ATI MENTAL FINAL 2023 EXAM {GRADED A}VERIFIED QUESTIONS AND ANSWERS

ATI MENTAL FINAL 2023 EXAM {GRADED A}VERIFIED QUESTIONS AND ANSWERS 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 the family member seems distracted. Which of the following is an appropriate action by the nurse? Ask the family member if she has any thoughts or questions about this portion of the treatment plan 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? You seem concerned about getting out of the hospital 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? Command Hallucinations A nurse is interviewing an older adult client in an outpatient mental health clinic. Which of the following strategies should the nurse use? Conduct the interview in a quiet area 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? Mild Anxiety A nurse is caring for a client with dementia. Which of the following interventions is useful for orienting a client to reality? Place a large wall calendar in the client’s room A nurse is caring for a client receiving tranylcypromine. Which of the following is an appropriate menu choice for the nurse to suggest? Roasted Chicken A nurse is developing a discharge plan for a client who has a history of gambling dependency and includes participation in a support group. The nurse should tell the client that which of the following is the purpose of attending a support group? Provide assurance that others have a similar problem A nurse is caring for a client receiving imipramine for depression. For which of the following adverse effects should the nurse monitor? Urinary Retention 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? Cocaine 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? Shuffling Gait A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following laboratory values should the nurse expect? CPK 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? Assess the client for evidence of a perceptual disturbance 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? I will change my route going home from work so I don’t pass my favorite bar 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? I feel so empty without my wife; it’s hard to get up every morning 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 Schedule a family conference 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? How long have you been having conversations with the president? A nurse is providing teaching to a client who is to be discharged 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? I will use peer support to maintain my abstinence 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? The client needs excessive external input to make everyday decisions 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? You sound angry and frustrated. Tell us more about how you are feeling. A nurse is planning to teach a group of parents about healthy adolescent behavior. Which of the following information should the nurse include? Exhibits a realistic self-concept 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? Divide the group into pairs to discuss a topic, then summarize the discussion to the group. 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 Inform the client that her admission will be confidential 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? Use a therapeutic holding technique 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? Flat affect 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? Request a professional interpreter to translate A nurse is communicating with a client in an inpatient mental health facility. Which of the following demonstrates the use of active listening? Attention to body language 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 Create a large personal space 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.) Distressing dreams, Difficulty concentrating, Exaggerated startle response 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 A nurse is caring for a client whose child recently died in a motor vehicle crash and states, "I just want to join him." Which of the following is the nurse's priority response? Are you thinking about harming yourself 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? Coarse hand tremor A nurse is caring for a client who has schizophrenia and is prescribed risperidone. Which of the following laboratory tests should the nurse monitor? Blood Glucose 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? The client will refrain from self-mutilation 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? Language Delay 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? (Click on the "Exhibit" button below for additional client information. There are three tabs that contain separate categories of data.) Serum sodium 125 mEq/L 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 include? Early identification of changes such as decreased social involvement is important 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? Offer the client food every hour 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 Is beginning to trust the nurse 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? Stay with the client in a quiet setting 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? Lip smacking and tongue rolling A client is experiencing a situational crisis. Which of the following findings should the nurse expect? The client recently lost a grandparent in a motor vehicle crash 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? I feel like you talk to me like my sister does A nurse is admitting an adolescent client who has anorexia nervosa. Which of the following clinical findings should the nurse expect? Amenorrhea 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? The right to treatment ensures individualized care A home health nurse is assessing an older adult client who lives alone. Which of the following findings should indicate to the nurse that the client is experiencing delirium? Sudden onset A nurse is caring for four clients in an inpatient mental health facility. Which of the following clients can give informed consent? A 35-year-old with major depressive disorder 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 actions should the nurse take first? Check the client for other signs and symptoms of abuse 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? Suppression 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? Accompany the client to a quiet room The nurse is caring for a client who has anorexia nervosa. Which of the following criteria requires hospitalization? Temperature of 35.6 (96.1) A nurse is caring for a client who has a history of substance use and was involuntarily admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take? Do not administer the lorazepam 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? Giving away possessions 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? My son enjoys a couple of drinks each night to unwind A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following medications should the nurse administer? Chlordiazepoxide 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.) OT, Meal delivery services, PT, Home health services A nurse is caring for a client in a 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? The client has decreased episodes of pressured speech 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 statements made by the client indicates a need for further teaching? This procedure can increase my risk for developing Parkinson’s Disease A client recently diagnosed with bipolar disorder is placed in a room with a client who has severe depression. The client who has 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? Move the client who has bipolar disorder to a private room 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? Tell the client to calm down or he will be dismissed from the session 1. 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 suicide. 2. 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 findings should the nurse report to the provider a. WBC count 2500/mm 3. 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. Wear sunglasses when outdoors 4. 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 date and time of the clients last drink 5. 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 6. 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 for a team of staff members to help with the situation 7. A nurse is conducting a private counseling session with a client who is a recent victim on intimate partner abuse. Which of the following statements by the client indicates that counseling has been effective. a. I feel more independent when I talk to you about what happened with my husband 8. A nurse is caring for a client who is scheduled to undergo electroconvulsive therapy. 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 9. A nurse working in a community mental health facility is teaching a client who has alcohol use disorder and is considering attending Alcoholic Anonymous. Which of the following statements by the client demonstrates an understanding of the teaching. a. In AA, I will play a role in the recovery of others who are addicted to alcohol 10. 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. Help the client to set time limits for compulsive behaviors 11. A nurse is reviewing the medical record of a client who has masochism. Which of the following information should the nurse expect in the clients history. a. Fantasies involving the act of being humiliated and bound 12. 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 hours 13. A nurse is preparing to administer chlorpromazine 0.55mg/kg to an adolescent client who weighs 110lb. Available is chlorpromazine syrup 10mg/5mL. How many mL should the nurse administer. a. 14 14. 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 post discharge activities should the nurse plan to include. a. Attending a relapse prevention group several times each week 15. 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 16. 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. a. It is easier to talk about my feelings now 17. A nurse is planning care for a preschool-age child who has ADHD. Which of the following interventions is the highest priority. a. Remove unnecessary equipment from the child’s surroundings 18. A nurse is teaching a client to use cognitive reframing to manage the stress of public speaking. Which of the following statements by the client indicates an understanding of the teaching. a. I know about the topic I’ve been asked to speak about 19. A nurse is caring for a client in a mental health facility who is placed in physical restraints for aggressive behavior. Which of the following behaviors indicates the client should have the restraints removed. a. Follows the nurses directions 20. 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 benztropine to treat which of the following adverse effects of haloperidol. a. Stiff and stooped posture 21. 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. Restrict caffeine in the diet 22. 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 think my lab results got mixed up with someone else’s 23. A nurse is documenting admission assessment findings for a client who has major depressive disorder. The nurse should identify which of the following findings as clinical manifestations a. Feelings of hopelessness, anhedonia, flat facial expression 24. 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. fever 25. A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse administer first. a. Diazepam 5 mg IV bolus 26. 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. Expresses interest in intimate relationships 27. A nurse is planning to develop a relationship with a new client. Order the phases of the nurse-client relationships by placing all of the letters in the correct sequence a. Identify safety risks b. Set the parameters during the orientation phase c. Promote problem solving skills d. Summarize the goals 28. A nurse takes a phone call from a man who states that he is a clients pastor and then asks about the client’s condition. Which of the following is an appropriate response by the nurse. a. Suggest that the caller contact the family regarding the clients condition 29. A nurse in a mental health facility is assessing the use of defense mechanisms in a client who has bulimia nervosa. Which of the following client behaviors should the nurse identify as displacement. a. The client criticizes the nurse at each medication administration time 30. 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 depressive disorder 31. 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 am leaving now but will return in a few minutes to see if you are calmer 32. A case manager is implementing a program to help clients increase adherence to their treatment regimen. Which of the following actions should the nurse take. a. Provide care for a clients physical health needs 33. 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 34. A nurse is admitting a client who has a history of alcohol and a new diagnosis of Korsakoffs syndrome. Which of the following should the nurse include in the clients plan of care a. Provide assistance with ambulation 35. 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. Instruct the client to avoid driving during initial therapy 36. A nurse is caring for a client who developed neuroleptic malignant syndrome 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. Decreased rigidity 37. 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 is experiencing command hallucinations 38. 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. Older children who are responsible for their younger siblings 39. 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. a. This medication may cause an elevated blood sugar, menstrual irregularities may occur, you may experience dizziness 40. A nurse in a mental health facility is admitting a client who is at risk for suicide. Which of the following nursing interventions should be included in the plan of care a. Initiate discussion regarding the clients thoughts about suicide 41. A nurse is planning care for an adult client who is experiencing delirium. Which of the following interventions will meet the needs of this client a. Permit the client daily rituals to decrease anxiety 42. 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 a private setting 43. 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. Epigastric pain 44. 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. Notify a protective agency 45. 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 the medication. a. Hand tremors 46. 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. a. Institute one to one observation, administer and antidepressant, 47. 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 48. A nurse is working with a group of older adult clients at an independent living facility who are discussing their plans for family reunions. Which of the following statements by a group member warrants further assessments by the nurse a. I’m not going to the reunion because no one asked me to help plan it 49. 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 states, “I’m red, in the head, and going to bed.” The nurse should document the clients speech pattern as which of the following a. Clang association 50. A nurse is planning care for a client who has OCD. Which of the following is the highest priority interventions by the nurse. a. Help the client to identify sources of anxiety 51. 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. Provide frequent high calorie snacks 52. A nurse is performing an admission assessment for a client who voluntarily 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. Are you having thoughts about harming yourself today 53. 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. Tell me more about your concerns 54. 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 55. A nurse is caring for a client in a mental facility. The nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse take. a. Report the occurrences to the charge nurse 56. 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 57. 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. Instructing the child to put away the books he threw during a period of aggression 58. 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. Promoting self-esteem by having a client identify personal strengths 59. 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 60. A nurse is facilitating a community meeting for inpatient clients. One client is constantly talking and using up the majority of the groups time. Which of the following interventions should the nurse implement. a. Ask group members to discuss their feelings about the clients monopolizing behavior OLD TESTS 1. The following statement is true of empathy a. The client must learn to develop empathy for the nurse b. It involves interjecting the nurses personal experiences and interpretations of the situation c. It results in negative therapeutic outcomes d. It is the ability to place oneself into the experience of another for a moment of time 2. The nurse asks the client what he would like to talk about. This is an example of what communication technique a. Offering self b. Encouraging expression c. Broad opening d. Focusing 3. A client says, “it has been so long since I have been with my family,” Which statement by the nurse is an example of restating a. When was the last time you say your family b. Tell me when you last saw your family c. Go on. Tell me more d. You say you have not seen your family in a while 4. The appropriate action for a student nurse who says the wrong thing is to do the following a. Pretend that the student nurse did not say it b. Ignore the error, since no one is perfect c. State that it was a joke d. Restate it by saying, “that didn’t come out right. What I meant was… 5. Which is a positive aspect of treating clients with a mental illness in a community-based care setting a. The client will have someone in their home at all times to ask questions and get any of their concerns answered b. The client will have to have supervision when he goes anywhere else in the community c. The client will not be allowed to go out with friends or family while in the program d. The client will be able to live in their own home while they still regularly see the therapist 6. The nurse and the client have just competed reviewing the client’s medications that he will be taking upon discharge. The nurses exemplifying which role during the intervention a. Parent surrogate b. Teacher c. Caregiver d. Advocate 7. A nurse is communicating with a newly admitted client. Which of the following is a barrier to therapeutic communication a. Listening attentively b. Reflecting meaning c. Offering advice d. Giving information 8. When a family asks a nurse for reassurance about a clients condition, which of the following is an appropriate response a. I think your son is getting better. What have you noticed b. I’m sure everything will be okay. It just takes time to heal c. I am not sure what is wrong. Have you asked the doctor about your concerns d. I understand you are concerned. Lets discuss what concerns you specifically 9. A nurse is communicating with a client in the in-patient behavioral health unit. The client moves closer and invades the nurse’s personal space, making the nurse uncomfortable. Which is an appropriate nursing intervention. a. The nurse ignores this behavior because it shows the client is progressing b. The nurse understands that clients require various amounts of personal space and accepts the behavior c. The nurse expresses a sense of discomfort and limits behavior d. The nurse confronts and yells loudly to inform the client that the client will be scheduled if this behavior continues 10. A client on a behavioral health unit is telling the nurse about losing an only child in a plane crash and about anger toward the airline. In which situation is the nurse demonstrating active listening a. Assuming a relaxed posture and leaning toward the client b. Expressing sorrow and sadness regarding the clients loss c. Repeating everything the client says to clarify d. Agreeing with the client 11. A client on the behavioral health unit says, “it’s a waste of time to be here. I can’t talk to you or anyone.” Which would be an appropriate therapeutic nursing response a. I find that hard to believe b. Are you feeling that no one understands c. I think you should calm down and look on the positive side d. Our staff here is excellent, and you are in good hands 12. Which is an example of the non-therapeutic technique of “giving reassurance” a. Hang in there, every dog has its day” b. Don’t worry, everything will work out c. That is good. I am glad you are here d. I think you should… 13. The nurse is setting with a client who is crying. After a few minutes the nurse places one hand on the clients shoulder. Which of the following best describes the purpose of the nurses touch with the client a. To offer comfort and support for the client b. To express sympathy to the client c. To extend an offer of friendship to the client d. To assess the clients kin temperature and circulation status 14. The nurse says to the client you become very anxious when we start talking about your drinking. Which of the following technique is the nurse using a. Verbalizing the implied b. Making an observation c. Translating into feelings d. Confronting behavior 15. A client is fearful and reluctant to talk. Which of the following techniques is most effective when trying to engage the client in interaction a. Silence b. Asking “why” questions c. Broad opening d. Focusing 16. A client yells, “all the nurses here are so mean. None of you really care about us” the most therapeutic response would be a. You seem very irritated b. We care bout you c. I cannot allow you to yell like that d. Oh really 17. Which of the following statements is true about a nurses self disclosure a. The more the nurse discloses, the more the client will disclose b. It is the basis for effective communication c. Self disclosure on the nurses part should benefit the client d. Self disclosure should be used with all clients to some degree 18. A client reports a pattern of being suspicious and mistrusting of others, causing difficulty in sustaining lasting relationships. Which stage according to Erickson’s psychosocial development was not successfully completed a. Initiative b. Trust c. Autonomy d. Industry 19. The nurse has established a therapeutic relationship with a client. The client is beginning to share feelings openly with the nurse. The relationship has entered which phase according to Peplau’s theory a. Orientation b. Identification c. Expiotation d. Resolution 20. During the assessment, the nurse asks the client to describe his problems. The purpose of this question is to obtain information about the clients a. Perception of the problem b. Admitting diagnosis c. Personal needs d. Communication skills 21. The client states that he is 14 trillion years old and created the world. The nurse documents this statement as an example of which type of thinking displayed by the client a. Delusional thinking b. Ideas of reference c. Word salad d. Hallucination 22. Which of the following questions is best to ask when assessing the clients judgment a. If you found yourself downtown without any money or a car, how should you get home b. On a scale of 1-10, how stressed would you rate yourself c. Can you describe you usual daily activities for me d. What problem would you like to work on while your hospitalized 23. The staff on the inpatient behavioral health unit is very busy and fall behind on periodic assessment of a severity depressed client. During the round, the client is discovered to have completed a suicide attempt in the bathroom. Which type of lawsuit could the clients family file a. Assault b. Breach of duty c. Malpractice d. Injury or damage 24. When is a nurse legally obligated to breach confidentiality a. At any time a client is threatening b. When the client violates the nurses boundaries c. Whenever the client becomes aggressive d. If threats are made to an identifiable third party 25. What is an essential component of a therapeutic nurse client relationship a. Catharsis b. Confrontation c. Empathy d. Education 26. The nurse is doing a 1 on 1 assessment interview in the crowded day-room, a client who is newly admitted starts to pace and breathe rapidly, and has a problem focusing on the nurse’s questions. What is the most appropriate approach of the nurse to take at this time a. Assist the client to a quiet area b. Reassure the client that its all right c. Tell the client to sit down and practice controlled breathing d. Stop the assessment interview and ask if going for a walk would be helpful 27. A client who has been diagnosed with bipolar is getting ready for discharge and asks the nurse if she will go on a data with him after discharge. The nurse responds by stating the purpose of her therapeutic relationship. What technique is the nurse using a. Confrontation b. Avoidance of the embarrassing situation c. Rationalization d. Defining the limits of the relationship 28. What is the best nursing interventions for a client who manifest anxiety by combative, aggressive behavior and angry outbursts a. Providing structure and limits b. Avoiding confrontation about the outbursts c. Allowing the expression of anger d. Offering choices to the client 29. How would the nurse evaluate the outcome of nursing interventions with a client who has a history of uncontrolled anger, what the client says, “I am really upset and angry” a. This is a indication of a positive outcome b. This statement is aimed at getting the nurses attention c. This client is bing manipulative toward the nurse d. This statement is indicative of suppression of anger 30. What criterion is used in most states for involuntary admission of a client to a behavioral health unit a. A history of chronic mental illness b. The lack of availability of appropriate housing/shelters for the client c. Danger to self or others d. The need to medications 31. Which legal charge would apply if the nurse placed a client in mechanical restraints without clinical justification a. Assault b. Breach of confidentiality c. False imprisonment d. Malpractice 32. The mini mental examination is a standard, reliable screening instrument used to assess for cognitive impairment and commonly used to screen for dementia (True or False) a. True b. False 33. Aggressive behavior is less common on behavioral units with strong psychiatric leadership, clear staff roles, and planned and adequate events. a. True b. False 34. Choose the correct five-phase aggression cycle a. Triggering, escalation, crisis, recover, post crisis b. Anger, contemplation, confrontation, aggression, and post crisis c. Triggering, crisis, escalation, post crisis, and honeymoon d. Crisis, triggering, recovery, post crisis, and escalation 35. Which of the following types of drugs requires cautious use with potentially aggressive clients a. Antipsychotic medications b. Benzodiazepines c. Lithium d. Mood stabilizers 36. A clients nursing care plan includes for auditory hallucinations. Indications that suggest the client may be hallucinating include a. Performing rituals and avoiding open spaces b. Elevated mood, hyperverbal, and distractibility c. Darting eyes, distracted and mumbling to self, d. Aloofness, easily distracted and suspicion 37. A client with the diagnosis of schizophrenia approaches the nurse and says “its best, its eat, no room for doom” the nurse can correctly asses this verbalization as a. Neologisms b. Associated looseness c. Clanging d. Ideas of reference 38. A client with schizophrenia begins to talk about creatures called “volmers” hiding in the warehouse where he works and undoing his work at night. The term “volmers” is a a. Neologisms b. Ideas of reference c. Clanging d. Hyper-verbalization 39. A newly admitted client diagnoses with paranoid schizophrenia is hypervigilant and constantly scans the environment. He states that he saw two doctors talking in the hall and they want to kill him. When charting, how would the nurse identify his behavior a. Echolasia b. Delusion of infidelity c. Auditory hallucinations d. Ideas of reference 40. A client with schizophrenia who admits to auditory hallucinations anxiously tells the nurse “The voice is telling me to do things”. What is the best response from the nurse? a. Let me get you some medicine and that will help decrease the voices b. Do you recognize the voice you hear c. What is the voice telling you to do d. How long has this been happening 41. The primary goal in working with an actively psychotic; suspicious client would be to a. Promote interaction with others on the unit b. Decrease his anxiety and increase trust c. Improve relationships with family and friends d. Encourage participation in group activities 42. The nurse is caring for a client with schizophrenia. Orders form the physician include 4 mg of haloperidol IM STAT and then 2mg po BID; 2 mg benztropin PO bid pern. Why is haloperidol administered a. To prevent neuroleptic malignant syndrome b. To decrease psychotic symptoms c. To induce sleep d. To reduce extrapyramidal syndrome 43. The primary focus of family therapy for clients with schizophrenia and their families is a. To keep the client and family in touch with the physicians and other health care team members b. To introduce the family to others in the community that may have the same problems c. To promote family interactions and increase the understanding of the illness d. To discuss abstract problem solving and concrete behaviors for coping with stress 44. A client on the behavioral health unit has been diagnosed with schizophrenia. He begins to tell the nurse about how the CIA and FBI are looking for him and will kill him if they see him is an example of what a. Delusion of grandeur b. Delusion of control or influence c. Delusion of persecution d. Delusion of reference 45. A client n the inpatient behavioral health unit has been diagnosed with schizophrenia. He begins to tell the nurse about how the FBI and president Obama are looking for him. The most important response be the nurse is a. The FBI is not interested in people like you, you are sick and in the hospital b. I know you believe that, but it is really hard for me to believe c. That is ridiculous, no one is going to hurt you, especially the FBI and I do not think you know the president d. Why do you think the FBI is going to kill you and how would they do it 46. A nurse is assessing a client who is currently taking thioridazine. Which of the following findings should the nurse identify as extrapyramidal symptoms. a. Urinary retention, diarrhea, and excessive sweating b. Drooling, involuntary arm movements and akathisia c. Decrease level of consciousness, urinary retention and involuntary movements of neck and head d. Hallucinations, urinary retention and diarrhea 47. A nurse is caring for a client who has schizophrenia and exhibits a lack of grooming and a flat affect along with anergia. The nurse should anticipate a prescription of which of the following medications. a. Thiothixene (Navane) b. Venlafaxine (Effexor) c. Chlorpromazine (Thorazine) d. Risperidone (Risperdal) 48. The use of appropriate communication to address hallucinations and delusions is imperative in order to work effectively with the client. Choose the best approach when dealing with these a. Attempt to focus conversations on reality based subjects b. Inform the client that he is bing “ridiculous” and he needs to focus on something that is real c. Move the client to an area where he can be alone and limit all communication with other staff and clients d. Informs the client in a very authoritative manner that he needs to stop thinking and focus on pleasant things that are real 49. Neuroleptic malignant syndrome is a serious and frequently fatal condition seen in those being treated with antipsychotic medications. It is characterized by the following symptoms a. Muscle rigidity, high fever, increase muscle enzymes and leukocytes b. Loss of consciousness, diaphoresis and diarrhea c. Akathesia, muscle rigidity, and agranulocytosis d. Seizures, loss of consciousness and low WBC count 50. Which instruction has priority when teaching a client taking clozapine (CLozaril) a. Report any signs and diarrhea and profuse sweating b. Report sore throat and fever immediately c. Reduce and limit the foods that are high in tyramine d. Avoid the sun and unprotected sex 51. All of the following are possible nursing diagnoses identified for a client with schizophrenia. The student nurse correctly anticipates which diagnosis will resolve when the client negative symptoms improve a. Risk for other directed violence b. Impaired verbal communication c. Social isolation d. Disturbed thought process 52. The nurse is preparing a client with schizophrenia for discharge. The nurse asks the client, “how are you going to care for yourself at home.”. The purpose of the question a. Self concept b. Social support system c. Insight d. Judgment 53. A client asks the nurse upon discharge, what to do if “I forget to take a dose of my medicine”. The nurse should explain to the client which of the following a. Educate the client to skip the dose and resume your regular dose the next time it is due b. Educate the client not to miss any doses or you will not maintain therapeutic drug levels c. Educate the client that if he remembers within 3-4 hours later than it is due, take it then. If her remembers more than 4 hours after it is due, do not take that dose d. Educate the client to double the dose next time the medication is scheduled 54. A client with schizophrenia is admitted to the inpatient behavioral health unit. He does not speak when spoken to but has been observed talking to himself on occasion. What outcome be at this time a. The client will increase his reality orientation b. The client will increase his socialization with others c. The client will express his feeling freely d. The client will begin talking to other clients 55. A highly suspicious client who has delusions of persecution about being poisoned has refused all meals for the past 2 days. Which of the following interventions would be most appropriate circumstance a. Fed the client via a feeding tube, and obtain a court order if needed b. Offer to taste each food item on the tray yourself while the client watches you c. Allow the client to contact a local restaurant and have the food delivered d. Provide individual packaged food and allow the client to open the food in front of you, prior to eating the food 56. The client is having auditory hallucinations telling him that he is ugly and fat. What would be the priority nursing diagnoses for this client a. Disturbed personal identity b. Disturbed sensory perception c. Impaired verbal communication d. Disturbed thought processes 57. A client received maintenance doses of fluphenazine deaconate (Prolixin Decononate) 25mg IM every 2 weeks for 2 years. The clinic nurse notes the client is grimacing her lips. On the next clinic visit, the client’s neck and shoulders twist in a slow, snakelike motion. The nurse should suspect the presence of and is a. Anticholinergic effects…consult the physician about possible medication changes b. Agranulocytosis…check the client complete blood count for changes c. Tourette’s syndrome…consult the clients physician about a neuron evaluation d. Tardive dyskinesia…administer the abnormal involuntary movement scale 58. A client is moving from chair to chair in the day room and pacing in the hallway repeatedly, rapidly and for extended periods is likely demonstrating what symptoms a. Anxiety b. A dystonic reaction c. Akathisia d. Tardive dyskinesia 59. A client recently diagnosed with schizophrenia has stabilized and is about to be discharge from the acute care facility. He will be living with his family, but the family knows nothing about its treatment, or the roll they play in his recovery. Which activity would be the most beneficial for the family to attend a. Psychoanalytic group b. Individual counseling c. Psychoeducational group d. Family therapy 60. A client with schizophrenia tells the nurse, “Everyone must listen to me. I am the redeemer. I will bring peace to this world.” From this the nurse can determine that an appropriate diagnosis is a. Social isolation b. Disturbed sensory perception c. Risk for suicide d. Disturbed though processes 61. A client who has schizophrenia is having a conversation with the nurse suddenly stops talking in the middle of a sentence. The client is experiencing which type of though disruption a. Thought broadcasting b. Thought withdrawal c. Thought blocking d. Thought insertion 62. The nurse is assessing for negative symptoms in a newly admitted client who has been diagnosed with schizophrenia. Which behavior is indicative of a negative symptoms a. Difficulty staying on subject when responding to assessment questions b. Mimicking the postural change made by the nurse during the assessment interview c. Belief of owning a transportation device allowing for travel to the center of the earth d. Hesitant to answer the nurses questions during the assessment interview 63. Somatic delusions are generally vague and unrealistic beliefs about the clients healthy or bodily functions a. True b. False 64. Nihilistic delusions are ideas of reference that involve the clients belief that television broadcasts, music or newspaper articles have special meaning to him or her a. True b. False 65. When the nurse is working with a client that is having delusions, the nurse must be careful to support and challenge the delusions. a. True b. False 66. Currently, the most prominent neurochemical theories of schizophrenia involve dopamine and serotonin a. True b. False 67. Catatonia is characterized by marked psychomotor disturbances, either excessive motor activity or virtual immobility and motionlessness a. True b. False 68. Clozapine (Clozaril) can dramatically rescue psychomotor symptoms and eliminate most of the negative symptoms of schizophrenia a. True b. False 69. The following is a list of positive symptoms that are characteristic of schizophrenia a. Disordered thinking, poor-problem solving and ability and difficulty concentrating b. Delusions, hallucinations, and bizarre behavior c. Anergia, alogis and avolition d. Hopelessness, low self esteem and risk for violence 70. Negative symptoms that are present in clients with schizophrenia is manifested in the following symptoms a. Long term memory deficits, suicidal ideation and hopelessness b. Affect, alogia, anergia, anhedonia, and avolition c. Inability to make decisions, difficulty concentrating, and low self esteem d. Alterations in speech, disordered thinking and hallucinations 71. Schizoaffective disorder is characterized by what 2 disorders a. Schizophrenia and delusional disorder b. Schizophrenia and depressive or bipolar disorder c. Schizophrenia and psychosis d. Schizophrenia and impairments of personality (Self and interpersonal) 72. The following is a list of the standardized screening tools that may be used in diagnosing and treating clients with schizophrenia. Choose the most appropriate tools that are used with schizophrenia. a. The axis #4, the delusion disorder assessment tool, and the cognitive/affective disorder rating scale b. Hamilton rating scale, the Houston hallucination rating scale, and the AIMS c. The global assessment of functioning (GAF), scale for assessment of negative symptoms, brief psychiatric rating scale (BPRS) d. Cognitive rating scale, the hallucinations/delusions review tool, and the affective symptom assessment tool 73. Choose the best answer that describes what information should be included in health teaching for the client with schizophrenia a. Understanding the disease process, how to monitor for sign and symptoms of reactions of meds with food groups-especially MAOI’s and methods to prevent addiction to antipsychotics b. Understanding the reason and prevention of schizophrenia, management of the medications and prevention of addiction to antipsychotics, exercise prevention due to extreme fatigue and weakness c. Case management of the disorder, the need for proper enrollment of a drug program for high costs of medications and home exercise program d. Understanding the disorder, need for self care to prevent relapse and medications-effects, adverse effects, and importance of compliance 74. A client has been admitted to a behavioral health unit and states that he believes the FBI is here on the unit and they want to put a chip into him so they can monitor him and if they come near him he will throw a chair or table at them. What would be the priority nursing diagnosis be for this client a. Risk for other directed violence b. Deficient diversional activity c. Ineffective health maintenance d. Impaired verbal communication 75. The following is use of words or phrases that are flowery, excessive and pompous a. Verbigeration b. Stilted language c. Echolalia d. Preservation 76. Alogia is poverty of content-described as the lack of any real meaning or substance in what the client says a. True b. False 77. The most common type of hallucination is a. Kinesthetic b. Visual c. auditory d. tactile 78. extrapyramidal side effects are reversible movement disorders induced by neuroleptic medication. They include the following: a. dystonic reactions, parkinsonism and akathisia b. neuropathy, altered consciousness and tardive dyskinesia c. muscle rigidity, high fever and increase muscle enzymes d. seizures, altered consciousness and dysphoria 79. individual and group therapy sessions are often supportive in nature. Choose the best answers that describes what other benefits may result from attending these groups. (Select all that Apply) a. Focus on topics of concern such as medication management, use of community supports, and family concerns b. Social skill training and cognitive adaptation training c. Opportunity for social contact and meaningful relationships with other people d. Religious involvement and community relationships and how to adapt to the environment 80. Conventional antipsychotics are use to treat mainly positive psychotic symptoms. The following medications are used to treat these symptoms, choose the medications that are in a. Risperidone (Risperdal), Ziprasidone (Geodon), and Clozapine (Clozaril) b. Paroxetine (Paxil), Lorazepam (Ativan), and Clanazepam (Klonopin) c. Olanzapint (Zyprexa), Quetiapine (Seroquel), and Aripiprazole (Abilify) d. Haloperidol (Haldol), Chlorpromazine (Thorazine), and Fluphenazine (Prolixin) 81. Atypical antipsychotics are current medications of choice for psychotic disorders and they treat both positive and negative symptoms a. True b. False 82. To minimize weight gain advise the client to do the following: (Mark all that apply) a. Chew gum-to keep moisture in mouth b. Follow a healthy, low-calorie diet c. Engage in regular exercise d. Choose foods low in tyramine 83. A nurse is completing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms a. Auditory hallucination b. Flat affect c. Lack of motivation-avolition d. Delusions of persecution e. Bizarre behavior-taking clothes off in public f. Use of clang associations 84. A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization a. I feel monsters pinching me all over b. I know that you are stealing my thoughts c. I am no one, and everyone is me d. I am a superhero and immortal 85. A nurse is providing discharge teaching for a client who has schizophrenia and a new prescription for iloperidone (Fanapt). Which of the following client statements indicates … a. If I feel drowsy during the day, I will stop taking this medication and call my provider b. I will be careful not to gain too much weight while taking this medication c. I will be able to stop taking this medication as soon as I feel better d. This medication is highly addictive and must be withdrawn slowly 86. Neuroleptic malignant syndrome is more common with the typical than the atypical antipsychotics a. True b. False 87. PACT is a program of case management that takes a team approach in providing comprehensive, community-based psychiatric treatment to clients with a serious and persistent a. True b. False 88. New onset of diabetes mellitus or loss of glucose control in clients who have diabetes is an adverse effect from some of the atypical antipsychotics a. True b. False 89. The client who hesitates 30 seconds or longer before responding to any question is described as having which one of the following a. Latency of response b. Paranoid delusions c. Poverty of speech 90. The overall goal of psychiatric rehabilitation is for the client to gain which one of the following a. Control of aggressiveness and violence type symptoms b. Freedom from hospitalizations c. Management of anxiety d. Recovery from the illness 91. Clients taking which of the following type of psychotropic medications need close monitoring of their cardiac status a. Antidepressants b. Stimulants c. Antiparkinsons d. Antipsychotics 92. According to the textbook, Videbeck, two antipsychotics are available in depot injection form, choose the correct medications a. Moban and Clozaril b. Navane and Stelazine c. Mellaril and Serentil d. Prolixin and Haldol 93. The analysis of assessment data generally falls into two main categories: data associated with the positive signs of the disease. Choose which nursing diagnoses is commonly based on the assessment of psychotic symptoms or positive signs. (Mark all that apply) a. Disturbed though processes b. Social isolation c. Disturbed sensory perception d. Self care deficit e. Impaired verbal communication 94. Clients who are left alone for long periods of time become more deeply involved in their psychosis, so frequent contact and time spent with the client are important even if the nurse is unsure that the client is aware of the nurses presence a. True b. False 95. The AIMS tool is used to screen for symptoms of what a. Seizure disorders b. Agranuolcyosis c. Movement disorders d. Cognitive recognition