ATI RN MENTAL HEALTH

ATI RN MENTAL HEALTH EXAM PACK-BEST FOR 2022 EXAM REVIEW ATI RN MENTAL HEALTH EXAM PACK-BEST FOR 2022 EXAM REVIEW 1. When admitting a client to an inpatient mental health facility, a nurse notices that the client seems withdrawn and appears fearful. To establish a trusting nurse-client relationship, the nurse should first a. Introduce the client to other clients in the day room (working phase) b. Inform the client that her admission will be confidential (orientation phase) c. Assist the client in facilitating behavioral change (working phase) d. Determine coping strategies that the client has used in the past (working phase) 2. A nurse is reviewing the potential adverse effects of lithium with a client who began the medication 2 weeks ago. For which of the following should the nurse instruct the client to monitor and report to the provider? a. Hearing loss b. Dry persistent cough c. Bruising d. Coarse hand tremor (indication toxicity ) 3. A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. Which of the following therapeutic nursing interventions is the highest priority? a. Encourage expression of feelings (acknowledge them) b. Promote attendance at an assertiveness training group (how to be assertive rather than aggressive) c. Assist the client to perform relaxation breathing (assist the child to calm down) d. Use a therapeutic holding technique (the greatest risk to this child and others is harm? Therefore, the nurse’s priority intervention is to use a therapeutic holding technique to de-escalate the behavior and prevent injury) 4. A nurse in a mental health facility observes a client who is experiencing panic level of anxiety. Which of the following actions should the nurse take first? a. Teach the client a relaxation technique (after the attack has subsided to prevent further escalations of anxiety) b. Establish an exercise routine for the client (after the attack has subsided to prevent further escalations anxiety) c. Assist the client to identify anxiety triggers d. Accompany the client to a quiet room 5. A nurse is caring for a client who is taking chlorpromazine for schizophrenia. Which of the following assessment findings indicates that the client is experiencing extrapyramidal adverse effects? a. Fever and sore throat (indicate agranulocytosis) b. Urinary retention (Anticholinergic side effect) c. Postural hypotension (cardiovascular side effect) d. Lip smacking and tongue rolling (indicate long-term extrapyramidal side effects associated with typical antipsychotic medications) 6. A nurse is preparing to administer diazepam 7.5 mg IV bolus to a client for alcohol withdrawal. Available is diazepam injection 5 mg/ml. How many mL should the nurse administer? (round the answer to the nearest tenth. Use a leading zero if applicable. Do not use a trailing zero.) 1.5 mL 7. A nurse is assessing a client in the emergency department. The client appears agitated, his blood pressure is 152/94 mm Hg, his heart rate is 104/min, and his pupils are dilated. The nurse should suspect intoxication with which of the following substances? a. Heroin (intoxication constricted pupils, decrease blood pressure) b. Cocaine (intoxication cause tachycardia, elevated blood pressure, dilated pupils and agitation) c. Benzodiazepines (decreased blood pressure) d. Inhalants (central nervous system depression) 8. A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following characteristics of this disorder should the nurse include in the teaching? a. Fear of abandonment (separation anxiety disorder) b. Language delay (autism spectrum disorder) c. Hostile behavior (oppositional defiant disorder) d. Motor and verbal tics (Tourette’s disorder) 9. A nurse is leading a group therapy session when a client becomes agitated and yells, “Listening to all of you is making me worse!” which of the following is an appropriate response? a. “You sound angry and frustrated. Tell us more about how you are feeling?” ( the nurse is making observations and exploring the client’s feelings to demonstrate caring) b. “Maybe you would like to go to another group from now on.” (nurse’s response is showing disapproval of the client and can make all of the clients defensive) c. “Let’s not talk about this now. We will talk more about this in our individual session.” (minimizing the client’s immediate concerns and feelings) d. “Do any of the other group members feel this way?”(showing disapproval of the client and can make all of the clients defensive) 10. A home health nurse is assessing an older adult client who lives alone. Which of the following finding should indicate to the nurse that the client is experiencing delirium? a. Sudden onset (suddenly over hours to days) b. Euthymic mood ( clients who have delirium have rapid mood swings) c. Flat affect (demonstrate expressions of feelings) d. Slow speech (raid, inappropriate speech and language) 11. A nurse is caring for a client who has schizophrenia. The treatment plan is for the client to increase his autonomy from his parents. Prior to discharge, the nurse should plan to a. Stress to the client that he need to be more independent (does not give him skills to gain autonomy. The nurse must assist the client to learn these skills) b. Schedule a family conference (Allows the nurse to work with both the client and his family to make an action plan for increased autonomy. This is a positive step for the client prior to discharge) c. Tell the client not to visit his family so often (The client needs emotional support from his family. Decreasing family visits could be obstructive to his emotional well-being and would not necessarily increase autonomy) d. Arrange housing placement for the client in another town (The client needs emotional support from his family. Moving him to another city could isolate him from this support an d would not necessarily increase autonomy) 12. A nurse in a provider’s office is talking with a client who has diabetes mellitus and an HbA1c of 8.5%. The client states that she is under a lot of stress and that she doesn’t want to talk about her diabetes mellitus right now. Based on these comments, the nurse should note that the client is demonstrating which of the following defense mechanisms? a. Suppression ( the client is suppressing her feelings about dealing with having a chronic illness when she consciously denies her current health status) b. Conversion (the client demonstrates conversion if she unconsciously converted her anxiety into physical symptoms) c. Displacement (the client demonstrates displacement if she transferred her feelings about her illness to another less threatening situation) d. Reaction formation (The client demonstrates reaction formation if she demonstrated the opposite behavior of what she is really feeling) 13. A nurse is caring for a client who has schizophrenia in a mental health facility. Which of the following places the client at greatest risk for self-directed injury or injuring others? a. Inability to communicate with others b. Feelings of absence of self-worth c. Lack of motivation to perform daily tasks d. Command hallucinations (A client who has schizophrenia and is experiencing command hallucinations may be told to hurt himself or others. Therefore, a client who is experiencing command hallucinations is at greatest risk for self-directed injury or injuring others) 14. A nurse is performing an assessment on a 78-year-old client who has injuries consistent with suspected abuse. Which of the following statements indicates the greatest potential risk factor for abuse? a. “My children manage my finances, but I still have to sign the checks.” b. “My son enjoys a couple of drinks each night to unwind.” c. “My daughter-in-law is expecting another baby soon.” d. “I plan on living on y own with the help of home health services.” 15. A nurse is obtaining a health history during a client’s admission to a mental health facility. The client begins to talk on her cell phone. When the client finishes talking, she reports to the nurse “That was the president, I leave in the morning on my new mission.” Which of the following is an appropriate response? a. “Do you want to leave so soon?” b. “I do not think the president will need you on this mission.” c. “How long have you been having conversations with the president?” d. “I think you need to talk to your provider about the mission.” 16. A client recently diagnosed with bipolar disorder is placed in a room with a client who has severe depression reports to the nurse, “That man in my room never sleeps and he keeps me up, too.” Which of the following is an appropriate intervention for the nurse to take? a. Move the client who has bipolar disorder to private room (clients who have bipolar disorder can disrupt the therapeutic milieu for other clients; therefore, the nurse should move this client to a private room) b. Administer sleep medication to the client who has bipolar disorder (not an appropriate intervention) c. Move the client who has severe depression to a private room (client who have severe depression are often at risk for self-harm and feel isolated; therefore, the nurse should not move this client to a private room) d. Administer sleep medication to the client who has severe depression 17. The nurse is caring for a client who has anorexia nervosa. Which of the following criteria requires hospitalization? a. Weight loss 10% of total body weight (weight loss over 30% of total body weight in six months) b. Temperature of 35.6˚C (96.1˚F)(severe hypothermia (temperature lower than 96.8˚F) due to loss of subcutaneous tissue or dehydration requires hospitalization) c. Serum potassium 3.8 mEq/L (WNL) d. Heart rate 54/min (HR is less than 40/min) 18. A nurse is caring for a client whose child recently died in motor vehicle crash and states. “I just want to join him.” Which of the following is the nurse’s priority response? a. “You may find it helpful to talk about your experience with a support person.” b. “Would you like me to stay with you so you don’t feel alone?” c. “Are you thinking about harming yourself?” d. “What you have gone through must be very difficult.” 19. A nurse is caring for a client receiving imipramine for depression. For which of the following adverse effects should the nurse monitor? a. Vertigo b. Decreased appetite c. Bradycardia d. Urinary retention 20. A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following medications should the nurse administer? a. Methadone b. Disulfiram c. Naltrexone d. Chlordiazepoxide (Librium) 21. A nurse is preparing to discharge an older adult client, who attempted suicide, to his home where he lives alone. The client also has difficulty performing ADLs. Which of the following referrals should the nurse initiate? (Select all that apply.) a. Occupational therapy b. Meal delivery services c. Speech therapy d. Physical therapy e. Home health services 22. A nurse is caring for a client who is deaf and is scheduled to have electroconvulsive therapy (ECT). The provider needs to explain the procedure to the client in order to obtain informed consent. Which of the following actions should the nurse take? a. Request a professional interpreter to translate b. Have a family member explain the information c. Ask an assistive personnel (AP) to use sign language d. Draw a diagram of the procedure 23. A nurse is caring for a client who has a history of substance use and was involuntarily admitted to mental health facility. When the nurse attempts to administer oral Lorazepam, the client refuses to take the medication and become physically aggressive. Which of the following actions should the nurse take? a. Request a prescription for IV Lorazepam b. Do not administer the Lorazepam c. Request that another nurse attempt to administer the Lorazepam d. Place the Lorazepam in the client’s food 24. During a client’s initial interview in a mental health inpatient setting, the nurse recognizes that the client maintains eye contact and leans toward him. The nurse should conclude that the client a. Is beginning to trust the nurse b. Is attempting to manipulate the nurse c. Is physically attracted to the nurse d. Needs to feel accepted by the nurse 25. A nurse is conducting a group therapy session for clients who have bipolar disorder. One of the clients begins bragging and dominating the conversation. Which of the following actions should the nurse take? a. Tell the client to calm down or he will be dismissed from the session b. Obtain an order form the provider to place the client in seclusion c. Ignore the client’s behavior and continue the session d. Interrupt the client and direct the discussion to another group member 26. A nurse is assessing a client in the emergency department who is brought in by a caregiver. The caregiver states the client fell recently. The nurse observes bruises on the client’s abdomen, back, and legs and suspects abuse. Which of the following action should the nurse take first? a. Initiate a referral to social services for suspected abuse b. Check the client for other signs and symptoms of abuse c. Assist the client to identify signs of escalating abuse d. Identify a family member who can provide support to the client 27. A nurse is providing teaching to a client who is to be discharge from an inpatient detoxification program and plans to attend Alcoholics Anonymous. Which of the following statements by the client indicates an understanding of the teaching? a. “I will learn ways to decrease my alcohol use.” (AA promotes abstinence) b. “I will use peer support to maintain my abstinence.” (encourage recovery ) c. “I will learn to take responsibility for my addiction.” (promotes responsibility for recovery) d. “I will use a health care professional as my sponsor.”(provides individual with sponsors who are in recovery for substance use) 28. A nurse is caring for a client with dementia. Which of the following interventions is useful for orienting a client to reality? a. Turn on the client’s television for entertainment throughout the day b. Place a large wall calendar in the client’s room c. Ask the family to bring the client’s rocking chair d. Provide the client with current issues of his favorite magazines 29. A nurse is planning to teach a group of parents about healthy adolescent behavior. Which of the following information should the nurse include? a. Displays an egocentric approach in problem-solving (preschooler) b. Requires literal explanations (toddler) c. Demonstrates mistrust of others (infant) d. Exhibits a realistic self-concept 30. A nurse is caring for a client who has alcoholic Cardiomyopathy. Which of the following laboratory values should the nurse expect? a. Increased creatine phosphokinase (CPK)( muscle enzyme released when muscle tissue is damaged, occur with Cardiomyopathy) b. Increased low-density lipoproteins (LDL) c. Decreased fasting blood sugar (FBS) d. Decreased aspartate aminotransferase (AST) 31. A nurse is admitting a client who has depression to an inpatient mental health facility. The client states that he feels so bad that he is certain he will never be discharged. Which of the following is an appropriate response? a. “The average client stay in our facility is only a few days.” (dismissive of the client’s concern) b. “The nurses at this hospital are very skilled at caring for people who have depression.”(response focuses on the needs of the care provider rather than the client’s) c. “You seem concerned about getting out of the hospital.”(response is making observations and encouraging the client to talk further about concerns) d. “Care at the hospital will help you to feel better about yourself.”(false reassurance for the client) 32. During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in her bed. The client reports that a bomb was placed in her room by a family member during visiting hours. Which of the following is an appropriate action by the nurse? a. Ask the client to identify the bomb in the room (inappropriate action because the nurse is responding as if the hallucination is real) b. Initiate disaster protocols per facility policies and procedures (without evidence of a disaster on a mental health unit) c. Assess the client for evidence of a perceptual disturbance(assess the situation to determine if the client is hallucinating or misperceiving external stimuli (experiencing illusions) d. Convince the client that there is no bomb in the client’s room (negates her experience) 33. A nurse is caring for a client who has schizophrenia and is prescribed risperidone. Which of the following laboratory tests should the nurse monitor? a. BUN b. Hemoglobin c. Platelet count d. Blood glucose (risperidone can cause diabetes mellitus to develop; therefore, the nurse should plan to monitor the client’s blood glucose level when taking this medication 34. A nurse is admitting an adolescent client who has anorexia nervosa. Which of the following clinical finding should the nurse expect? a. Tooth erosion (bulimia from self-induced vomiting) b. Amenorrhea (caused by low weight) c. Russell’s sign (calluses on knuckles can occur due to self-inducing vomiting) d. Parotid gland swelling (increased serum amylase levels) 35. A nurse is caring for a client who is scheduled to undergo electroconvulsive therapy (ECT). The provider has explained the procedure to the client. Which of the following statement s made by the client indicates a need for further teaching? a. “Following the procedure, I can expect to have short-term memory loss.” b. “I can expect to have two treatments a week for the next 4 to 6 weeks.” c. “During the procedure, I will have a cardiac monitor in place.” d. “This procedure can increase my risk for developing Parkinson’s disease.” 36. A nurse working in a clinic is assessing a client whose partner died 4 months ago. Which of the following statements indicates the client is at risk for complicated grief? a. “I wish I had been nicer and more generous with my wife before she died.”(expressing guilt which is expected during bereavement) b. “I told my wife to go to the doctor, but she wouldn’t listen to me.” (expressing anger) c. “I feel so empty without my wife; it’s hard to get up every morning.”( risk for complicated grief) d. “I think about my wife all the time when I go on outings with my family.”(expressing preoccupation with the image of the decreased) 37. A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom of this disorder? a. Flat affect (absence of emotion, negative symptom) b. Flight of ideas (thought disorder. Positive symptom) c. Agitated behavior( bizarre behavior, positive symptom) d. Hallucinations (alteration in perception, positive symptom) 38. A nurse is facilitating a bereavement support group and observes that one member remains silent, even after attending several sessions. Which of the following strategies should the nurse use to encourage the member’s participation? a. Remind the group that everyone should have a chance to participate (effective with group members who monopolize the discussion) b. Ask the group to share observations of other group members (effective with group member who monopolize the discussion. Allowing the group to address the silence of one member might cause the member to withdraw and stop attending sessions) c. Divide the group into pairs to discuss a topic, then summarize the discussion to the group (draw a silent member into group participation) d. Focus on other group members and emphasize their helpfulness (effective with group members who demonstrate demoralizing or negative behavior) 39. A nurse is planning discharge teaching with a family member of a client who has a new diagnosis of depression. Which of the following information about relapse should the nurse included? a. Additional acute episode of depression are unlikely following inpatient care b. Early identification of changes such as decreased social involvement is important c. Medication compliance will prevent further need for inpatient hospitalization d. It is helpful to regularly reinforce to the client that things will get better 40. A nurse is obtaining a history and physical on a client who presents to the emergency department of a mental health facility. The nurse recognizes which of the following assessment findings as being consistent with posttraumatic stress disorder (PTSD)? (Select all that apply.) a. Distressing dream (persistently reexperince the event the triggers PTSD in the form of distressing dreams) b. Delusions (false fixed belief that are difficult to eradicate) c. Difficulty concentrating (persistent increased arousal) d. Compulsions (compelled to repeatedly perform to reduce anxiety) e. Exaggerated startle response (persistent increased arousal) 41. A nurse is preparing to participate in an interdisciplinary conference for a client who has bipolar disorder. Which of the following behaviors is the highest priority for the nurse to report to the treatment team? a. Calling family members (client has support) b. Spending time alone (withdrawn from others) c. Giving away possession (risk for suicide) d. Excessive crying (showing signs of depression) 42. A nurse is developing a plan of care for a client who exhibits anger, aggression, and violent behavior on the unit. The priority nursing intervention is to a. Implement the use of seclusion and restraints b. Defuse the situation using therapeutic communication c. Administer prescribed tranquilizing medications d. Create a large, personal space (greatest risk is injury to the client, staff, and other, and client to ensure safety for the nurse and client) 43. While observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors is consistent with this condition? a. The client need excessive external input to make everyday decisions b. The client demonstrates a dedication to his job that excludes time for leisure activities (OCD) c. The client adheres to a rigid set of rules (OCD) d. The client has difficulty starting new relationships unless he feels accepted (avoidant personality disorder are unwilling to get involved socially unless one is accepted) 44. A nurse is providing teaching to a client who has a new prescription for haloperidol. Which of the following side effects should the nurse instruct the client to report to the provider? a. Blurred vision b. Photosensitivity c. Shuffling gait (Pseudoparkinsonism, 5 hr to 30 days after beginning treatment) d. Dry mouth 45. A nurse working in an outpatient clinic is assessing a university student who says he feels restless and irritable before taking an exam. The nurse should assess the clinical findings as which of the following? a. Mild anxiety ( restlessness, irritability, nail biting, and fidgeting) b. Moderate anxiety (tension, palpitation, increased heart rate, and diaphoresis) c. Severe anxiety (difficulty sleeping, light headedness, nausea, tremors, and a sense of impending doom) d. Panic (hyperactivity, severe tremors, and uncoordinated impulsive behavior) 46. A nurse is caring for a client who has borderline personality disorder. Which of the following is the priority goal when planning care for this client? a. The client will take prescribed medications as scheduled b. The client will express feelings of frustration c. The client will refrain from self-mutilation d. The client will participate in group therapy 47. A nurse is developing a discharge plan for a client who has a history of gambling dependency and included participation in a support group. The nurse should tell the client that which of the following is the purpose of attending a support group? a. Establish a therapeutic relationship b. Provide assurance that others have a similar problem c. Learn about medication management d. Develop an understanding of unconscious thoughts. 48. A nurse is communicating with a client in an inpatient mental health facility. Which of the following demonstrates the use of active listening? a. Offering self (demonstrate genuine interest in the client) b. Use of silence (demonstrate willingness to wait for the client’s response) c. Attention to body language d. Reflection of feelings (encourage the client to acknowledge his feeling) 49. A nurse is providing care for a client who has bipolar disorder and is experiencing acute mania. The client’s morning lithium level is 1.5 mEq/L. Which of the following additional laboratory data has the highest priority? Vs: temp: 37.3˚C (99.2˚F), pulse 88/min, respirations 18/min, BP 138/88 mm hg. History and physical: Client has been hospitalized for manic episodes 3 times in the past 2 years. Reports inability to sleep. Report nausea, vomiting, and thirst. Family reports client has lost 5 lb in last week. Prescription: Lithium carbonate 600 mg PO three times a day, Risperidone 3 mg PO daily. a. Serum erythrocyte sedimentation rate 18mm/hr b. Hemoglobin 15 g/dl c. Serum T₄5 mcg/dl d. Serum sodium 125 mEq/L (low sodium level) 50. A client is experiencing a situational crisis. Which of the following findings should the nurse expect? a. The client recently lost a grandparent in a motor vehicle crash b. The client’s town was hit by a tornado (adventitious crisis when an external disaster occurs) c. The client’s youngest son leaves for college (maturational crisis during a natural life event) d. The client is ambivalent about her upcoming retirement (maturational crisis) 51. A nurse is caring for four clients in an inpatient mental health facility. Which of the following clients can give informed consent? a. A 17-year-old who lives with friends (minor) b. A 50-year-old who has a blood alcohol level of 0.08 (intoxicated) c. A 35-year-old who has major depressive disorder d. A 65-year-old who just received a dose of morphine (functionally incompetent due to the effect on the CNS) 52. A nurse is conducting a counseling session with a client who has depression. Which of the following statements by the client indicates the client is demonstrating transference? a. “Thank you for taking my side in group today.” b. “I feel like you talk to me like my sister does. “ c. “You are helping me learn a lot about myself in counseling.” d. “I’m not looking forward to the end of our sessions.” 53. A nurse is caring for a client receiving tranylcypromine. Which of the following is an appropriate menu choice for the nurse to suggest? a. Roasted chicken b. Avocado salad c. Bologna sandwich d. Cheddar cheese 54. A nurse is interviewing an older adult client in an outpatient mental health clinic. Which of the following strategies should the nurse use? a. Ask questions in a similar manner as when interviewing a younger client b. Dim lighting to minimize stimuli c. Remain as close to the client as possible when communicating d. Conduct the interview in a private area 55. A client who has paranoid schizophrenia is attending a treatment planning conference with a family member. During the discussion of the medication adherence portion of the plan, the nurse notices that he family member seems distracted. Which of the following is an appropriate action by the nurse? a. Call the family member to the side to inquire if he has question or concerns about the treatment plan b. Advise the family member that this treatment plan has been developed specifically for the client to follow c. Ask the family member if she has any thoughts or questions about this portion of the treatment plan d. Document that the family member does not support the medication treatment plan 56. A nurse is meeting with a client being discharged from a substance use disorder treatment program. Which of the following client statements indicates the client is planning to make a lifestyle change? a. “I will volunteer to be the designated driver when my friends are drinking so I know I will not drink.” b. “I will change my route going home from work so I don’t pass my favorite bar.” c. “I will need to attend AA meetings regularly for the next three months.” d. “I will tell my family to go to Alanon meetings so they can make sure I do not drink.” 57. A nurse is caring for a client who has schizophrenia and is threatening to harm others on the unit. The provider prescribes haloperidol and seclusion. Which of the following should be included in the plan of care? a. Offer the client food every hour b. Limit the client’s fluid intake c. Document the client’s behavior every 8 hr d. Obtain baseline serum sodium level 58. A nurse is admitting a client to an inpatient unit who is in the acute stages of schizophrenia. The nurse observes the following findings: restlessness, pacing with clenched fists, eyes darting to one side, and muttering. Which of the following interventions should the nurse initiate? a. Encourage the client to express feeling verbally b. Involve the client in activities on the unit c. Stay with the client in a quiet setting d. Tell the client that she needs to calm down 59. A nurse is caring for a client in mental health facility who has recently started a new prescription for valproic acid. For which of the following should the nurse monitor to determine effectiveness of the medication? a. The client has decreased preoccupation with thought of food b. The client states that her craving for alcohol has decreased c. The client has decreased episodes of pressured speech d. The client is no longer experiencing agnosia 60. A nurse is planning a teaching session regarding the code of ethics for registered nurses. Which of the following should the nurse include in the teaching? a. Client confidentiality applies until the client dies b. Privileged communication protects nurse-nurse communication c. The duty to protect third parties requires a nurse to testify about a client d. The right to treatment ensures individualized care A nurse is performing an admission assessment for a client who voluntary entered an outpatient mental health crisis facility. The client states, “I’ve lost control of everything in my life!” which of the following questions should the nurse ask first? a. “What has helped you to cope with a crisis in the past?” b. “Who can we call to support you during this crisis?” c. “Are you having thoughts about harming yourself today?” d. “What event brought on this crisis?” 2. A nurse in a mental health facility is assessing the use of defense mechanisms in a client show has bulimia nervosa. Which of the following client behaviors should the nurse identify as displacement? a. The client reports a headache each day when group therapy is scheduled b. The client criticizes the nurse at each medication administration time c. The client continually talks about the benefits of healthy eating habits d. The client complains about the taste of the food 3. A nurse in a community mental health clinic is planning staff education about the levels of prevention of intimate partner abuse. Which of the following should the nurse identify as a strategy for primary prevention? a. Referring a client who left a violent relationship to a legal advocacy program b. Administering pharmacotherapy to minimize long-term effects of violence c. Promoting self-esteem by having a client identify personal strengths d. Establishing a support group for survivors to foster emotional healing 4. A nurse is admitting a client who has schizophrenia and has recently attempted to commit suicide. The client is angry over this admission and wants to go home. Which of the following interventions should the nurse anticipate implementing? (Select all that apply.) a. Place the client in seclusion b. Obtain a no-suicide contract c. Institute one-to-one observation d. Administer an antidepressant medication e. Restrain the client during change of shift 5. A nurse in a community health center is obtaining a health history of an older adult client who reports being abused by a caregiver. Which of the following actions is appropriate for the nurse to take? a. Arrange for admission to a long-term care facility b. Notify a protective agency c. Inform the client’s family d. Discuss the concerns with the caregiver 6. A nurse is providing discharge teaching for a client who has a prescription for buspirone. Which of the following should the nurse include in the teaching? a. Taking the medication with grapefruit juice can intensify the effects of the medication b. It may take up to a week for the medication to reach its full therapeutic effect c. Avoid sudden discontinuation of this medication to prevent withdrawal symptoms d. When filling the prescription for this medication it is limited to a 90-day supply 7. A nurse in a mental health facility is admitting a client who is at risk for suicide. Which of the following nursing intervention should be included in the plan of care? a. Search the client’s personal belongings daily for potentially harmful objects b. Minimize talking about the client’s future plans c. Assess the client for manifestations of psychosis on a regular basis d. Initiate discussion regarding the client’s thoughts about suicide 8. A nurse is caring for a client who is in hospice for an inoperable brain tumor. When completing a spiritual assessment as part of end-of-life care, which of the following interventions should the nurse implement? a. Discuss spiritual issues in a conversational manner b. Engage in a formal discussion of the client’s religious beliefs c. Prompt the client to the specific when asking question related to his own spirituality d. Offer suggestions based on personal spiritual values 9. A nurse is planning care for a newly admitted client who has bipolar disorder. Which of the following is the priority action by the nurse? a. Schedule the client for group therapy sessions b. Maintain consistent rules c. Provide frequent high-carlorie snacks d. Avoid the use of value judgments 10. A nurse is caring for a client who was sexually assaulted in her home. The nurse should recognize that the client is recovering when she a. Moves to a different residence b. Seeks out different groups of friends c. States a plan to revise her daily schedule d. Expresses interest intimate relationships 11. A nurse is planning to interview an older adult client to obtain a mental health history. Which of the following techniques is appropriate? a. Interview the client in private setting b. Begin the interview by explaining the plan of care c. Use open-ended questions throughout the interview d. Ask the client to complete a detailed questionnaire 12. A nurse is planning care for a client who has obsessive compulsive disorder. Which of the following is the highest priority intervention by the nurse? a. Develop a structured activity schedule for the client b. Help the client to identify sources of anxiety c. Teach the client focused relaxation techniques d. Encourage nonritualistic behavior with positive reinforcement 13. A nurse is planning to develop a relationship with a new client. Order the phases of the nurse- client relationship by placing all of the letters in the letters in the correct sequence. a. Recognize safety risks b. Set the parameters of the relationship c. Promote problem-solving skills d. Summarize relationship goals 14. A nurse is planning care for four clients in a mental health facility. Which of the following clients is at greatest risk for injury when performing ADLs? a. The client who has stage 6 Alzheimer’s disease b. The client who is in the maintenance phase of schizophrenia c. The client who has obsessive-compulsive disorder d. The client who has dysthymic disorder 15. A nurse is planning care for a preschool-age child who has ADHD. Which of the following interventions is the highest priority? a. Decrease distractions during meal times b. Provide positive feedback when the child completes a task c. Clearly identify consequences for unacceptable behavior d. Remove unnecessary equipment from the child’s surroundings. 16. A nurse working in a community mental health facility is teaching a client who has alcohol use disorder and is considering attending Alcoholics Anonymous (AA). Which of the following statements by the client demonstrates an understanding of the teaching? a. “I can have an occasional drink with dinner after completing AA.” b. “AA can also help me with my addiction to pain medication.” c. “AA will allow me to confront family members who also have alcohol use disorder.” d. “In AA, I will play a role in the recovery of others who are addicted to alcohol.” 17. A nurse is reviewing the laboratory values for a client who has been taking clozapine for schizophrenia for the last 3 months. Which of the following laboratory finding should the nurse report to the provider? a. Serum chloride 3.8 mEq/L b. WBC count 2500/mm³ c. Total serum bilirubin 0.8 mg/dL d. Alanine aminotransferase 16 units/L 18. A nurse is caring for a client who has end stage pancreatic cancer. The nurse overhears the client say to her sister, “I love our time together. I am going to miss you.” Which of the following grief reactions is the client experiencing? a. Anticipatory b. Inhibited c. Disenfranchised d. distorted 19. A nurse is admitting a client who is experiencing alcohol withdrawal delirium. The nurse plans a room assignment. Which of the following clients is the most appropriate roommate for this client? a. A client who has insomnia b. A client who receives frequent visitors c. A client who is hypervigilant d. A client who has depressive disorder 20. A case manager is implementing a program to help client increase adherence to their treatment regime. Which of the following actions should the nurse take? a. Provide care for a client’s physical health needs b. Track the outcomes of client care c. Develop community based program goals d. Promote client use of a crisis hotline 21. A nurse is admitting a client who has of alcohol use and a new diagnosis of Korsakoff’s syndrome. Which of the following should the nurse include in the client’s plan of care? a. Initiate contact precautions b. Provide assistance with ambulation c. Teach stress-management techniques d. Administer lithium therapy 22. A nurse is planning care for an older adult client who is experiencing delirium. Which of the following interventions will meet the needs of this client? a. Offer the client various choices for meal selection b. Assign different nursing personnel for each shift c. Permit the client daily rituals to decrease anxiety d. Maintain an environment that has low lighting 23. A nurse in a 24-hr mental health facility is planning discharge for a client who has a long history of alcohol use disorder. Which of the following postdischarge activities should the nurse plan to include? a. Taking the oral medication buprenorphine to prevent alcohol use b. Attending a relapse prevention group several times each week c. Beginning a methadone treatment program at a local center d. Living with her mother, who has promised to keep her away from alcohol 24. A nurse is caring for a client who is schedules to undergo electroconvulsive therapy (ECT). Which of the following client statements indicates that further teaching is needed? a. “I will be able to stop taking my antidepressant after the treatment.” b. “I can expect to experience some memory loss after the procedure.” c. “My blood pressure will be checked frequently after the procedure.” d. “I will receive a muscle-relaxant before the doctor begins the treatment.” 25. A nurse is planning strategies to address suicide in the community. Which of the following should the nurse plan as a tertiary intervention? a. Refer families to a grief counselor following a suicide b. Work with the school nurse to identify students at risk for suicide c. Establish a telephone hotline for individuals experiencing a suicidal crisis d. Review suicide precautions with acute care nursing staff 26. A nurse is teaching a client who is to start therapy with paroxetine. The nurse should instruct the client to report which of the following findings immediately to the provider? a. Insomnia b. Sexual dysfunction c. Dry mouth d. fever 27. A nurse is receiving shift report for four clients in an acute care mental health facility. Which of the following clients should the nurse assess first? a. A client who does not recognize familiar people b. A client who cannot verbalize his needs c. A client who is awake and disoriented at night d. A client who is experiencing command hallucinations 28. A nurse is caring for a client who has an anxiety disorder and displays obsessive-compulsive behavior. Which of the following actions should the nurse take to assist the client to decrease the unwanted behaviors? a. Have the client monitor the number of times the client has compulsive thoughts b. Discourage the client’s verbalization of thoughts that provoke anxiety c. Help the client to set time limits for compulsive behaviors d. Assist the client to minimize anxiety by taking extra care with grooming activities 29. A nurse is planning teaching about relapse prevention to a client who just began an outpatient substance use disorder treatment program. Which of the following strategies should the nurse use at the beginning of the program? a. Simplify program rules and objectives for the client b. Provide opportunities in the program for the client to rehearse new coping skills c. Determine with the client what secondary gain the addiction provides d. Assist the client to identify healthy supportive relationships 30. A nurse is caring for a client who has bipolar disorder and is taking valproic acid. Which of the following is the priority assessment finding? a. The client has not slept in 24 hr b. The client states missing a dose of valproic acid yesterday c. The client has been evicted from his apartment d. The client reports fine hand tremors 31. A nurse is teaching a client to use cognitive refraining to manage the stress of public speaking. Which of the following statements by the client indicates an understanding of the teaching? a. “I have stayed up all night giving this speech in the mirror.” (increasing the amount of time the client practices the speech by staying up all night will increase the client’s stress and does not change the perception of the activity) b. “I know about the topic I’ve been asked to speak about.”(a technique that replaces negative thoughts with positive self-statements is the correct use of cognitive reframing and will reduce the client’s anxiety) c. “I was asked to speak because I’m expected to know about the topic.”( the client is verbalizing a statement that is based on other people’s perceptions This does not change the client’s perception of the activity and will not reduce the client’s anxiety) d. “I will be done speaking in about an hour, and then I can relax.” (The client is verbalizing that his anxiety will be reduced when the activity is completed. This does not change the client’s perception of the activity and thus will not reduce his anxiety) 32. A nurse is discussing simple restitution with the parents of a school-age child who has conduct disorder. Which of the following should the nurse recommend when discussing this behavioral management technique? a. Advising the parents to ignore the child’s attention-seeking behavior if it is not dangerous (planned ignoring behavioral management technique) b. Recommending a change in activity if the child begins to demonstrate frustration (restructuring as a behavioral management technique) c. Establishing clear expectations for the child’s behavior during meals(using limit setting as a behavior management technique) d. Instructing the child to put away the books he threw during a period of aggression (simple restitution as a behavioral management technique) 33. A nurse on a medical-surgical unit is assessing a client who has acute pancreatitis related to chronic alcohol use disorder. Which of the following is an expected finding? a. Hypoglycemia (acute pancreatitis to have hyperglycemia due to impaired insulin release from the pancreas) b. Decreased serum amylase(acute pancreatitis to have an elevated serum amylase due to injury to the cells of the pancreas) c. Epigastric pain (expect to client who has acute pancreatitis to have severe and constant epigastric pain) d. Hyperactive bowel sounds (decreased, and possibly absent ,bowel sounds due to the risk for paralytic ileus) 34. A nurse is assessing a family’s dynamics during a counseling session. The nurse should recognize which of the following as an indication of a boundary issue? a. An adolescent family member who questions parental authority (demonstrating appropriate behavior for developmental age) b. A family with three generations in the same household (scenario occurs in many households) c. Older children who are responsible for their younger siblings (enmeshed boundaries in which there are no distinctions between the roles of family members) d. Two adults and their children from prior relationships in the same household (blended family) 35. A nurse is providing teaching to a client who is to begin undergoing light therapy at home to treat seasonal affective disorder. Which of the following should the nurse include in the teaching? a. Have a family member present during treatment ( precaution is not necessary with light therapy) b. Increase fluid intake (does not increase the risk of dehydration) c. Change position slowly (hypotension or dizziness) d. Wear sunglasses when outdoors (eye strain and sensitivity to light) 36. A nurse is documenting admission assessment finding s for a client who has major depressive disorder. The nurse should identify which of the following finding as clinical manifestations? (select all that apply.) a. Feeling of hopelessness (the nurse should document feeling of hopelessness as a clinical manifestation of major depressive disorder) b. Pressured speech (this clinical manifestation is associated with clients who are experiencing mania, rather than major depressive disorder) c. Grandiosity (this clinical manifestation is associated with clients who are experiencing mania, rather than major depressive disorder) d. Anhedonia(the nurse should document the inability to experience pleasure as a clinical manifestation of major depressive disorder) e. Flat facial expression (the nurse should document a flat facial expression as a clinical manifestation of major depressive disorder) 37. A nurse is having a conversation with a client who frequently becomes angry and aggressive toward others. When the client becomes verbally abusive toward the nurse, which of the following statements by the nurse is appropriate? a. “I will take away privileges if you continue to be abusive.”(Threatening the client verbally is not appropriate response to the client’s verbal abuse) b. “I am leaving now but will return in few minutes to see if you are calmer.”(an effective technique for handling verbal abuse is to leave the room immediately and return later to check on the client. The nurse should keep communication neutral and refrain from arguing with the client) c. “You have no right to talk like this and must stop yelling.”(simply telling the client to stop may reinforce the client’s inappropriate behavior) d. “I don’t talk angrily to you and you shouldn’t talk that way to me.”(Arguing with the client about the verbal abuse may simply reinforce the client’s inappropriate behavior) 38. A nurse is caring for a client who is receiving hospice care and refusing nourishment. The client tells the nurse “There is no point in eating because I am dying anyway.” Which of the following is a therapeutic response? a. “We need to discuss this with your family first.” (the nurse’s response is dismissive of the client’s concerns and the client does not need his family’s permission to refuse treatment) b. “Tell me more about your concerns.”(the nurse is offering a general lead to give the client a chance to elaborate his feelings, which enables the nurse to gain insight on his right to refuse treatment) c. “Would you rather not receive any care or treatment?”(the nurse’s response is a close- ended question and does not allow the client to express his feelings regarding his right to refuse treatment) d. “Do you have an advance directive on file?”(the nurse’s response is a close-ended question and may make the client defensive) 39. A nurse is caring for a client who is experience alcohol withdrawal. Which of the following medications should the nurse administer first? VS: HR 110/min, BP 170/96 mm hg, Temp 38.9˚C (102˚F); History and physical: client states he consumed alcohol 12 hr prior to admission. Client has 12 packs per year smoking history; Progress report (Nurse’s Notes): Tremors of hands and fingers bilaterally. Client restless and unable to sit still. Client is diaphorestic and has flushed skin. Emesis of 30 mL bile-colored fluid. a. Diazepam 5 mg IV bolus (The greatest risk to the client experiencing alcohol withdrawal is seizures and an elevated heart rate and blood pressure. IV diazepam acts rapidly to prevent seizures, stabilize vital signs, and decrease the intensity of withdrawal symptoms) b. Clonidine 0.1 mg transdermal patch (stabilize vital signs and is used as an adjunct to a benzodiazepine. It is administered only PO or transdermally and does not act rapidly) c. Naltrexone 380 mg IM (long-term abstinence maintenance, but it is not the first medication the nurse should administer) d. Bupropion 150 mg PO (smoking cessation, but it is not the first medication the nurse should administer) 40. A nurse is caring for a client who has a new prescription for lithium carbonate. Prior to administering this medication, the nurse reviews the client’s laboratory reports. The nurse should withhold the medication and call the provider based on which of the following laboratory values? a. Bun 45 mg/dL (BUN 10-30 mg/dl) b. Serum sodium 138 mg/dL (134-145) c. T₃ 175 ng/mL(110-230) d. Total cholesterol 190 mg/dL (<200) 41. A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding his admission, the client stats, “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? a. Clang association (rhyme or contain a string of words that may have the same beginning sound) b. Word salad (words are completely meaningless and disorganized) c. Neologism (words that are made up by the client) d. Echolalia (client repeats the words of another person) 42. A nurse is caring for a client who developed neuroleptic malignant syndrome (NMS) as a result of taking haloperidol. After administering dantrolene IV, the nurse should monitor the client for which of the following findings indicating that the treatment is effective? a. Increased level of consciousness (Dantrolene can cause drowsiness and confusion) b. Decreased rigidity (Dantrolene is a muscle relaxant. For client who have NMS, it can reduce muscle rigidity and spasms) c. Increased heart rate (cause tachycardia, but this is not indicate that treatment is effective) d. Decreased blood pressure(blood pressure fluctuation) 43. A nurse is caring for a client who has recently been admitted with anorexia nervosa and needs to increase oral intake. Which of the following interventions should the nurse implement? a. Offer rewards for gaining weight (the nurse should offer rewards for the amount of calories consumed, not the amount of weight gained) b. Initially increase daily intake to 2,500 calories (initial intake should not go below 1,200 calories per day, but 2,500 calories may be too overwhelming. The client should begin with small frequent meals until food tolerance increases) c. Temporarily decrease fiber intake (a high-fiber diet may be helpful in controlling constipation, a problem that commonly occurs in clients who have anorexia nervosa) d. Restrict caffeine in the diet (should avoided due to its stimulative and diuretic effects) 44. A nurse is caring for a client who has paranoid schizophrenia, has been physically violent toward others and received several as needed doses of haloperidol IM. The nurse is preparing to administer benstropine to treat which of the following adverse effects of haloperidol? a. Increased blood pressure and pulse rate ( Haloperidol can cause an increase in blood pressure and pulse rate; however, this not the reason for prescribing benstropine) b. Stif f and stooped posture (manifestation of Pseudoparkinsonism, which is an extrapyramidal side effect of haloperidol that can be treated with benstropine) c. Sore throat and mouth sores (no common adverse effects of haloperidol) d. Abdominal pain and diarrhea (administration of haloperidol can cause diarrhea and resulting abdominal pain; however, this is not a reason to prescribe benstropine) 45. A nurse is planning care for a client who has depression and has made frequent suicide attempt. Which of the following statements indicates the client has a decreased risk for suicide? a. “I’m relieved now that my financial affairs are in order.” (depression verbalize getting their affair in order, they are at an increased risk for suicide) b. “It is easier to talk about my feelings now.”(client express their feelings, positive treatment outcome) c. “Suddenly I have enough energy to do anything I want.”(depression suddenly have more energy, they are at an increased risk for suicide) d. “Thank you for always taking such good care of me.”(depression often show an appreciation for loved ones when they are comtemplating suicide) 46. A nurse is caring for a client who has a history of aggressive behavior. The client is playing cards and throws the cards at other clients. Which of the following interventions is appropriate in this situation? a. Ask the client to express how he is feeling (to prevent further escalation of the client’s anger, the nurse should use therapeutic communication to determine what the client feeling) b. Admonish the client for inappropriate behavior(scolding the client is likely to escalate the aggressive behavior) c. Explain the rules of the unit to the client (reiterating the rules of the unit is unlikely to reduce the client’s aggression and can escalate the situation d. Take the cards away from the client (removing the cards at this time might increase the client’s aggression and escalate the situation) 47. A nurse is preparing to administer chlorpromazine 0.55 mg/kg to an adolescent client who weighs 110 lbs. Available is chlorpromazine syrup 10 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number.) 2.2 lb/1kg =110 lb/x kg X=50 0.55mgx 50kg =27.5 mg 10 mg/5 mL= 27.5 mg/X mL X = 13.75 = 14 mL 48. A nurse is conducting a private counseling session with a client who is a recent victim of intimate partner abuse. Which of the following statements by the client indicates that counseling has been effective? a. “I have no reason to prepare a getaway kit, because my husband has changed.” b. “I feel more independent when I talk to you about what happened with my husband.” c. “I’m going to try to keep the house clean like my husband wants it.” d. “I still wonder what I did to make my husband act that ways?” 49. A nurse is facilitating a community meeting for inpatient clients. One client is constantly talking and using up the majority of the group’s time. Which of the following interventions should the nurse implement? a. Tell the client that the he must talk less or he will be removed from the meeting b. Focus on other group members and ignore the client who is doing all the talking c. End the group meeting and take the client aside to discuss his behavior d. Ask group members to discuss their feelings about this client’s monpolizing behavior 50. A nurse is teaching a female client who has schizophrenia about a new prescription for risperidone. Which of the following should the nurse include in the teaching (select all that apply.) a. “This medication may nausea an excessive growth of body hair.” b. “This medication may cause an elevated blood sugar.” c. "menstrual irregularities may cause an elevate blood sugar.” d. “You may experience dizziness while taking this medication.” e. “You may notice a increase in sexual desire while taking this medication.” 51. A nurse is caring for a client in a mental health facility. The nurse overhears another staff member make derogatory comments to the client. Which of following actions should the nurse take? a. Confront the staff member b. Encourage the client to report the incident. c. Document has enough the client‘s health record. d. Report the occurrences to the charge nurse. 52. A nurse is caring for a client who has just been told he is dying. The nurse determines that the client is going through a typical early stage of grief when he says, a. “I’m trying to feel at peace with my diagnosis.” b. “I’m so angry that I’d like to hurt someone.” c. “I think my lab results got mixed up with someone else’s.” d. “I just want to live to see my daughter get married.” 53. A nurse is admitting a client who is experiencing alcohol withdrawal and appears shaky, irritable, and reports nausea. Which of the following is the priority information for the nurse to obtain? a. The number of years the client has been drinking b. The events that triggered the client’s alcohol use c. The date and time of the client’s last drink d. The client’s family history of substance use 54. A nurse takes a phone call from a man who states that he is a client’s pastor and then asks about the client’s condition. Which of the following is an appropriate response by the nurse? a. Refer the caller to the hospital’s public relations department and notify the client b. Tell the caller that he must come to the hospital to get that information c. Put the caller on hold and forward the call to the charge nurse d. Suggest that the caller contact the family regarding the client’s condition 55. A nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that she stopped taking her lithium 2 weeks ago. The nurse recognizes which of the following as an expected adverse effect that may have caused the client to stop taking a. Hand tremors b. Photophobia c. Sore throat d. constipation 56. A nurse in a mental health unit observes a client who has acute mania hit another client. Which of the following actions should the nurse take first? a. Call the provider to obtain an immediate order for restraint b. Prepare to administer benzodiazepine IM c. Call for a team of staff members to help with the situation d. Approach the client while speaking in a low, calm voice 57. 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 is the highest priority? a. Advise the client to take frequent sips of water b. Instruct the client to avoid driving during initial therapy c. Consult a dietitian for a calorie-controlled diet plan d. Recommend that the client exercise regularly 58. A nurse is working with a group of older adult client at an independent living facility who are discussing their plans for family reunions. Which of the following statements by a group member warrants further assessment by the nurse? a. “I should have taken the time to enjoy the reunions with my wife when she was alive.” b. “I wish that we would have had family reunions when I was younger, so I could have enjoyed them more.” c. “I’d like to go back to the days when my children were small and enjoyed spending time playing with their cousins.” d. “I’m not going to the reunion because no one asked me to help plan it.” 59. A nurse is caring for a client in a mental health facility who is place in physical restraints for aggressive behavior. Which of the following behaviors indicates the client should have the restraints removed? a. Follows the nurse’s directions b. Makes eye contact with the nurse c. Asks for a drink of water d. Stays awake throughout the day 60. A nurse is reviewing the medical record of a client who has masochism. Which of the following information should the nurse expect in the client’s history? a. Exposing his genitalia to unsuspecting strangers b. Sexual fantasies involving non-living objects c. Urges to touch and rub against non-consenting individuals d. Fantasies involving the act of being humiliated and bound