2019 ATI Mental Health Proctored Exam With Answers-218 Solved Questions

ATI MENTAL HEALTH PROCTORED EXAM 2019 WITH
NGN QUESTIONS AND VERIFIED
SOLUTIONS / A+ GRADE UPDATED

1. A client is fearful of driving and enters a behavioral therapy program to help him
overcome his anxiety. Using systematic desensitization, he is able to drive down a familiar
street without experiencing a panic attack. The nurse should recognize that to continue
positive results, the client should participate in which of the following?
a. Biofeedback
b. Relaxation techniques
c. Cognitive restructuring
d. Positive reinforcement
Answer: d. Positive reinforcement
2. A nurse is counseling a client following the death of the client’s partner 8 months ago.
Which of the following client statements indicates maladaptive grieving?
a. “I feel like I can't go on without my partner.”
b. “I cry every day and can't seem to stop.”
c. “I have trouble sleeping and have no appetite.”
d. “I still don’t feel up to returning to work.”
Answer: d. “I still don’t feel up to returning to work.”
3. A nurse in an inpatient mental health facility is assessing a client who has schizophrenia
and is taking haloperidol (antipsychotic, 1st gen). Which of the following clinical findings is
the nurse’s priority?
a. Weight gain
b. Constipation
c. Hand tremors
d. High fever (Complication: agranulocytosis)

Answer: d. High fever (Complication: agranulocytosis)
4. A nurse is planning care for a client who has obsessive compulsive disorder. Which of the
following recommendations should the nurse include in the client’s plan of care?
a. Aversion therapy
b. Flooding therapy
c. Thought Stopping
d. Relaxation therapy
Answer: c. Thought Stopping
5. A nurse is providing teaching to the daughter of an older client who has obsessivecompulsive disorder. Which of the following statements by the daughter indicates an
understanding of the teaching?
a. “I will insist that my mother perform her rituals every day.”
b. “I will limit my mother’s clothing choices when she is getting dressed.”
c. “I will avoid discussing my mother’s obsessions with her.”
d. “I will join my mother in her rituals to show support.”
Answer: b. “I will limit my mother’s clothing choices when she is getting dressed.”
6. A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the
following actions should the nurse take?
a. Engage in a debate with the client to redirect their energy
b. Provide a structured environment with minimal stimulation
c. Avoid power struggles by remaining neutral
d. Encourage the client to make decisions independently
Answer: c. Avoid power struggles by remaining neutral
7. A nurse is providing behavioral therapy for a client who has OCD. The client repeatedly
checks that the doors are locked at night. Which of the following instructions should the
nurse give the client when using thought stopping technique?
a. “Repeat a calming phrase when you think about checking the locks.”

b. “Use deep breathing exercises when you think about checking the locks.”
c. “Visualize a peaceful place when you think about checking the locks.”
d. “Snap a rubber band on your wrist when you think about checking the locks.”
Answer: d. “Snap a rubber band on your wrist when you think about checking the locks.”
8. A nurse is caring for a client who has a cocaine use disorder. Which of the following
manifestations should the nurse expect the client to have during withdrawal?
a. Increased energy
b. Fatigue
c. Euphoria
d. Dilated pupils
Answer: b. Fatigue
9. A nurse is reviewing the medical record of a client who is taking clozapine. For which of
the following findings should the nurse withhold the medication and notify the provider?
a. WBC
b. Blood glucose level
c. Liver function tests
d. Serum electrolytes
Answer: a. WBC
10. A nurse is creating a plan of care for a client who has major depressive disorder. Which
of the following interventions should the nurse include in the plan?
a. Encourage the client to isolate themselves to rest
b. Encourage physical activity for the client during the day
c. Provide high-calorie foods to increase energy levels
d. Allow the client to make decisions regarding their care
Answer: b. Encourage physical activity for the client during the day
11. A nurse is assessing a client who is experiencing acute alcohol withdrawal. Which of the
following findings should the nurse expect?

a. Bradycardia
b. Hypotension
c. Insomnia
d. Constipation
Answer: c. Insomnia
12. A nurse is caring for a client who has schizophrenia and displays severe symptoms of the
disorder. Which of the following actions should the nurse take?
a. Provide frequent, lengthy explanations to the client
b. Assign a staff member to monitor the client's every move
c. Allow the client to refuse medication and treatment
d. Direct the client to perform her own daily hygiene and grooming tasks
Answer: d. Direct the client to perform her own daily hygiene and grooming tasks
13. A nurse is caring for a client who was involuntarily committed and is scheduled to
receive electroconvulsive therapy. The client refuses the treatment and will discuss why with
the healthcare team. Which of the following actions should the nurse take?
a. Document the client’s refusal of the treatment in the medication record
b. Convince the client of the importance of the treatment
c. Restrain the client to administer the treatment
d. Inform the client that refusal of the treatment is not an option
Answer: a. Document the client’s refusal of the treatment in the medication record
14. A nurse is providing crisis intervention for a client who was involved in a violent mass
casualty situation in the community. Which of the following actions should the nurse take
during the initial session with the client?
a. Identify the client’s usual coping style
b. Encourage the client to avoid discussing the event
c. Provide detailed information about the event
d. Discuss long-term goals with the client
Answer: a. Identify the client’s usual coping style

15. A nurse in the emergency department is caring for a client who reports feeling sad,
worthless, and hopeless 9 months after the death of her son. Which of the following actions
should the nurse take first?
a. Offer the client a tissue and ask her to describe her feelings
b. Provide the client with a list of grief support groups in the area
c. Assess the client's risk for self-harm or suicide
d. Ask the client if she has thought about harming herself
Answer: c. Assess the client's risk for self-harm or suicide
16. A nurse is planning care for an adolescent who has autism spectrum disorder. Which of
the following outcomes should the nurse include in the plan of care?
a. Verbally express feelings of anxiety
b. Initiate physical contact with peers
c. Initiate social interactions with caregiver
d. Maintain eye contact during conversations
Answer: c. Initiate social interactions with caregiver
17. A nurse is caring for a client who is experiencing active auditory hallucinations. Which
of the following should the nurse take?
a. Provide a quiet environment for the client
b. Encourage the client to verbalize the hallucinations
c. Acknowledge the client's experience as real
d. Focus the client on reality-based activities
Answer: d. Focus the client on reality-based activities
18. A nurse is conducting an admission interview with a client who is experiencing mania.
Which of the following findings should the nurse report to the provider?
a. Reports eating twice in the past week
b. Difficulty falling asleep at night
c. Talks rapidly and jumps from topic to topic

d. Has not bathed in 2 days
Answer: d. Has not bathed in 2 days
19. A nurse is caring for a client who has anorexia nervosa. Which of the following findings
requires immediate intervention by the nurse?
a. Reports feeling cold all the time
b. Refuses to eat meals with others
c. +2 edema of the lower extremities
d. Heart rate of 50 bpm
Answer: c. +2 edema of the lower extremities
20. A nurse is planning care for a client who has a recent diagnosis of antisocial personality
disorder. Which of the following outcomes should the nurse include in the care plan?
a. The client treats others with respect
b. The client demonstrates empathy toward others
c. The client follows rules and regulations
d. The client seeks out opportunities for group therapy
Answer: a. The client treats others with respect
21. A nurse is caring for a client who is prescribed massage therapy to treat panic disorder.
The client states “I can't stand to be touched by another person”. Which of the following
response should the nurse make?
a. "Let's try the massage therapy anyway; it might help."
b. "You should really give the massage therapy a chance; it's part of your treatment plan."
c. "I will let your provider know that you would like a treatment other than massage."
d. "Why don't you try a different form of massage therapy?"
Answer: c. "I will let your provider know that you would like a treatment other than
massage."

22. A nurse in a group home facility is caring for a client who is developmentally disabled.
The client has been stealing belongings from the other clients. Which of the following
techniques should the nurse use?
a. Negative reinforcement
b. Positive reinforcement
c. Punishment
d. Extinction
Answer: b. Positive reinforcement
23. A nurse in a mental facility is caring for a newly admitted client. Which of the following
resources should the nurse recommend to help the client adapt to the healthcare setting?
a. A Community meeting
b. Individual therapy
c. Group therapy
d. Medication management
Answer: a. A Community meeting
24. A nurse is teaching the caregiver of a client who has advanced Alzheimer’s disease about
home safety. Which of the following statements by the caregiver indicates an understanding
of the teaching?
a. "I will install locks on the outside of the doors to prevent wandering."
b. "I will place a sliding bolt lock just above the doorknob."
c. "I will keep the house well-lit to prevent falls."
d. "I will leave the stove on low heat to keep food warm."
Answer: b. "I will place a sliding bolt lock just above the doorknob."
25. A nurse is beginning a therapeutic relationship with a client. The nurse should plan to
accomplish which of the following tasks during the working phase?
a. Establish trust and rapport
b. Evaluate progress toward predetermined goals
c. Explore and understand the client's thoughts and feelings

d. Set goals and develop a plan of action
Answer: b. Evaluate progress toward predetermined goals
26. A nurse is planning care for a client who has anorexia nervosa and is admitted to an
inpatient eating disorder unit. Which of the following is an appropriate intervention?
a. Encourage the client to eat quickly to ensure an adequate intake of food.
b. Monitor the client's weight daily to track progress.
c. Initiate a relationship built on trust with the client.
d. Provide the client with a list of "good" and "bad" foods to help with meal planning.
Answer: c. Initiate a relationship built on trust with the client.
27. A nurse is providing discharge teaching about manifestations of relapse to the family of a
client who has schizophrenia. Which of the following information should the nurse include
in the teaching?
a. The client develops an inability to concentrate.
b. The client experiences increased appetite.
c. The client exhibits improved sleep patterns.
d. The client demonstrates increased interest in social activities.
Answer: a. The client develops an inability to concentrate.
28. A nurse in a mental health facility is caring for a client. Which of the following actions
should the nurse take during the working phase of the nurse-client relationship?
a. Establish trust and rapport with the client.
b. Set boundaries with the client.
c. Promote problem-solving skills.
d. Encourage the client to express feelings.
Answer: c. Promote problem-solving skills.
29. A nurse is planning care for a client who has dementia. Which of the following
interventions should the nurse include in the plan?
a. Encourage the client to participate in activities that require complex thought processes.

b. Provide the client with a detailed schedule of daily activities.
c. Limit the client's access to familiar environments to prevent confusion.
d. Provide finger food to enhance caloric intake.
Answer: d. Provide finger food to enhance caloric intake.
30. A nurse is developing a teaching plan for the family of an older adult client who is to
receive transcranial magnetic stimulation. Which of the following information should the
nurse include in the teaching plans?
a. The client might have a headache after treatment.
b. The client will need to remain completely still during the procedure.
c. The client will need to avoid eating or drinking before the procedure.
d. The client may experience a tingling sensation at the site of the electromagnet.
Answer: a. The client might have a headache after treatment.
31. A nurse overhears a client saying, “I am a spy, a spy for the FBI. I am an I, an eye for an
eye, an eye in the sky. Sky is up high.” The nurse should document the client’s statement as
which of the following speech alterations?
a. Clang association
b. Word salad
c. Echolalia
d. Neologism
Answer: a. Clang association
32. A nurse is assessing a client who has neuroleptic malignant syndrome. Which of the
following clinical findings should the nurse expect?
a. Bradycardia
b. Temperature 40°C (104°F)
c. Hypotension
d. Muscle rigidity
Answer: b. Temperature 40°C (104°F)

33. A nurse in an acute care mental health facility is planning discharge care for a client who
sustained a traumatic brain injury. For which of the following needs should the nurse
collaborate with a clinical psychologist?
a. The client needs to begin a group therapy program prior to discharge
b. The client requires assistance with activities of daily living
c. The client needs education on medication management
d. The client needs a referral to a vocational rehabilitation program
Answer: a. The client needs to begin a group therapy program prior to discharge
34. A nurse is caring for a client who reports that he is angry with his partner because she is
thinking he is just trying to gain attention. When the nurse attempts to talk to the client, he
becomes angry and tells her to leave. Which of the following defense mechanisms is the
client demonstrating?
a. Rationalization
b. Displacement
c. Projection
d. Reaction formation
Answer: b. Displacement
35. A nurse is teaching a client who has schizophrenia about her new prescription for
risperidone. Which of the following statements should be included in the teaching?
a. You should discontinue this medication if you develop muscle rigidity
b. You may experience weight loss as a side effect of this medication
c. You should avoid grapefruit juice while taking this medication
d. You should take this medication with food to minimize gastrointestinal upset
Answer: a. You should discontinue this medication if you develop muscle rigidity
36. A nurse is talking to a client following a group therapy session. The client tells the nurse
that one of the other clients in the group made an inappropriate comment. Which of the
following responses should the nurse make?
a. "You sound upset about today’s session."

b. "Let’s focus on your feelings about what happened."
c. "It’s important to remember that everyone has their own perspective."
d. "You should confront the other client about their behavior."
Answer: a. "You sound upset about today’s session."
37. A nurse is reviewing the laboratory report of a client who is taking carbamazepine for
bipolar disorder. Which of the following laboratory results should the nurse report to the
provider?
a. Sodium 140 mEq/L
b. Platelets 90,000/mm³
c. Hemoglobin 14 g/dL
d. Potassium 4.2 mEq/L
Answer: b. Platelets 90,000/mm³
38. A nurse is providing teaching about disorder management for a client who has PTSD.
Which of the following statements should the nurse include in the teaching?
a. "Avoid discussing the traumatic event to prevent re-traumatization."
b. "Engage in activities that keep your mind off the traumatic experience."
c. "Talking about the traumatic experience is recommended."
d. "Try to suppress your thoughts and feelings related to the traumatic event."
Answer: c. "Talking about the traumatic experience is recommended."
39. A nurse is providing teaching about disulfiram to a client who has a history of alcohol
use. Which of the following instructions should the nurse include in the teaching?
a. "You will need to take the medication once daily."
b. "You should take the medication only when you feel the urge to drink."
c. "You should avoid using mouthwash that contains alcohol."
d. "You can safely drink alcohol in moderation while taking this medication."
Answer: a. "You will need to take the medication once daily."
c. "You should avoid using mouthwash that contains alcohol."

40. A nurse in a mental health facility is making plans for a client's discharge. Which of the
following interdisciplinary team members should the nurse contact to assist the client with
housing placement?
a. Social worker
b. Physical therapist
c. Occupational therapist
d. Speech therapist
Answer: a. Social worker
41. A nurse is providing teaching to a client who has depressive disorder and a new
prescription for doxepin. Which of the following instructions should the nurse include in the
teaching?
a. "Take the medication with a glass of grapefruit juice."
b. "Sit on the side of the bed for a few minutes before standing."
c. "Avoid taking the medication with food to enhance absorption."
d. "Take the medication immediately before bedtime."
Answer: b. "Sit on the side of the bed for a few minutes before standing."
42. A nurse is caring for a client who has borderline personality disorder and has been
engaging in self-mutilation. The nurse should encourage the client to participate in which of
the following groups?
a. Alcoholics Anonymous
b. Narcotics Anonymous
c. Substance Abuse Counseling
d. Dialectical Behavior Therapy
Answer: d. Dialectical Behavior Therapy
43. A nurse is caring for a client following a physical assault. The client states, “I don't
remember what happened to me.” The nurse should recognize that the client is using which
of the following defense mechanisms?
a. Projection

b. Repression
c. Rationalization
d. Displacement
Answer: b. Repression
44. A nurse is preparing to administer haloperidol 7mg IM to a client who is severely
agitated. Available is haloperidol injection 5mg/mL. How many mL should the nurse
administer?
Answer: 1.4 mL
Calculation: 7 mg / 5 mg/mL = 1.4 mL
45. A charge nurse is discussing the care of a client who has a substance use disorder with a
staff nurse. Which of the following statements by the staff nurse should the charge nurse
identify as countertransference?
a. "The client is just like my brother who finally overcame his habit."
b. "I feel like we're making progress with this client."
c. "I understand how difficult this must be for the client."
d. "I think we need to explore other treatment options for this client."
Answer: a. "The client is just like my brother who finally overcame his habit."
46. A nurse is teaching a client who has a new prescription for phenelzine to treat depression.
The nurse instructs the client to avoid foods with tyramine to prevent which of the
following?
a. Hypothyroidism
b. Hypertensive crisis
c. Hyperkalemia
d. Hyperglycemia
Answer: b. Hypertensive crisis
47. A nurse is caring for a client who has a personality disorder and is using transference to
cope. Which of the following behaviors should the nurse expect?

a. Displacement of emotions onto the nurse
b. Reaction to the nurse as though she were his mother
c. Projection of personal feelings onto the nurse
d. Identification with the nurse's role
Answer: b. Reaction to the nurse as though she were his mother
48. A nurse is admitting a client who has generalized anxiety disorder. Which of the
following actions should the nurse plan to take first?
a. Determine how the client handles stress
b. Ask the client to identify her strengths
c. Provide the client with a quiet environment
d. Teach the client to use guided imagery
Answer: a. Determine how the client handles stress
49. A nurse is teaching a client who has bipolar disorder and a new prescription for lithium
carbonate. Which of the following statements by the client indicates an understanding of the
teaching?
a. I will take the medication with food to avoid stomach upset
b. I will avoid foods high in tyramine to prevent a hypertensive crisis
c. I will call my doctor if I have a headache
d. I will call my doctor if I have diarrhea
Answer: d. I will call my doctor if I have diarrhea
50. A nurse is caring for a client who is experiencing a panic attack. Which of the following
actions should the nurse take?
a. Place the client in seclusion
b. Encourage the client to use deep breathing techniques
c. Instruct the client to breathe into a paper bag
d. Administer a sedative medication as ordered
Answer: b. Encourage the client to use deep breathing techniques

51. A nurse is caring for a client who is starting treatment for substance use disorder. Which
of the following actions indicates the nurse is practicing the ethical principle of
nonmaleficence?
a. Encouraging the client to attend a support group
b. Withholding a prescribed medication that is causing adverse effects for the client
c. Educating the client about potential triggers for substance use
d. Administering a lower dose of medication to minimize side effects
Answer: b. Withholding a prescribed medication that is causing adverse effects for the client
52. A nurse is caring for a client who has just returned to the unit after receiving
electroconvulsive therapy treatments. Which of the following assessments is the nurse’s
priority?
a. Level of orientation
b. Blood pressure
c. Oxygen saturation
d. Presence of gag reflex
Answer: d. Presence of gag reflex
53. A nurse in the emergency department is counseling a client who reports experiencing
intimate partner violence. Which of the following actions should the nurse take?
a. Request permission from the client to take photographs of the injuries.
b. Offer to help the client escape from the partner the next time violence occurs
c. Determine what the client did to trigger the violent incident.
d. Tell the client that staying with the partner shows a lack of judgment.
Answer: a. Request permission from the client to take photographs of the injuries.
54. A nurse is reviewing the medication administration record of a client who has
schizophrenia. The nurse should plan to initiate the abnormal involuntary movement scale to
monitor for adverse effects of which of the following medications?
a. Amantadine
b. Benztropine

c. Diphenhydramine
d. Haloperidol
Answer: d. Haloperidol
55. A nurse is planning overall strategies to address problems for a client who has borderline
personality disorder. Which of the following strategies is the priority for the nurse to
incorporate in the plan of care?
a. Encourage the client to participate in group therapy
b. Establish a schedule for regular physical activity
c. Implement measures to prevent intentional self-inflicted injury
d. Provide education about healthy relationships
Answer: c. Implement measures to prevent intentional self-inflicted injury
56. A nurse is obtaining a medical history from a client who is requesting a prescription for
bupropion for smoking cessation. Which of the following assessment findings in the client’s
history should the nurse report to the provider?
a. History of seasonal affective disorder
b. History of depression
c. Recent head injury
d. Recent weight gain
Answer: c. Recent head injury
57. A nurse is caring for a client who has bipolar disorder and is experiencing a manic
episode. Which of the following actions should the nurse take?
a. Encourage the client to join group activities
b. Provide the client with high-calorie snacks
c. Dim the lights in the client’s room
d. Allow the client to choose his own schedule
Answer: c. Dim the lights in the client’s room

58. A nurse is caring for a client who is admitted to a mental health facility after attempting
suicide. Which of the following actions should the nurse take first?
a. Implement continuous one to one observation
b. Develop a safety plan with the client
c. Encourage the client to attend group therapy
d. Administer prescribed antidepressant medications
Answer: a. Implement continuous one to one observation
59. A nurse in an outpatient clinic is assessing a client who has anorexia nervosa. Which of
the following findings indicates the need for hospitalization?
a. Temperature 35.6°C (96.1°F)
b. Weight 10% below ideal body weight
c. Pulse rate 54/min
d. Blood pressure 100/60 mm Hg
Answer: a. Temperature 35.6°C (96.1°F)
60. A nurse is providing teaching for a newly licensed nurse about the constructive use of
defense mechanisms. Which of the following examples should the nurse include in the
teaching?
a. A client who is angry with his roommate punches a pillow
b. A client who is afraid of heights avoids elevators
c. A client who is stressed starts smoking
d. A student who is upset with her teacher writes a story about an excellent student
Answer: d. A student who is upset with her teacher writes a story about an excellent student
61. A nurse is caring for a client who has a prescription for phenelzine. The nurse should
instruct the client to avoid which of the following over-the-counter medications?
a. Acetaminophen
b. Calcium carbonate
c. Docusate sodium
d. Pseudoephedrine

Answer: d. Pseudoephedrine
62. An older adult client is brought to the mental health clinic by her daughter. The daughter
reports that her mother is not eating and seems uninterested in routine activities. The
daughter states, “I’m so worried that my mother is depressed.” Which of the following
responses should the nurse make?
a. “Tell me the reasons you think your mother is depressed.”
b. “You shouldn’t worry so much. These things happen.”
c. “It’s not unusual for someone your mother’s age to be a little blue.”
d. “Your mother might be right. Older adults often get depressed.”
Answer: a. “Tell me the reasons you think your mother is depressed.”
63. A nurse is planning care for a newly admitted client who has anorexia nervosa. Which of
the following interventions should the nurse include in the plan?
a. Allow the client to eat at her own pace
b. Let the client choose her own meals
c. Notify the client about designated times for meals
d. Weigh the client daily after meals
Answer: c. Notify the client about designated times for meals
64. A nurse in a community health facility is interviewing a client who recently lost his job.
The client states “I was fired because my boss doesn't like me.” Which of the following
defense mechanisms is the client displaying?
a. Denial
b. Rationalization
c. Projection
d. Displacement
Answer: b. Rationalization

65. A nurse in an alcohol treatment facility is caring for a client who states, “My job is so
stressful that the only way I can cope is to drink.“ The nurse should recognize that the client
is displaying which of the following defense mechanisms?
a. Denial
b. Regression
c. Rationalization
d. Projection
Answer: c. Rationalization
66. A nurse is providing counseling for a family that consists of two parents and their two
adolescent children. Which of the following family members should the nurse identify as
acting in the role of monopolizer?
a. The father who tries to avoid conflict
b. The mother who does not express her opinion
c. The adolescent son who is passive during the discussion
d. The adolescent daughter who attempts to dominate the discussion
Answer: d. The adolescent daughter who attempts to dominate the discussion
67. A nurse is caring for a client in a mental health facility. The client is agitated and
threatens to harm herself and others. Which of the following is the nurse’s priority
intervention?
a. Offer the client a quiet place to calm down
b. Administer prescribed medication for agitation
c. Call for assistance from other staff members
d. Set limits on the client’s behavior
Answer: d. Set limits on the client’s behavior
68. A nurse is assessing a client who has bipolar disorder and is taking lamotrigine. Which of
the following findings is the nurse’s priority?
a. Blurred vision
b. Headache

c. Nausea
d. Skin rash
Answer: d. Skin rash
69. A nurse is assessing a young adult female client for schizophrenia. Which of the
following findings should the nurse identify as a risk factor for this condition?
a. Family history of diabetes
b. Environmental stress
c. Personal history of depression
d. History of substance abuse
Answer: b. Environmental stress
70. A nurse is caring for a client in an inpatient mental health facility. The client tells the
nurse that the government is reading her mail. Which of the following responses should the
nurse make?
a. “That is not true. The government is not reading your mail.”
b. “Why do you think the government is reading your mail?”
c. “It must be frightening to think that someone is reading your mail.”
d. “Let’s talk about something other than the government.”
Answer: c. “It must be frightening to think that someone is reading your mail.”
71. A nurse is assessing a client who is restless and constantly mutters to himself. Which of
the following findings should lead the nurse to suspect delirium?
a. The client’s speech is clear and coherent
b. The client is oriented to person, place, and time
c. The client’s manifestations developed suddenly
d. The client’s symptoms improve with distraction
Answer: c. The client’s manifestations developed suddenly
72. A nurse is leading a crisis intervention group for adolescents who witnessed the suicide
of a classmate. Which of the following actions should the nurse take first?

a. Encourage group discussion about the suicide
b. Teach the adolescents about the stages of grief
c. Help the adolescents create a memory book
d. Identify prior coping skills
Answer: d. Identify prior coping skills
73. A nurse is providing crisis intervention for a client who was involved in a violent mass
casualty situation in the community. Which of the following actions should the nurse take
during the initial session with the client?
a. Identify the client’s usual coping style
b. Establish rapport with the client
c. Encourage the client to express feelings
d. Develop a long-term treatment plan
Answer: a. Identify the client’s usual coping style
74. A nurse is caring for a client who has borderline personality disorder. Which of the
following outcomes should the nurse include in the treatment plan?
a. The client will adhere to medication regimen
b. The client will verbalize improved mood
c. The client will participate in group therapy sessions
d. The client will practice effective communication skills
Answer: b. The client will verbalize improved mood
75. A nurse is assisting with obtaining informed consent for a client who has been deemed
legally incompetent. Which of the following actions should the nurse take?
a. Explain implied consent to the client’s family
b. Contact the facility social worker to obtain the consent
c. Request that the client’s guardian sign the consent
d. Ask the charge nurse to obtain informed consent
Answer: c. Request that the client’s guardian sign the consent
Rationale:

Client who has been judged incompetent has a temporary or permanent guardian appointed
by the court. The guardian can sign the informed consent for the client.
SINGLE QUESTIONS
76. A nurse in a community health center is working with a group of clients who have
posttraumatic stress disorder. Which of the following interventions should the nurse include
to reduce anxiety among the group members?
a. Massage therapy
b. Guided imagery
c. Music therapy
d. Group exercise
Answer: b. Guided imagery
77. A client who has a recent diagnosis of bipolar disorder is placed in a room with a client
who has severe depression. The client who has depression reports to the nurse, "My
roommate never sleeps and keeps me up, too." Which of the following actions should the
nurse take?
a. Offer the client who has depression a sleep aid
b. Provide earplugs for the client who has depression
c. Move the client who has bipolar disorder to a private room
d. Allow the client who has depression to stay in a different room for sleep
Answer: c. Move the client who has bipolar disorder to a private room
78. A nurse is reviewing laboratory results for a client who has schizophrenia and is taking
clozapine. Which of the following values should the nurse identify as a contraindication for
receiving clozapine?
a. Serum potassium 4.2 mEq/L
b. Blood glucose 110 mg/dL
c. WBC count 2,500/mm3
d. Platelet count 200,000/mm3

Answer: c. WBC count 2,500/mm3
79. A nurse is caring for four clients in the emergency department. The nurse should identify
which of the following clients can give informed consent?
a. A 35-year-old client who has major depressive disorder
b. A 17-year-old client who is experiencing alcohol withdrawal
c. A 20-year-old client who has schizophrenia and is disoriented to place and time
d. A 28-year-old client who has a traumatic brain injury and is receiving oxygen
Answer: a. A 35-year-old client who has major depressive disorder
80. A nurse is facilitating a community meeting for acute care clients. One client is
constantly talking and using the majority of the group's time. Which of the following
interventions should the nurse implement?
a. Politely ask the client to be quiet and listen to others
b. Ignore the client's behavior and continue with the meeting
c. Redirect the client's focus to the agenda topics
d. Ask group members to discuss their feelings about the client's monopolizing behavior
Answer: d. Ask group members to discuss their feelings about the client's monopolizing
behavior
81. A nurse in a community health center teaching families of clients who have posttraumatic
stress disorder about expected clinical manifestations. Which of the following manifestations
should the nurse include?
a. Experiences feelings of isolation
b. Exhibits rapid speech
c. Demonstrates increased appetite
d. Engages in risky behaviors
Answer: a. Experiences feelings of isolation
82. A nurse is preparing to administer diazepam 7.5 MG 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 10th. Use a leading zero if it applies. Do not
use a trailing zero.)
a. 1.5
b. 0.5
c. 2.0
d. 1.0
Answer: a. 1.5
83. A nurse is planning prevention strategies for partner violence in the community. Which
of the following strategies should the nurse include as a method of secondary prevention?
a. Educating adolescents about healthy relationships
b. Establishing screening programs to identify at-risk clients
c. Providing counseling services to individuals who have experienced violence
d. Creating awareness campaigns about the effects of violence on families
Answer: b. Establishing screening programs to identify at-risk clients
84. A nurse is assessing a client for risk factors for the development of depression. The nurse
should identify that which of the following factors places the client at increased risk for
depression?
a. The client has COPD
b. The client practices regular physical exercise
c. The client has a strong social support system
d. The client consumes a balanced diet
Answer: a. The client has COPD
85. A nurse is preparing to discharge to home an older adult client who attempted suicide.
The client lives alone and has difficulty performing activities of daily living. Which of the
following referrals should the nurse initiate? (Select all that apply.)
a. Occupational therapy
b. Meal delivery services
c. Physical therapy

d. Home health services
Answer: a. Occupational therapy
b. Meal delivery services
c. Physical therapy
d. Home health services
86. A nurse is caring for a school-aged child who has conduct disorder and is being
physically aggressive toward other children in the unit. Which of the following actions
should the nurse take first?
a. Place the child in seclusion
b. Administer a PRN antipsychotic medication
c. Notify the child's parents
d. Initiate a group therapy session
Answer: a. Place the child in seclusion
87. A nurse is caring for a client who has a new diagnosis of bulimia nervosa. Which of the
following diagnosis procedures should the nurse anticipate the provider should describe
during the medical evaluation?
a. ECG
b. MRI
c. PET scan
d. EEG
Answer: d. ECG
88. A nurse is caring for a client who exhibits excessive compliance, passivity, and selfdenial. The nurse should recognize that these findings are associated with which of the
following personality disorders?
a. Narcissistic
b. Borderline
c. Antisocial
d. Dependent

Answer: d. Dependent
89. A nurse is caring for a client who is involuntarily admitted for major depressive disorder
and refuses to take prescribed antianxiety medication. Which of the following actions should
the nurse take?
a. Administer the medication by force
b. Offer the client the medication at the next scheduled dose time
c. Request a prescription for a different medication
d. Document the refusal in the client's chart
Answer: b. Offer the client the medication at the next scheduled dose time
90. A nurse is caring for a client in the emergency department who states she was beaten and
sexually assaulted by her partner. After a rapid assessment, which of the following actions
should the nurse plan to take next?
a. Offer prophylactic medication to prevent STI’s
b. Collect forensic evidence
c. Notify the police
d. Provide emotional support
Answer: a. Offer prophylactic medication to prevent STI’s
91. A nurse is caring for a client who has major depressive disorder. After discussing the
treatment with his partner, the client verbally agrees to electroconvulsive therapy (ECT) but
will not sign the consent form. Which of the following actions should the nurse take?
a. Proceed with the ECT without the signed consent form
b. Obtain a court order for the ECT
c. Encourage the client to reconsider and sign the form
d. Cancel the scheduled ECT procedure
Answer: d. Cancel the scheduled ECT procedure
92. A nurse is caring for a client who reports that he is angry with his partner because she
thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he

becomes angry and tells her to leave. Which of the following defense mechanisms is the
client demonstrating?
a. Regression
b. Reaction formation
c. Rationalization
d. Displacement
Answer: d. Displacement
93. A nurse is advising an assistive personnel (AP) on the care of a client who has major
depressive disorder. The AP states that he is irritated by the client’s depression. Which of the
following statements by the nurse is appropriate?
a. "You should try to ignore the client’s behavior."
b. "It’s important that the client feel safe verbalizing how she is feeling."
c. "You should tell the client to stop being so negative."
d. "Why do you feel irritated by the client’s depression?"
Answer: b. "It’s important that the client feel safe verbalizing how she is feeling."
94. A charge nurse is discussing mental status exams with a newly licensed nurse. Which of
the following statements by the newly licensed nurse indicates an understanding of the
teaching? (Select all that apply)
a. "To assess cognitive ability, I should ask the client to count backward by sevens."
b. "To assess affect, I should observe the client's facial expression."
c. "To assess language ability, I should instruct the client to write a sentence."
d. "To assess insight, I should ask the client to explain the purpose of a common object."
Answer: a. "To assess cognitive ability, I should ask the client to count backward by
sevens."
b. "To assess affect, I should observe the client's facial expression."
c. "To assess language ability, I should instruct the client to write a sentence."
95. A nurse is planning care for a client who has a mental health disorder. Which of the
following actions should the nurse include as a psychobiological intervention?

a. Teach the client relaxation techniques.
b. Monitor the client for adverse effects of the medications.
c. Assist the client with problem-solving skills.
d. Encourage the client to attend group therapy sessions.
Answer: b. Monitor the client for adverse effects of the medications.
96. A nurse in an outpatient mental health clinic is preparing to conduct an initial client
interview. When conducting the interview, which of the following actions should the nurse
identify as the priority?
a. Determine the client's support system.
b. Identify the client's perception of her mental health status.
c. Establish a plan for ongoing care.
d. Review the client's medical history.
Answer: b. Identify the client's perception of her mental health status.
97. A nurse is told during change of shift report that a client is stuporous. When assessing the
client, which of the following findings should the nurse expect?
a. The client is combative.
b. The client has increased muscle tone.
c. The client arouses briefly in response to a sternal rub.
d. The client is unable to move purposefully.
Answer: c. The client arouses briefly in response to a sternal rub.
98. A nurse is teaching a client with schizophrenia about her new prescription for
risperidone. Which of the following statements should the nurse include in the teaching?
a. "You will experience weight loss while taking this medication."
b. "This medication will cure your schizophrenia."
c. "You should take this medication with food to avoid stomach upset."
d. "You may experience immediate relief of your symptoms after taking this medication."
Answer: c. "You should take this medication with food to avoid stomach upset."

99. A nurse is admitting a client who has generalized anxiety disorder. Which of the
following actions should the nurse plan to take first?
a. Provide the client with a quiet environment.
b. Assess the client's current anxiety level.
c. Teach the client relaxation techniques.
d. Administer an anxiolytic medication as prescribed.
Answer: a. Provide the client with a quiet environment.
100. A nurse is conducting an admission interview with a client who is experiencing mania.
Which of the following findings should the nurse report to the provider?
a. Reports feeling restless.
b. Reports eating twice in the past week.
c. Exhibits pressured speech.
d. Demonstrates inflated self-esteem.
Answer: b. Reports eating twice in the past week.
101. A nurse is planning care for a client who has OCD. Which of the following
recommendations should the nurse include in the client's plan of care?
a. Encourage the client to avoid situations that trigger obsessions.
b. Teach the client thought stopping.
c. Instruct the client to perform rituals more quickly to save time.
d. Advise the client to resist engaging in compulsive behaviors.
Answer: b. Teach the client thought stopping.
102. A nurse is caring for a client who has bipolar disorder and is experiencing a manic
episode. Which of the following actions should the nurse take?
a. Provide the client with a quiet environment.
b. Dim the lights in the client's room.
c. Encourage the client to engage in physical activity.
d. Offer the client high-calorie snacks.
Answer: b. Dim the lights in the client's room.

103. A nurse is leading a crisis intervention group for adolescents who witnessed the suicide
of a classmate. Which of the following actions should the nurse take first?
a. Provide education about the stages of grief.
b. Encourage the adolescents to express their feelings.
c. Identify prior coping skills.
d. Refer the adolescents to individual therapy.
Answer: c. Identify prior coping skills.
104. A nurse overhears a client saying, "I am a spy, a spy for the FBI. I am an I, an eye for an
eye, an eye in the sky. Sky is up high." The nurse should document the client's statement as
which of the following speech alterations?
a. Echolalia
b. Flight of ideas
c. Neologism
d. Clang association
Answer: d. Clang association
105. A nurse is talking with a group of parents who have recently experienced the death of a
child. Which of the following actions should the nurse take?
a. Provide each parent with a list of local therapists.
b. Encourage the parents to focus on their other children.
c. Suggest forming a weekly support group for parents who have experienced the death of a
child.
d. Offer the parents information about grief stages.
Answer: c. Suggest forming a weekly support group for parents who have experienced the
death of a child.
106. A nurse in a community health center is working with a group of clients who have posttraumatic stress disorder. Which of the following interventions should the nurse include to
reduce anxiety among the group members?

a. Deep breathing exercises
b. Guided imagery
c. Cognitive restructuring
d. Progressive muscle relaxation
Answer: b. Guided imagery
107. A nurse is planning care for a client who is to undergo electroconvulsive therapy (ECT).
Which of the following actions should the nurse include in the plan?
a. Administer a sedative prior to the procedure.
b. Monitor the client's cardiac rhythm during the procedure.
c. Encourage the client to eat a heavy meal before the procedure.
d. Provide the client with a full explanation of the procedure immediately before it begins.
Answer: b. Monitor the client's cardiac rhythm during the procedure.
108. A nurse is planning prevention strategies for partner violence in the community. Which
of the following strategies should the nurse include as a method of secondary prevention?
a. Providing counseling services for victims of partner violence.
b. Establishing screening programs to identify at-risk clients.
c. Educating the community about the warning signs of partner violence.
d. Offering anger management classes for individuals at risk of perpetrating partner violence.
Answer: b. Establish screening programs to identify at-risk clients.
109. A nurse in a mental health facility is caring for a client who has schizophrenia. Which
of the following findings places the client at greater risk for self-directed injury or injuring
others?
a. Social withdrawal
b. Flat affect
c. Command hallucinations
d. Loose associations
Answer: c. Command hallucinations

110. A nurse is planning a peer group discussion about the DSM-5. Which of the following
information is appropriate to include in the discussion? (Select all that apply)
a. The DSM-5 is a classification system for mental health disorders.
b. The DSM-5 establishes diagnostic criteria for individual mental health disorders.
c. The DSM-5 provides information on the prevalence of mental health disorders.
d. The DSM-5 assists nurses in planning care for clients who have mental health disorders.
e. The DSM-5 indicates expected assessment findings of mental health disorders.
Answer: b. The DSM-5 establishes diagnostic criteria for individual mental health disorders.
d. The DSM-5 assists nurses in planning care for clients who have mental health disorders.
e. The DSM-5 indicates expected assessment findings of mental health disorders.
111. A nurse in an emergency mental health facility is caring for a group of clients. The nurse
should identify which of the following clients requires a temporary emergency admission?
a. A client who has schizophrenia and is experiencing auditory hallucinations.
b. A client who has major depressive disorder and is expressing suicidal ideation.
c. A client who has borderline personality disorder and assaulted a homeless man with a
metal rod.
d. A client who has bipolar disorder and is experiencing a manic episode.
Answer: c. A client who has borderline personality disorder and assaulted a homeless man
with a metal rod.
112. A nurse is teaching a client who has a depressive disorder about fluoxetine. Which of
the following information should the nurse include in the teaching?
a. "You may experience an increase in appetite while taking this medication."
b. "This medication will improve your mood immediately."
c. "You should take this medication on an empty stomach."
d. "You may experience a decreased sex drive while taking this medication."
Answer: d. "You may experience a decreased sex drive while taking this medication."
113. A nurse is teaching a client about adverse effects of zolpidem. Which of the following
adverse effects should the nurse include in the teaching?

a. Insomnia
b. Weight gain
c. Daytime sleepiness
d. Increased appetite
Answer: c. Daytime sleepiness
114. A nurse is assessing a client who is taking bupropion. The nurse should recognize which
of the following findings as an indication that the medication is effective?
a. Increased anxiety
b. Increased urge to smoke
c. Increased appetite
d. Decreased urge to smoke
Answer: d. Decreased urge to smoke
115. A nurse is preparing to administer benztropine 2 mg IM every 12 hr to a client who is
experiencing an extrapyramidal reaction. Available is 1 mg/mL. How many milliliters should
the nurse administer?
a. 0.5 mL
b. 1 mL
c. 1.5 mL
d. 2 mL
Answer: d. 2 mL
116. A nurse is providing discharge teaching to a client with a new prescription for
phenelzine. The nurse should instruct the client to avoid which of the following foods when
taking this medication?
a. Bananas
b. Spinach
c. Salami
d. Oranges
Answer: c. Salami

117. A nurse is teaching a client who has bipolar disorder about lithium. Which of the
following statements should the nurse include in the teaching?
a. "You may experience weight gain while taking lithium."
b. "You should limit your fluid intake while taking lithium."
c. "Notify your provider if you experience vomiting or diarrhea."
d. "You should take lithium with food to prevent stomach upset."
Answer: c. "Notify your provider if you experience vomiting or diarrhea."
118. A nurse is preparing to administer fluoxetine 40 mg PO daily. The amount available is
fluoxetine 20 mg/5 mL. How many milliliters should the nurse administer?
a. 5 mL
b. 10 mL
c. 15 mL
d. 20 mL
Answer: 10 mL
119. A nurse is caring for a client who has generalized anxiety disorder and is taking
buspirone. Which of the following adverse effects should the nurse report to the provider?
a. Dry mouth
b. Dizziness
c. Nausea
d. Sweating
Answer: d. Sweating
120. A nurse is providing discharge teaching to a client who has bipolar disorder and will be
discharged with a prescription for lithium. The nurse should teach the client which of the
following factors puts her at risk for lithium toxicity?
a. The client drinks 2 liters of water daily
b. The client eats a low-sodium diet
c. The client runs 4 miles outdoors every afternoon

d. The client takes a daily multivitamin
Answer: c. The client runs 4 miles outdoors every afternoon
121. A nurse is developing a plan of care for a client who has a depressive disorder and is
taking amitriptyline. Which of the following actions should the nurse include in the plan of
care?
a. Monitor for signs of lithium toxicity.
b. Teach the client about the importance of a low-tyramine diet.
c. Assess the client's blood pressure regularly.
d. Weigh the client weekly.
Answer: d. Weigh the client weekly.
122. A nurse is planning care for a client who is scheduled to receive ECT. Which of the
following medications should the nurse anticipate administering prior to the procedure?
a. Lorazepam
b. Naloxone
c. Atropine
d. Haloperidol
Answer: c. Atropine
123. A nurse in the emergency department is planning care for a client who is admitted for an
overdose of phencyclidine. Which of the following actions should the nurse plan to take?
a. Administer ammonium chloride.
b. Monitor for signs of serotonin syndrome.
c. Prepare to administer naloxone.
d. Monitor for signs of malignant hyperthermia.
Answer: a. Administer ammonium chloride.
124. A nurse is reinforcing teaching with an older adult client who has major depressive
disorder and a prescription for nortriptyline 25 mg daily. Which of the following client
statements indicates understanding of the teaching?

a. "I should take this medication on an empty stomach."
b. "I should increase my fluid intake while taking this medication."
c. "I should avoid foods that are high in tyramine."
d. "I should sit on the side of the bed before standing up in the morning."
Answer: d. "I should sit on the side of the bed before standing up in the morning."
125. A nurse decides to put a client who has a psychotic disorder in seclusion overnight
because the unit is very short-staffed, and the client frequently fights with other clients. The
nurse's actions are an example of which of the following torts?
a. Assault
b. False imprisonment
c. Battery
d. Invasion of privacy
Answer: b. False imprisonment
126. A client tells a nurse, "Don't tell anyone but I hid a sharp knife under my mattress in
order to protect myself from my roommate, who is always yelling at me and threatening
me." Which of the following actions should the nurse take?
a. Promise the client not to tell anyone about the knife
b. Advise the client to confront the roommate about the behavior
c. Ignore the client's statement
d. Report the incident to the health care team, but do not inform the client
Answer: d. Report the incident to the health care team, but do not inform the client
127. A nurse is caring for a client who is in mechanical restraints. Which of the following
statements should the nurse include in the documentation? (Select all that apply)
a. "Client slept for 6 hours during the night."
b. "Client was offered 8 oz of water every hr."
c. "Client shouted obscenities at assistive personnel."
d. "Client received chlorpromazine 15 mg by mouth at 1000."
Answer: b. "Client was offered 8 oz of water every hr."

c. "Client shouted obscenities at assistive personnel."
d. "Client received chlorpromazine 15 mg by mouth at 1000."
128. A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway
with another nurse. Which of the following actions should the nurse take first?
a. Report the incident to the charge nurse
b. Tell the nurse to stop discussing the behavior
c. Document the incident in the client's chart
d. Ask the nurse to explain the hallucinations in more detail
Answer: b. Tell the nurse to stop discussing the behavior
129. A nurse is caring for the parents of a child who has demonstrated changes in behavior
and mood. When the mother of the child asks the nurse for reassurance about her son's
condition, which of the following responses should the nurse make?
a. "I'm sure everything will be fine. Try not to worry."
b. "I can't discuss the details of your son's condition."
c. "You shouldn't worry about your son's condition right now."
d. "I understand you're concerned. Let's discuss what concerns you specifically."
Answer: d. "I understand you're concerned. Let's discuss what concerns you specifically."
130. A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm
coughing because I have that cold that everyone has been getting." The nurse should identify
that the client is using which of the following defense mechanisms?
a. Projection
b. Denial
c. Rationalization
d. Sublimation
Answer: b. Denial
131. A nurse is providing preoperative teaching for a client who was just informed that she
requires emergency surgery. The client has a respiratory rate of 30/min and says, "This is

difficult to comprehend. I feel shaky and nervous." The nurse should identify that the client
is experiencing which of the following levels of anxiety?
a. Mild
b. Moderate
c. Severe
d. Panic
Answer: b. Moderate
132. A nurse is caring for a client who is experiencing moderate anxiety. Which of the
following actions should the nurse take when trying to give necessary information to the
client? (Select all that apply.)
a. Provide detailed instructions for the client to follow.
b. Discuss prior use of coping mechanisms with the client.
c. Use medical jargon to ensure the client understands the seriousness of the situation.
d. Demonstrate a calm manner while using simple and clear directions.
Answer: b. Discuss prior use of coping mechanisms with the client.
d. Demonstrate a calm manner while using simple and clear directions.
133. A nurse is talking with a client who is at risk for suicide following the death of his
spouse. Which of the following statements should the nurse make?
a. "You should try to stay strong for your family."
b. "I know how you feel. I lost someone close to me once too."
c. "Losing someone close to you must be very upsetting."
d. "Have you considered seeking counseling for your grief?"
Answer: c. "Losing someone close to you must be very upsetting."
134. A charge nurse is discussing the characteristics of a nurse-client relationship with a
newly licensed nurse. Which of the following characteristics should the nurse include in the
discussion? (Select all that apply)
a. It is casual and informal.
b. It involves mutual sharing of personal information.

c. It is goal-directed.
d. Behavioral change is encouraged.
e. A termination date is established.
Answer: c. It is goal-directed.
d. Behavioral change is encouraged.
e. A termination date is established.
135. A nurse is in the working phase of a therapeutic relationship with a client who has
methamphetamine use disorder. Which of the following actions?
a. The client asks the nurse for advice on how to manage his cravings for methamphetamine.
b. The client accuses the nurse of telling him what to do just like his ex-girlfriend.
c. The client expresses frustration with the limitations of the treatment program.
d. The client discusses his plans for managing triggers for methamphetamine use.
Answer: b. The client accuses the nurse of telling him what to do just like his ex-girlfriend.
136. A nurse is caring for a client who is starting treatment for substance use disorder. Which
of the following actions indicate the nurse is practicing the ethical principle of
nonmaleficence?
a. Providing the client with accurate information about the risks and benefits of treatment.
b. Encouraging the client to participate in group therapy sessions.
c. Withholding the prescribed medication that is causing adverse effects for the client.
d. Assisting the client in developing a relapse prevention plan.
Answer: c. Withholding the prescribed medication that is causing adverse effects for the
client.
137. A nurse in a group home facility is caring for a client who is developmentally disabled.
The client has been stealing belongings from other clients. Which of the following
techniques should the nurse use?
a. Negative reinforcement to decrease undesired behavior.
b. Punishment to decrease undesired behavior.
c. Positive reinforcement to increase desired behavior.

d. Extinction to decrease undesired behavior.
Answer: c. Positive reinforcement to increase desired behavior.
138. A nurse is caring for a client who is experiencing a panic attack. Which of the following
actions should the nurse take?
a. Encourage the client to talk about the source of anxiety.
b. Provide distractions to shift the client's focus away from the panic.
c. Offer reassurance that everything will be fine.
d. Have the client breathe into a paper bag.
Answer: d. Have the client breathe into a paper bag.
139. The nurse is caring for a client following a physical assault. The client states "I don't
remember what happened to me." The nurse should recognize that the client is using which
of the following defense mechanisms?
a. Projection
b. Displacement
c. Rationalization
d. Repression
Answer: d. Repression
140. A nurse is providing behavior therapy for a client who has obsessive-compulsive
disorder. The client repeatedly checks that the doors are locked at night. Which of the
following instructions should the nurse give the client when using thought stopping
technique?
a. Count to 10 whenever you go to check the locks.
b. Replace the thought of checking the locks with a pleasant image.
c. Focus on abdominal breathing whenever you go to check the locks.
d. Snap a rubber band on your wrist when you think about checking the locks.
Answer: d. Snap a rubber band on your wrist when you think about checking the locks.

141. A nurse is admitting a client who has generalized anxiety disorder. Which of the
following actions should the nurse plan to take first?
a. Provide the client with a quiet environment.
b. Administer a PRN dose of lorazepam (Ativan).
c. Offer the client a high-protein diet.
d. Encourage the client to participate in group therapy.
Answer: a. Provide the client with a quiet environment.
142. A nurse is caring for a client whose child has a terminal illness. The client requests
information about how to deal with the upcoming loss. Which of the following statements
should the nurse make?
a. "It is not uncommon to feel angry toward yourself or others."
b. "You should focus on the positive memories you have with your child."
c. "Try to stay busy to distract yourself from your feelings."
d. "Avoid discussing your feelings with others to prevent further sadness."
Answer: a. "It is not uncommon to feel angry toward yourself or others."
143. A nurse is teaching a client who has bipolar disorder and a prescription for lithium.
Which of the following instructions should the nurse include in the teaching?
a. "Take this medication with food."
b. "You should avoid drinking any fluids while taking this medication."
c. "Take this medication only when you feel a mood swing coming on."
d. "You can stop taking this medication once you feel better."
Answer: a. "Take this medication with food."
144. A nurse is planning care for four clients in a mental health facility. Which of the
following clients is at the greatest risk for injury when performing ADLs?
a. A client who has severe Alzheimer's disease.
b. A client who has schizophrenia and is experiencing auditory hallucinations.
c. A client who has major depressive disorder and is refusing to eat.

d. A client who has borderline personality disorder and is engaging in self-harming
behaviors.
Answer: a. A client who has severe Alzheimer's disease.
145. A nurse is updating the plan of care for a client who has bulimia nervosa and is 5%
above his ideal body weight. Which of the following interventions should the nurse include
in the plan?
a. Identify the client's trigger foods.
b. Encourage the client to skip meals to reduce calorie intake.
c. Monitor the client's weight daily.
d. Teach the client about the health risks associated with bulimia nervosa.
Answer: a. Identify the client's trigger foods.
146. A nurse who works with newborns is assessing the potential for abuse or neglect. Which
of the following family groups should the nurse identify as the highest potential for future
child abuse?
a. A family where one or both parents witnessed intimate partner violence in the home as
children.
b. A family where both parents are highly educated and financially stable.
c. A family where the grandparents live with the parents and newborn.
d. A family where the parents have a strong support network of friends and relatives.
Answer: a. A family where one or both parents witnessed intimate partner violence in the
home as children.
147. A nurse is performing an admission assessment on a client and notices that the client
appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the
following actions should the nurse take first?
a. Inform the client that her admission is confidential.
b. Ask the client to sign a consent form for treatment.
c. Offer the client a snack or beverage.
d. Introduce the client to the other members of the healthcare team.

Answer: a. Inform the client that her admission is confidential.
148. A nurse is caring for four clients in an inpatient mental health facility. Which of the
following clients can give informed consent?
a. A 35-year-old client who has major depressive disorder.
b. A 16-year-old client who is admitted for treatment of anorexia nervosa.
c. A 50-year-old client who is experiencing a manic episode.
d. A 72-year-old client with dementia who is admitted for behavioral disturbances.
Answer: a. A 35-year-old client who has major depressive disorder.
149. 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
I'm going to bed!" The nurse should document the client's speech pattern as which of the
following?
a. Echolalia
b. Neologism
c. Clang association
d. Loose association
Answer: c. Clang association
150. A nurse is educating the parent of a child who has a new diagnosis of autism spectrum
disorder. Which of the following manifestations of this disorder should the nurse include in
the teaching?
a. Hyperactivity
b. Language delay
c. Impaired social skills
d. Intense focus on one topic
Answer: b. Language delay
151. A nurse in a mental health unit is admitting a client who is anxious because he often
hears voices telling him what to do. Which of the following actions should the nurse take?

a. Offer the client a quiet environment
b. Ask the client what the voices are saying
c. Administer an antianxiety medication
d. Place the client in seclusion
Answer: b. Ask the client what the voices are saying
152. A nurse is caring for an older adult client who begins to cry and states, "I knew God
would punish me and I deserve this horrible sickness!" Which of the following responses
should the nurse make?
a. "Let's talk about what is upsetting you."
b. "Why do you feel this way?"
c. "God does not punish people with sickness."
d. "You must have done something wrong to feel this way."
Answer: a. "Let's talk about what is upsetting you."
153. A nurse is talking with a client who is beginning chemotherapy. The client tells the
nurse that she is mourning the loss of her hair. Which of the following actions should the
nurse take first?
a. Discuss the importance of hair with the client.
b. Reassure the client that her hair will grow back after treatment.
c. Offer the client a wig or other head covering.
d. Acknowledge the client's feelings about losing her hair.
Answer: d. Acknowledge the client's feelings about losing her hair.
154. 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 laboratory
findings should the nurse report to the provider?
a. Sodium level 125 mEq/L
b. Blood glucose level 110 mg/dL
c. Potassium level 4.0 mEq/L
d. BUN level 20 mg/dL

Answer: a. Sodium level 125 mEq/L
155. A nurse in an emergency department is caring for an 18-month-old toddler who has a
fractured left femur. Which of the following statements by the toddler's parent should cause
the nurse to suspect child abuse?
a. "I didn't see how it happened, but I found him crying in his crib."
b. "He fell down the stairs while playing with his older sibling."
c. "I noticed a bruise on his arm a few days ago, but I thought it was from rough play."
d. "He just started walking, so I'm not surprised he fell and hurt himself."
Answer: c. "I noticed a bruise on his arm a few days ago, but I thought it was from rough
play."
156. A client is fearful of driving and enters a behavioral therapy program to help him
overcome his anxiety. Using systematic desensitization, he is able to drive down a familiar
street without experiencing a panic attack. The nurse should recognize that to continue
positive results, the client should participate in which of the following?
a. Guided imagery
b. Assertiveness training
c. Role-playing
d. Biofeedback
Answer: d. Biofeedback
157. A nurse is counseling a client following the death of the client's partner 8 months ago.
Which of the following client statements indicates maladaptive grieving?
a. "I have started attending a support group."
b. "I find comfort in looking at photos of us together."
c. "I talk to my partner's picture every night."
d. "I still don't feel up to returning to work."
Answer: d. "I still don't feel up to returning to work."

158. A nurse in an inpatient mental health facility is assessing a client who has schizophrenia
and is taking haloperidol (antipsychotic, 1st gen). Which of the following clinical findings is
the nurse's priority?
a. Dry mouth
b. Constipation
c. Drowsiness
d. High fever
Answer: d. High fever
159. A nurse is providing teaching to the daughter of an older client who has obsessivecompulsive disorder. Which of the following statements by the daughter indicates an
understanding of the teaching?
a. "I will encourage my mother to resist her rituals."
b. "I will limit my mother's exposure to situations that trigger her rituals."
c. "I will discourage my mother from discussing her obsessions."
d. "I will limit my mother's clothing choices when she is getting dressed."
Answer: d. "I will limit my mother's clothing choices when she is getting dressed."
160. A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the
following actions should the nurse take?
a. Provide a structured environment
b. Encourage socialization with peers
c. Provide unlimited access to stimulating activities
d. Avoid power struggles by remaining neutral
Answer: d. Avoid power struggles by remaining neutral
161. A nurse is caring for a client who has a cocaine use disorder. Which of the following
manifestations should the nurse expect the client to have during withdrawal?
a. Euphoria
b. Fatigue
c. Increased appetite

d. Decreased heart rate
Answer: b. Fatigue
162. A nurse is reviewing the medical record of a client who is taking clozapine. For which
of the following findings should the nurse withhold the medication and notify the provider?
a. Blood pressure 140/90 mm Hg
b. WBC count 3,000/mm3
c. Hemoglobin 14 g/dL
d. Blood glucose 110 mg/dL
Answer: b. WBC count
163. A nurse is creating a plan of care for a client who has major depressive disorder. Which
of the following interventions should the nurse include in the plan?
a. Limit the client's access to visitors
b. Encourage physical activity for the client during the day
c. Provide frequent opportunities for the client to be alone
d. Encourage the client to make decisions for others
Answer: b. Encourage physical activity for the client during the day
164. A nurse in a group home facility is caring for a client who is developmentally disabled.
The client has been stealing belongings from other clients. Which of the following
techniques should the nurse use?
a. Negative reinforcement to decrease undesired behavior
b. Positive reinforcement to increase desired behavior
c. Punishment to decrease undesired behavior
d. Extinction to decrease undesired behavior
Answer: b. Positive reinforcement to increase desired behavior
165. A nurse is caring for a client who is experiencing a panic attack. Which of the following
actions should the nurse take?
a. Have the client breathe into a paper bag

b. Offer the client a glass of cold water
c. Instruct the client to take deep breaths
d. Provide a quiet environment for the client
Answer: c. Instruct the client to take deep breaths
166. The nurse is caring for a client following a physical assault. The client states "I don't
remember what happened to me." The nurse should recognize that the client is using which
of the following defense mechanisms?
a. Regression
b. Suppression
c. Repression
d. Rationalization
Answer: c. Repression
167. A nurse is teaching a client who has schizophrenia about her new prescription for
risperidone. Which of the following statements should the nurse include in the teaching?
a. You should continue this medication if you develop muscle rigidity.
b. You should expect to see improvement in your symptoms within 24 hours.
c. You should discontinue this medication if you experience weight gain.
d. You should avoid taking this medication with food.
Answer: a. You should continue this medication if you develop muscle rigidity.
168. A nurse is planning care for an adolescent who has autism spectrum disorder. Which of
the following outcomes should the nurse include in the plan care?
a. Maintains eye contact during interactions with others.
b. Initiates social interactions with caregivers.
c. Verbalizes the importance of personal space.
d. Demonstrates the ability to interpret figurative language.
Answer: b. Initiates social interactions with caregivers.

169. A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the
following interventions should the nurse include in the plan?
a. Encourage the client to eat three large meals per day.
b. Provide the client with a list of low-calorie foods.
c. Allow the client to select menu items based on their caloric content.
d. Encourage the client to participate in family therapy.
Answer: d. Encourage the client to participate in family therapy.
170. A school nurse is caring for an adolescent client whose teacher reports changes in
school performance and withdrawal from interaction with classmates. Which of the
following interventions is the nurse's priority at this time?
a. Contact the adolescent's parents.
b. Determine when the adolescent's change in behavior began.
c. Meet with the adolescent privately to discuss the concerns.
d. Refer the adolescent to a mental health professional for evaluation.
Answer: a. Contact the adolescent's parents.
171. A nurse is assessing a client who is withdrawing from heroin. Which of the following
manifestations should the nurse expect?
a. Increased appetite
b. Slurred speech
c. Bradycardia
d. Hypotension
Answer: b. Slurred speech
172. A nurse is assessing a client who has histrionic personality disorder. Which of the
following findings should the nurse expect?
a. Social withdrawal
b. Attention seeking
c. Perfectionism
d. Fear of abandonment

Answer: b. Attention seeking
173. A nurse is providing teaching to the daughter of an older client who has obsessivecompulsive disorder. Which of the following statements by the daughter indicates an
understanding of the disorder?
a. I will limit my mother's clothing choices when she is getting dressed.
b. I will encourage my mother to spend more time on her rituals to feel better.
c. I will avoid discussing my mother's obsessions and compulsions with her.
d. I will participate in my mother's rituals to help her feel more comfortable.
Answer: a. I will limit my mother's clothing choices when she is getting dressed.
174. A nurse in a mental health facility is caring for a client who has borderline personality
disorder. Which of the following should the nurse expect?
a. Avoidance of relationships
b. Self-mutilation
c. Grandiosity
d. Preoccupation with perfectionism
Answer: b. Self-mutilation
175. A nurse in an emergency mental health facility is caring for a group of clients. The
nurse should identify which of the following clients requires a temporary emergency
admission?
a. A client who has depression and is experiencing suicidal ideation.
b. A client who has schizophrenia and is experiencing auditory hallucinations.
c. A client who has borderline personality disorder and assaulted a homeless man with a
metal rod.
d. A client who has bipolar disorder and is experiencing a manic episode.
Answer: c. A client who has borderline personality disorder and assaulted a homeless man
with a metal rod.

176. A nurse is caring for the parents of a child who has demonstrated changes in behavior
and mood. When the mother of the child asks the nurse for reassurance about her son's
condition, which of the following responses should the nurse make?
a. "Your son will be fine. There's nothing to worry about."
b. "I'm sure everything will turn out okay in the end."
c. "It's normal for children to go through ups and downs."
d. "I understand you're concerned. Let's discuss what concerns you specifically."
Answer: d. "I understand you're concerned. Let's discuss what concerns you specifically."
177. A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm
coughing because I have that cold that everyone has been getting." The nurse should identify
that the client is using which of the following defense mechanisms?
a. Projection
b. Denial
c. Rationalization
d. Displacement
Answer: b. Denial
178. A nurse is in the working phase of a therapeutic relationship with a client who has
methamphetamine use disorder. Which of the following actions indicates transference
behavior?
a. The client expresses anger towards the nurse for enforcing unit rules.
b. The client accuses the nurse of telling him what to do just like his ex-girlfriend.
c. The client asks the nurse for advice on managing cravings.
d. The client discusses feelings of guilt related to past behaviors.
Answer: b. The client accuses the nurse of telling him what to do just like his ex-girlfriend.
179. A nurse is caring for a client whose child has a terminal illness. The client requests
information about how to deal with the upcoming loss. Which of the following statements
should the nurse make?
a. "You should focus on taking care of yourself right now."

b. "It's important to stay strong for your other children."
c. "You'll need to be prepared to move on with your life."
d. "It is not uncommon to feel angry toward yourself or others."
Answer: d. "It is not uncommon to feel angry toward yourself or others."
180. A nurse is teaching a client who has bipolar disorder and a prescription for lithium.
Which of the following instructions should the nurse include in the teaching?
a. "Take this medication on an empty stomach."
b. "Take this medication with food."
c. "Avoid foods high in tyramine while taking this medication."
d. "You should notice a difference in your mood within a few hours."
Answer: b. "Take this medication with food."
181. A nurse is planning care for four clients in a mental health facility. Which of the
following clients is at the greatest risk for injury when performing ADLs?
a. A client who has schizophrenia
b. A client who has bipolar disorder
c. A client who has major depressive disorder
d. A client who has severe Alzheimer's disease
Answer: d. A client who has severe Alzheimer's disease
182. A nurse who works with newborns is assessing the potential for abuse or neglect. Which
of the following family groups should the nurse identify as the highest potential for future
child abuse?
a. A family where both parents are highly educated
b. A family where one or both parents have a history of depression
c. A family where both parents have stable employment
d. A family where one or both parents witnessed intimate partner violence in the home as
children
Answer: d. A family where one or both parents witnessed intimate partner violence in the
home as children

183. A nurse is performing an admission assessment on a client and notices that the client
appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the
following actions should the nurse take first?
a. Inform the client that her admission is confidential.
b. Offer the client a warm blanket.
c. Ask the client if she would like to have a family member present.
d. Provide the client with a list of community resources.
Answer: a. Inform the client that her admission is confidential.
184. A nurse is planning care for a client who has dementia. Which of the following
interventions should the nurse include in the plan?
a. Give detailed instructions for completion of self-care activities.
b. Minimize opportunities for the client to make choices.
c. Keep the client's daily routine unpredictable.
d. Use medical terminology when communicating with the client.
Answer: a. Give detailed instructions for completion of self-care activities.
185. A nurse is planning overall strategies to address problems for a client who has
borderline personality disorder. Which of the following strategies is the priority for the nurse
to incorporate in the plan of care?
a. Encourage the client to participate in group therapy.
b. Help the client explore the origins of her disorder.
c. Assist the client to maintain awareness of her thoughts and feelings.
d. Provide the client with a list of coping mechanisms.
Answer: c. Assist the client to maintain awareness of her thoughts and feelings.
186. A nurse is providing discharge teaching about expected adverse effects to a client who
has a new prescription for lithium. Which of the following adverse effects should the nurse
include? (Select all that apply).
a. Thirst

b. Sedation
c. Dry skin
Answer: a. Thirst
b. Sedation
c. Dry skin
187. A nurse is assessing a client who has schizophrenia. Which of the following finding
should the nurse document as positive symptoms of schizophrenia? (Select all that apply.)
a. Flight of ideas
b. Delusions of grandeur
c. Auditory hallucinations
Answer: a. Flight of ideas
b. Delusions of grandeur
c. Auditory hallucinations
188. A nurse is caring for a client whose partner died 6 months ago. Which of the following
findings is the nurse's priority?
a. The client says he feels guilty about not spending more time with his partner
b. The client reports feeling lonely and isolated
c. The client has lost 10 pounds since his partner's death
d. The client avoids talking about his partner
Answer: a. The client says he feels guilty about not spending more time with his partner
189. A nurse is caring for a client who has bipolar disorder and is refusing to take prescribed
medications. Which of the following ethical principles to the nurse displaying when he
supports the clients refusal of medication?
a. Autonomy
b. Beneficence
c. Nonmaleficence
d. Justice
Answer: a. Autonomy

190. A nurse in an outpatient clinic is assessing a client who has anorexia nervosa. Which of
the following findings indicates the need for hospitalization?
a. Heart rate 58/min
b. Temp below 96.7°F
c. Weight loss of 10% of body weight in the last 6 months
d. Potassium level 3.2 mEq/L
Answer: b. Temp below 96.7°F
191. A nurse is obtaining a medical history from a client who is requesting a prescription for
bupropion for smoking cessation. Which of the following assessment finding in the client’s
history should the nurse report to the provider?
a. History of hypertension
b. Allergy to aspirin
c. Family history of diabetes
d. Recent head injury
Answer: d. Recent head injury
192. A nurse is providing crisis intervention for a client who was involved in a violent mass
causality situation in the community. Which of the following actions should the nurse take
during the initial session with the client?
a. Encourage the client to focus on the positive aspects of the situation
b. Identify the client’s usual coping style
c. Recommend long-term psychotherapy
d. Discuss the client’s childhood experiences
Answer: b. Identify the client’s usual coping style
193. A Nurse in the community health facility is interviewing a client who recently lost his
job. The client states “I was fired because my boss doesn’t like me” Which of the following
defense mechanisms is the client displaying?
a. Rationalization

b. Projection
c. Displacement
d. Denial
Answer: a. Rationalization
194. A nurse is assessing a client who recently experienced the loss of their partner. Which of
the following question is the priority for the nurse to ask during situational crisis?
a. How do you usually cope with stressful situations?
b. Do you have any family or friends who can support you?
c. Have you experienced any changes in your sleep or appetite?
d. Who do you talk to when you need help?
Answer: d. Who do you talk to when you need help?
195. A nurse is caring for a client who was involuntarily committed and is scheduled to
receive ECT. The client refuses treatment and will not discuss why with the healthcare team.
Which of the following actions should the nurse take?
a. Convince the client of the benefits of ECT
b. Contact the client’s family to discuss the situation
c. Document the refusal of the treatment in the medical record
d. Administer the treatment against the client’s will
Answer: c. Document the refusal of the treatment in the medical record
196. A nurse is leading a grief support group for a bereaved client. Which of the following
statements should the nurse report to the provider as an indication of clinical depression?
a. “I miss my loved one so much.”
b. “I feel like I am angry at the whole world right now.”
c. “I cry every day and can’t seem to stop.”
d. “I feel numb and disconnected from everything.”
Answer: b. “I feel like I am angry at the whole world right now.”

197. A nurse is caring for a client who is undergoing electroconvulsive therapy. Which of the
following tasks should the nurse delegate to assistive personnel?
a. Assist the client to ambulate for the first time following the procedure.
b. Monitor the client’s vital signs during the procedure.
c. Administer the prescribed medication before the procedure.
d. Explain the procedure to the client and obtain informed consent.
Answer: a. Assist the client to ambulate for the first time following the procedure.
198. A nurse is caring for a client who has depression following a recent job loss. Which of
the following questions should the nurse ask to assess the client’s personal coping skills?
a. “Have you been feeling sad or down most of the time?”
b. “Do you have thoughts of harming yourself?”
c. “How have you dealt with similar situations in the past?”
d. “Are you experiencing any changes in your sleep or appetite?”
Answer: c. “How have you dealt with similar situations in the past?”
199. A nurse conducting an admission interview with a new client who tells the nurse, “My
life is so stressful. I can’t take it anymore.” Which of the following responses should the
nurse take first?
a. “Let’s talk more about what you are experiencing.”
b. “Have you thought about harming yourself?”
c. “I will notify the doctor of your feelings.”
d. “You should try to relax and not worry so much.”
Answer: a. “Let’s talk more about what you are experiencing.”
200. A nurse is caring for a client who is experiencing alcohol withdrawal and notes visible
tremors and an elevated blood pressure and heart rate. Which of the following medications
should the nurse prepare to administer?
a. Naltrexone
b. Disulfiram
c. Acamprosate

d. Lorazepam
Answer: d. Lorazepam
201. A nurse in a mental health facility is reviewing the laboratory results of a client who is
taking lithium carbonate. Which of the following findings places the client at risk for lithium
toxicity?
a. Sodium 132 mEq/L
b. Potassium 4.2 mEq/L
c. Calcium 9.0 mg/dL
d. Magnesium 2.0 mg/dL
Answer: a. Sodium 132 mEq/L
202. A nurse is leading a critical incident stress debriefing with a group of staff members
following a mass trauma incident. Which of the following interventions should the nurse
take first?
a. Provide information about common stress reactions.
b. Offer resources for ongoing support.
c. Facilitate discussion of the event.
d. Reassure staff members that the debriefing is confidential.
Answer: d. Reassure staff members that the debriefing is confidential.
203. A nurse is caring for a client who has borderline personality disorder and has been
engaging in self-mutilation. The nurse should encourage the client to participate in which of
the following groups?
a. Substance abuse group
b. Anger management group
c. Medication management group
d. Dialectical behavior treatment group
Answer: d. Dialectical behavior treatment group

204. A nurse in an alcohol rehabilitation facility is creating a discharge plan for a client who
has alcohol use disorder. Which of the following recommendations should the nurse include
in the plan?
a. Request a discharge prescription for buprenorphine for the client.
b. Recommend participation in community-based support groups.
c. Encourage the client to attend social events where alcohol is served.
d. Provide information on local bars and liquor stores.
Answer: b. Recommend participation in community-based support groups.
205. A nurse is caring for a client whose child has a terminal illness. The client requests
information about how to deal with the upcoming loss. Which of the following statements
should the nurse make?
a. "You should focus on taking care of yourself right now."
b. "It's important to stay strong for your other children."
c. "You'll need to be prepared to move on with your life."
d. "It is not uncommon to feel angry toward yourself or others."
Answer: d. "It is not uncommon to feel angry toward yourself or others."
206. A nurse is teaching a client who has bipolar disorder and a prescription for lithium.
Which of the following instructions should the nurse include in the teaching?
a. "Take this medication on an empty stomach."
b. "Increase your intake of foods rich in sodium."
c. "Limit your fluid intake to avoid lithium toxicity."
d. "Take this medication with food."
Answer: d. "Take this medication with food."
207. A nurse is planning care for four clients in a mental health facility. Which of the
following clients is at the greatest risk for injury when performing ADLs?
a. A client who has severe Alzheimer's disease.
b. A client who has major depressive disorder.
c. A client who has schizophrenia.

d. A client who has generalized anxiety disorder.
Answer: a. A client who has severe Alzheimer's disease.
208. A nurse is updating the plan of care for a client who has bulimia nervosa and is 5%
above his ideal body weight. Which of the following interventions should the nurse include
in the plan?
a. Identify the client's trigger foods.
b. Encourage the client to weigh himself daily.
c. Monitor the client's electrolyte levels weekly.
d. Teach the client about the importance of a low-fat diet.
Answer: a. Identify the client's trigger foods.
209. A nurse who works with newborns is assessing the potential for abuse or neglect. Which
of the following family groups should the nurse identify as having the highest potential for
future child abuse?
a. A family where one or both parents witnessed intimate partner violence in the home as
children.
b. A family where both parents are actively involved in the community.
c. A family where the parents have strong social support networks.
d. A family where the parents have stable employment and income.
Answer: a. A family where one or both parents witnessed intimate partner violence in the
home as children.
210. A nurse is performing an admission assessment on a client and notices that the client
appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the
following actions should the nurse take first?
a. Inform the client that her admission is confidential.
b. Explain the purpose of the assessment to the client.
c. Provide the client with information about the unit rules and routines.
d. Ask the client about her preferences for care and treatment.
Answer: a. Inform the client that her admission is confidential.

211. A nurse is caring for four clients in an inpatient mental health facility. Which of the
following clients can give informed consent?
a. A 35-year-old client who has major depressive disorder.
b. A 17-year-old client who has schizophrenia.
c. A 20-year-old client who has bipolar disorder.
d. A 15-year-old client who has anorexia nervosa.
Answer: a. A 35-year-old client who has major depressive disorder.
212. 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
I'm going to bed!" The nurse should document the client's speech pattern as which of the
following?
a. Echolalia.
b. Neologism.
c. Circumstantiality.
d. Clang association.
Answer: d. Clang association.
213. A nurse is educating the parent of a child who has a new diagnosis of autism spectrum
disorder. Which of the following manifestations of this disorder should the nurse include in
the teaching?
a. Impulsivity.
b. Language delay.
c. Repetitive behaviors.
d. Hyperactivity.
Answer: b. Language delay.
214. A nurse in a mental health unit is admitting a client who is anxious because he often
hears voices telling him what to do. Which of the following actions should the nurse take?
a. Ignore the client's statements about hearing voices.

b. Ask the client what the voices are saying.
c. Tell the client that the voices are not real.
d. Offer the client medication to stop the voices.
Answer: b. Ask the client what the voices are saying.
215. A nurse is caring for an older adult client who begins to cry and states, "I knew God
would punish me and I deserve this horrible sickness!" Which of the following responses
should the nurse make?
a. "I'm sure you did nothing to deserve this illness."
b. "Don't blame yourself for your illness."
c. "Let's talk about what is upsetting you."
d. "You shouldn't feel that way about yourself."
Answer: c. "Let's talk about what is upsetting you."
216. A nurse is talking with a client who is beginning chemotherapy. The client tells the
nurse that she is mourning the loss of her hair. Which of the following actions should the
nurse take first?
a. Discuss the importance of hair with the client.
b. Provide the client with a wig or head covering.
c. Reassure the client that hair loss is temporary.
d. Encourage the client to express her feelings.
Answer: a. Discuss the importance of hair with the client.
217. 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 laboratory
findings should the nurse report to the provider? (Click on the "Exhibit" button below for
additional client information. There are three tabs that contain separate categories of data.)
a. Sodium level 125 mEq/L.
b. Potassium level 4.5 mEq/L.
c. Calcium level 9.0 mg/dL.
d. Magnesium level 2.0 mg/dL.

Answer: a. Sodium level 125 mEq/L.
218. A nurse in an emergency department is caring for an 18-month-old toddler who has a
fractured left femur. Which of the following statements by the toddler's parent should cause
the nurse to suspect child abuse?
a. "My child was riding a bicycle and fell off."
b. "I heard a snap when my child fell down the stairs."
c. "I found my child crying and holding her leg."
d. "My child's sibling accidentally tripped her."
Answer: b. "I heard a snap when my child fell down the stairs."