VATI PN Mental Health Assessment Final Exam –
2025/2026 Edition – Real Exam Questions with 100%
Verified Correct Answers
A nurse is assisting with the care of a client immediately following electroconvulsive therapy
(ECT). Which of the following findings should the nurse document as an unexpected response to
the procedure? - CORRECT ANSWER-Irregular heart rhythm
An irregular heart rhythm is an unexpected response to ECT. During the procedure, the client's
heart can be stressed, which can cause cardiac abnormalities. especially if the client already has
impaired cardiac function. The nurse should document this finding and notify the charge nurse
or the client's provider.
A nurse is caring for a client who says, "I quit taking my lithium. I did not like the way I felt on
that drug." Which of the following responses should the nurse make? - CORRECT ANSWER-
"How do you feel when you take the medication?"
encouraging the client to describe their perception of the medication's adverse effects. This is a
therapeutic communication technique in which the nurse asks an open-ended question to
obtain further information from the client. The nurse is also
A nurse is discussing confidentiality with a client who was just admitted to an acute mental
health unit. Which of the following client statements indicates an understanding of the
teaching? - CORRECT ANSWER-"You have to report it if I threaten to hurt anyone.
The nurse has a legal and ethical obligation to maintain a client's confidentiality. The client's
confidential information is protected by HIPAA. However, there are exceptions to this rule,
including the duty to warn and the reporting of abuse. If a client states that they have the intent
to harm any individual, the nurse has the legal obligation to ensure that the person who was
threatened is notified of this threat so necessary protective actions can be taken.
, A nurse is caring for a client who is experiencing acute alcohol withdrawal. The client becomes
agitated, and the nurse administers lorazepam 2 mg IM. Which of the following actions should
the nurse take? - CORRECT ANSWER-Ensure a staff member remains with the client
continuously.
The client needs continuous evaluation and observation during the acute alcohol withdrawal
phase due to the risk for harm to themselves or others.
A nurse is caring for a client who recently experienced a traumatic event. The nurse should
identify that which of the following is an example of the client using repression as a defense
mechanism? - CORRECT ANSWER-The client reports not being able to remember anything
about the event.
The nurse should identify the use of repression as a defense mechanism when the client reports
not being able to remember anything about a traumatic event after it occurs. Repression is the
unconscious process of blocking unpleasant or traumatic memories to avoid addressing the
emotions associated with them.
A nurse is caring for a client who has schizophrenia. The client is refusing to participate in the
current group activity. Which of the following statements should the nurse make? - CORRECT
ANSWER-"You do not have to participate right now if you don't feel comfortable."
Clients who have schizophrenia often have difficulty interacting with others. The nurse should
allow the client to observe the group until they feel comfortable participating. This response by
the nurse is therapeutic because it indicates acceptance of the client's feelings.
A nurse is caring for a client who is admitted for alcohol use disorder. The client states, "I have
not had anything to drink for 24 hours." Which the following is the priority nursing
intervention? - CORRECT ANSWER-Check the client's vital signs.
2025/2026 Edition – Real Exam Questions with 100%
Verified Correct Answers
A nurse is assisting with the care of a client immediately following electroconvulsive therapy
(ECT). Which of the following findings should the nurse document as an unexpected response to
the procedure? - CORRECT ANSWER-Irregular heart rhythm
An irregular heart rhythm is an unexpected response to ECT. During the procedure, the client's
heart can be stressed, which can cause cardiac abnormalities. especially if the client already has
impaired cardiac function. The nurse should document this finding and notify the charge nurse
or the client's provider.
A nurse is caring for a client who says, "I quit taking my lithium. I did not like the way I felt on
that drug." Which of the following responses should the nurse make? - CORRECT ANSWER-
"How do you feel when you take the medication?"
encouraging the client to describe their perception of the medication's adverse effects. This is a
therapeutic communication technique in which the nurse asks an open-ended question to
obtain further information from the client. The nurse is also
A nurse is discussing confidentiality with a client who was just admitted to an acute mental
health unit. Which of the following client statements indicates an understanding of the
teaching? - CORRECT ANSWER-"You have to report it if I threaten to hurt anyone.
The nurse has a legal and ethical obligation to maintain a client's confidentiality. The client's
confidential information is protected by HIPAA. However, there are exceptions to this rule,
including the duty to warn and the reporting of abuse. If a client states that they have the intent
to harm any individual, the nurse has the legal obligation to ensure that the person who was
threatened is notified of this threat so necessary protective actions can be taken.
, A nurse is caring for a client who is experiencing acute alcohol withdrawal. The client becomes
agitated, and the nurse administers lorazepam 2 mg IM. Which of the following actions should
the nurse take? - CORRECT ANSWER-Ensure a staff member remains with the client
continuously.
The client needs continuous evaluation and observation during the acute alcohol withdrawal
phase due to the risk for harm to themselves or others.
A nurse is caring for a client who recently experienced a traumatic event. The nurse should
identify that which of the following is an example of the client using repression as a defense
mechanism? - CORRECT ANSWER-The client reports not being able to remember anything
about the event.
The nurse should identify the use of repression as a defense mechanism when the client reports
not being able to remember anything about a traumatic event after it occurs. Repression is the
unconscious process of blocking unpleasant or traumatic memories to avoid addressing the
emotions associated with them.
A nurse is caring for a client who has schizophrenia. The client is refusing to participate in the
current group activity. Which of the following statements should the nurse make? - CORRECT
ANSWER-"You do not have to participate right now if you don't feel comfortable."
Clients who have schizophrenia often have difficulty interacting with others. The nurse should
allow the client to observe the group until they feel comfortable participating. This response by
the nurse is therapeutic because it indicates acceptance of the client's feelings.
A nurse is caring for a client who is admitted for alcohol use disorder. The client states, "I have
not had anything to drink for 24 hours." Which the following is the priority nursing
intervention? - CORRECT ANSWER-Check the client's vital signs.
