ATI Mental Health Test A
1. A nurse is caring for a client who has been receiving hemodialysis for 3 years. The client's
wife tells the nurse that he frequently states a desire to stop going to his dialysis treatments.
Which of the following is an appropriate response by the nurse?
Answer: I understand this is very upsetting for you. Tell me how you feel about his
comments.”
2. When admitting a client to an inpatient mental health facility, a RN notices that a client
seems withdrawn and appears fearful. To establish a trusting nurse-client relationship, the
RN should first
Answer: inform the client that her admission will be confidential.
3. A RN is caring for a client who has schizophrenia and is prescribed risperidone
(Risperdal). What lab test should the RN monitor?
Answer: blood glucose (can cause diabetes mellitus)
4. A RN has a client with stage 5 Alzheimer’s disease. What nursing intervention assists in
orienting the client to reality?
Answer: Talking to the client about meaningful daily activities.
5. A RN is caring for a client who is scheduled to undergo ECT. The provider has explained
the procedure to the client. What statement indicates a need for further teaching?
Answer: “This procedure can increase my risk for developing Parkinson’s disease.”
6. A client diagnosed with paranoid schizophrenia is attending a treatment planning
conference with a family member. During the discussion of the medication adherence portion
of the plan, the RN notices that the family member seems distracted. Which of the following
is the right RN action?
Answer: Ask the family member if she has any thoughts or questions about this portion of
the treatment plan.
7. RN is monitoring for serotonin syndrome when caring for a client who is starting a new
prescription of Zoloft after a MAOI was discontinued 12 days ago. What should the RN
monitor and report to the provider?
Answer: Fever (indicates serotonin syndrome – should wait 14 days before starting new
med)
8. A client states to the RN, “I feel as though I am the only one in the world feeling so
depressed.” The RN responds, “I know what you mean.” The RN is obstructing
communication in which of the following ways
Answer: Minimizing feelings (by agreeing with him and not demonstrating empathy)
9. RN caring for client with OCD who must hands 16 minutes and comb his hair 7 times, and
turn the light on and of 20 times before meals. What is the right intervention?
Answer: Teach client about thought-stopping technique
10. RN caring for client who is deaf and is scheduled for ECT, the provider needs to explain
the procedure to the client in order to obtain informed consent. What action should the RN
take?
Answer: Request a profession interpreter to translate.
11. RN caring for adolescent client who is yelling at the RN and throws a tray at the wall.
What is appropriate RN response?
Answer: You seem angry at everyone (acknowledging feelings)
12. RN caring for client who started taking tranylcypromine (Parnate). Which of the
following OTC meds should the RN teach to avoid?
Answer: Phenylephrine (Neo-synephrine)
13. Bipolar client present to mental health clinic and report the RN that she stopped taking
her lithium 2 weeks ago. What is an expected finding of this client who stopped her meds?
Answer: Hand tremors (are expected side effect that may cause med adherence issues)
14. RN caring for client who has a terminal illness and is assisting him with accepting
impending death. What behavior indicates client has met this goal?
Answer: Discussing end of life decisions
15. RN caring for client who is diagnosed with depression and is taking phenelzine (nardil).
The client said he ate a grilled cheese for lunch. RN should monitor for?
Answer: Hypertension
16. RN is caring for a client who has anorexia nervosa and has been admitted to inpatient
mental health. What should the RN include in the plan of care?
Answer: Provide opportunities for the client to journal her for intake (provides opportunity
to develop self-awareness of disease & provides info when planning client’s meals?
17. RN is teaching the family of a client dx with PTSD. RN should include what in teaching
the family that clients who have PTSD
Answer: often have feelings of isolation
18. A RN is caring for a client who has dementia and has had aggressive outbursts. Which of
the following interventions should the RN try first to reduce these outbursts?
Answer: Repeated use of redirection
19. RN is interviewing on older adult client. What action is appropriate?
Answer: Sit or stand at the same level as the client.
20. RN in a clinic is assessing a client whose wife died 4 months ago. What statement
indicates the client is at risk for complicated grief?
Answer: “I feel so empty without my wife; it is hard to get up every morning” (difficulty
carrying on normal activities after a loss, indication of complicated grieving)
21. What should the RN implement when providing a therapeutic environment for clients is
an inpatient mental health unit?
Answer: Give explanations to the clients for decisions that are made.
22. A RN is preparing to discharge an older adult client, who attempted suicide, to his home
where lives alone. The client also has difficulty performing ADLs. Which of the following
referrals should the RN initiate?
Answer: OT, meal delivery, PT, Home Health Services.
23. RN is caring for a schizophrenic client. The treatment plan is for the client to increase his
autonomy from his parents. Prior to discharge, the RN should plan to
Answer: schedule a family conference
24. A client has been diagnosed with HIV. Which of the following statements by the client
should indicate that the client is using spirituality in a positive way to deal with the
diagnosis?
Answer: “My faith will help me through this difficult time.”
25. A RN is planning care for a newly admitted client who is experiencing a manic episode
of bipolar disorder. Which of the following interventions is the highest priority?
Answer: Provide frequent high-calorie snacks.
26. RN is developing a discharge plan for a client who has a history of gambling dependency
and includes participation in a support group. The RN should tell the client that which of the
following is the purpose of the support group?
Answer: Provide assurance that others have a similar problem.
27. While observing group therapy, a RN recognizes that a client is behaving in a way
suggestive of a personality disorder. Which of the following behaviors is consistent with this
condition?
Answer: Client needs excessive external input to make everyday decisions (reflective of
dependent personality disorder)
28. A child has been diagnosed with conduct disorder is behaving in a destructive manner,
throwing objects and kicking others. Which of the following therapeutic measures is the
highest priority?
Answer: Use a therapeutic holding technique (to precent harm to others)
29. RN is caring for a client who stops talking mid-sentence and begins talking and
responding to voices not hear by the RN. What is the appropriate response by the RN?
Answer: Ask what the clients are saying.
30. RN 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 addition lab
data has the highest priority?
Answer: Serum sodium of 125 mEq/L – shows reduced renal excretion of lithium
31. RN is caring for a client who has schizophrenia in a mental health facility. Which of the
following places the client at the greatest risk for self-directed injury or injuring others?
Answer: Command hallucinations
32. A kid is admitted to an acute care adolescent unit after attempting to commit suicide.
Which of the following interventions should the RN plan to implement first?
Answer: Arrange one-to-one observation of the client.
33. A client recently diagnosed with bipolar disorder is placed in a room with a client
diagnosed with severe depression. The client who has depression reports to the RN, “That
man in my room never sleeps and he keeps me up, too.” Which of the following is an
appropriate intervention for the RN to take?
Answer: Move client with bipolar disorder to a private room.
34. A nurse in an inpatient facility is preparing room assignments for four clients. Which of
the following clients is least likely to attempt to climb out of bed or wander?
Answer: Stage 7 Alzheimer’s disease (has impaired or absent cognitive, communication,
and/or motor skills)
35. A client is undergoing ECT and will receive succinylcholine (Anectine). In response to a
client’s question about this med, the RN should provide what explanation?
Answer: “Anectine is given to reduce muscle movements during therapy”
36. A RN is caring for a client who was brought into the outpatient clinic by his daughter
after she found him wandering the streets crying. Which of the following question should the
RN ask the client first?
Answer: “What was happening before you began to feel like this”?
37. A client on a mental health unit points out to a RN that the RN becomes angry when
clients are late for group therapy sessions. With which of the following responses does the
RN model appropriate communication?
Answer: “You are correct. I should be more patient and find out why they were late.”
38. A RN is establishing a plan of care for the client who exhibits angry, aggressive, and
violent behavior in the unit. The priority nursing intervention is to
Answer: create a large, personal space.
39. RN is planning care for a client who is experiencing alcohol withdrawal delirium. Which
of the following meds should the RN administer to treat alcohol withdrawal syndrome?
Answer: Chlordiazepoxide (Librium) – a benzo
40. A client’s husband died in a mother-vehicle crash 1 month ago. The client’s daughter
informs the RN that her mother still cries herself to sleep each night, and she asks the RN to
“help my mom control herself.” Which of the following is an appropriate response by the
RN?
Answer: “Its hard to see your mother so upset, but crying is one way of expressing her
feelings.”
41. A RN is aware that a client who has stage 4 Alzheimer’s disease may exhibit
Answer: inability to manage finances (stage 4 has difficulty with tasks that require planning,
like finances)
42. During AM rounds, a nurse finds a client who has schizophrenia trembling and tearful in
her bed. The client reports that a bomb was placed by her room by a family member during
visitation hours. Which of the following is an appropriate action by the RN?
Answer: Assess the client further for signs of perceptual disturbance (to determine if client is
hallucination or misperceiving external stimuli)
43. A RN is caring for a client who has schizophrenia and is threatening to harm others on
the unit. The provider prescribed haloperidol (Haldol) and seclusion. Which of the following
should be included in the plan of care?
Answer: take the client’s vital signs every hour (to monitor BP)
44. A RN is caring for a client who has depression and is scheduled to have ECT within the
next hour. During preop care, the client informs the RN that he doesn’t want to have the
procedure done. Which of the following statements by the RN is appropriate?
Answer: “Lets discuss what reasons you have for not wanting the procedure.”
45. A RN is obtaining a history and physical on a client who present to the ED of a mental
health facility. The RN recognizes which of the following assessment findings as being
consistent with PTSD?
Answer: distressing dreams, difficulty concentrating, exaggerated startle response
46. A RN is caring for a client who has had an anxiety disorder and is newly admitted to an
inpatient mental health facility. Which of the following should the RN do first?
Answer: ID the client’s perception of his stressors
47. A client admitted to a psych inpatient unit is in the acute stages of schizophrenia. The RN
observes the following symptoms: restlessness, pacing with clenched fists, eyes darting to
one side, and muttering. Which of the following interventions should the RN initiate?
Answer: Staty with the client in a quiet setting.
48. During a group therapy session with a nurse, a client who has schizophrenia becomes
increasingly agitated, shouting and gesturing in an angry manner toward the group and the
RN. Which of the following actions should the RN take first?
Answer: Move other group members away from the client.
49. A RN is communicating with a client in an inpatient mental health facility. Which of the
following demonstrates use of active listening?
Answer: Attention to body language (IDs verbal and nonverbal communication)
50. A RN is preparing to teach a group of parents about healthy adolescent behavior. Which
of the following info should the RN plan to include?
Answer: Exhibits a realistic self-concept
51. When communicating with a client who is depressed and withdrawn, which of the
following nursing interventions is appropriate?
Answer: Be prepared to wait for the client to respond.
52. A RN is performing an assessment on a 78 year old client who has injuries consistent
with suspected abuse. Which of the following statements indicated the greatest potential risk
factors for abuse?
Answer: “My son enjoys a couple of drinks each night to unwind.”
53. RN is involved in systematic desensitization therapy for a client with fear of crowds.
Place steps in order.
Answer: ID specific stimulus cues. Expose fears slowly. RN should then ID what stage
cause the most anxiety. Then lase schedule to practice exposure to fear.
54. A RN is reaching a spouse of a client who has bipolar disorder to recognize signs of acute
mania. Which of the following is an example of a manifestation that the client’s spouse
should report?
Answer: Inability to sleep
55. RN is caring for a client who is diagnosed with borderline personality disorder. Which is
the priority goal when planning care?
Answer: Client will refrain from self-mutilation.
56. RN caring for older adult who recently lost spouse of 55 years after a long illness. IN
initial interview, client state, “Non one can understand my loss. She was my soul mate.”
What response is appropriate?
Answer: “This must be a very difficult time for you.”
57. RN is performing a routine physical assessment on an older adult client with dementia.
The RN notices he has bruises in various healing stages. Client reports caregiver hits him.
What should RN do?
Answer: Follow guidelines regulating reporting of suspicious findings.
58. RN is caring for a client who has a hx of aggressive behavior. The client is playing cards
and throw the cards at other clients. Which of the following interventions is appropriate in
the situation?
Answer: Ask the client to express how he is feeling.
59. RN is caring for a client who has a hx of substance abuse and was involuntarily
committed. When nurse attempts to administer lorazepam (Ativan) the client refuses and
becomes aggressive. What action should RN take?
Answer: Do not administer (he retains right)
60. RN is conducting a group therapy session for clients with bipolar disorder. One client
begins to brag and dominate the conversation. What action should the RN take?
Answer: Tell client to calm down or he will be dismissed from session.
