correct Answers: A, B, D
Rationale: Serotonin syndrome manifests with neuromuscular excitation (hyperreflexia,
,clonus), autonomic instability (tachycardia, hyperthermia), and altered mental status (agitation).
Bradycardia (C) and hypothermia (E) are not expected; tachycardia and hyperthermia are.
6. A nurse is reviewing the laboratory results of a client taking lithium. Which of the following
values should the nurse report immediately?
A. Lithium level 0.8 mEq/L
B. Lithium level 1.9 mEq/L
C. TSH 2.0 mIU/L
D. Sodium 138 mEq/L
Correct Answer: B. Lithium level 1.9 mEq/L
Rationale: Therapeutic lithium range is 0.6–1.2 mEq/L. A level of 1.9 mEq/L indicates toxicity
and requires immediate intervention. 0.8 mEq/L (A) is therapeutic. TSH and sodium (C, D) are
within normal limits.
7. A nurse is assessing a client who has been taking clozapine for 6 weeks. Which of the
following findings requires immediate follow-up?
A. Weight gain of 3 lb
B. Sore throat and fever
C. Increased salivation at night
D. Drowsiness after morning dose
Correct Answer: B. Sore throat and fever
Rationale: Clozapine can cause agranulocytosis. Sore throat and fever may indicate severe
neutropenia/infection and require immediate CBC evaluation. Weight gain, sialorrhea, and
sedation (A, C, D) are common, expected side effects.
8. A nurse is caring for a client experiencing acute alcohol withdrawal. Which of the following
findings indicates the greatest risk?
A. HR 110/min
B. Tremors
C. Visual hallucinations
D. Seizure activity
, Correct Answer: D. Seizure activity
Rationale: Seizures during alcohol withdrawal are life-threatening and indicate severe
withdrawal. Tachycardia, tremors, and hallucinations (A, B, C) are concerning but less
immediately lethal. Benzodiazepines are first-line for withdrawal seizures.
9. A nurse is teaching a client about the adverse effects of monoamine oxidase inhibitors
(MAOIs). Which of the following foods should the client avoid?
A. Bananas
B. Aged cheese
C. White rice
D. Applesauce
Correct Answer: B. Aged cheese
Rationale: Aged cheese is high in tyramine; combined with MAOIs it can precipitate a
hypertensive crisis. Bananas (A) contain tyramine in the peel but overripe bananas are more
concerning; aged cheese is the classic correct answer. Rice and applesauce (C, D) are safe.
10. A nurse is assessing a client with generalized anxiety disorder. Which of the following
findings should the nurse expect?
A. Episodic panic attacks
B. Excessive worry for at least 6 months
C. Fear of social situations
D. Compulsive rituals
Correct Answer: B. Excessive worry for at least 6 months
Rationale: GAD is characterized by excessive, uncontrollable worry about multiple areas for
≥6 months. Episodic panic (A) describes panic disorder. Social fear (C) describes social anxiety.
Compulsions (D) describe OCD.
11. A nurse is evaluating a client's understanding of the therapeutic relationship. Which of the
following phases involves establishing trust and defining goals?
A. Preinteraction
B. Orientation
