2023-2024 ATI Mental Health Practice Exam With Answers-340 Solved Questions

MENTAL HEALTH | ATI MENTAL HEALTH FORM A , B, C
ACTUAL EXAMS QUESTIONS AND CORRECT ANSWERS 2023-2024
UPDATE ALREADY A GRADED|BRAND NEW!!
1. 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 should discontinue the medication if you develop muscle rigidity
B. You will experience weight loss while taking this medication
C. You will notice your symptoms improve than 24 hours of taking this medication
D. You should increase your consumption of complex carbohydrates
Answer: B. You will experience weight loss while taking this medication
2. 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. Determine how the client handle stress
C. Teach the client to use guided imagery
D. Ask the client to identify her strengths
Answer: A. Provide the client with a quiet environment
3. 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. States that he hasn't bathed in 2 days
B. Reports eating twice in the past week
C. Make inappropriate sexual comments
D. Speak in rhyming sentences
Answer: B. Reports eating twice in the past week
4. A nurse is planning care for a client who has OCD. Which of the following
recommendation should the nurse include in the client’s plan of care?
A. Validation therapy
B. Thought stopping
C. Operant conditioning

D. Reality orientation therapy
Answer: B. Thought stopping
5. A nurse is caring for a client who has bipolar disorder and experiencing a manic episode.
Which of the following actions should the nurse take?
A. Encouraged client to join group activities
B. Dim the lights in the client’s room
C. Provide detailed explanations to the client
D. Administer methylphenidate to the client
Answer: B. Dim the lights in the client’s room
6. 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. Initiate referrals
B. Review Community Resources
C. Identify prior coping skills
D. Discuss the importance of confidentiality
Answer: C. Identify prior coping skills
7. A nurse overhears a client saying, “I am a spy, a spy for the FBI. I am an I, an eye for an
eye, and eye in the sky. Sky is up high.” The nurse should document the client statement as
which of the following speech alterations?
A. Echolalia
B. Word salad
C. Neologism
D. Clang Association
Answer: D. Clang Association
8. 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 am so worried that my mother is depressed.” Which of the following responses
should the nurse make?
A. Everyone gets depressed from time to time
B. You shouldn't worry about this, because depressive disorder is easily treated

C. Older adults are usually diagnosed with depressive disorder as they age
D. Tell me the reasons you think your mother is depressed
Answer: D. Tell me the reasons you think your mother is depressed
9. 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. Meets own needs without manipulating others
B. Initiate social interactions with caregivers
C. Change his behavior as a result of peer pressure
D. Acknowledges that his delusions are not real
Answer: B. Initiate social interactions with caregivers
10. A nurse is providing behavioral therapy for a client who has OCD. The client repeatedly
checks that the doors unlocked at night. Which of the following instructions should the nurse
give the client when using thought stopping technique?
A. Snap a rubber band on your wrist when you think about checking the locks
B. Ask a family member to check the locks for you at night
C. Focus on abdominal breathing whenever you go to check the locks
D. Keep a journal of how often you check the locks
Answer: A. Snap a rubber band on your wrist when you think about checking the locks
11. A nurse is caring for a client who is starting treatment for substance abuse disorder. Which
the following actions indicates the nurse is practicing the ethical principle of nonmaleficence?
A. Providing a client with quality care regardless of ability to pay for treatment
B. Educating the client about legal rights concerning treatment
C. Withholding a prescribed medication that is causing adverse effect for the client
D. Being truthful with the client about the manifestations of withdrawal
Answer: C. Withholding a prescribed medication that is causing adverse effect for the client
12. 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. Crisis Intervention to decreasing anxiety
B. Aversion therapy to provide distraction

C. Pairing a maladaptive behavior w a painful stimuli to change behavior
D. Positive reinforcement to increase desired behavior
E. Systematic desensitization to extinguish the behavior
Answer: E. Systematic desensitization to extinguish the behavior
13. A nurse is caring for a client who is experiencing a panic attack. Which of the following
actions should the nurse take?
A. Ask the client to discuss precipitating events
B. Speak to the client and a high-pitched voice
C. Place the client in seclusion
D. Have the client breathe into a paper bag
Answer: D. Have the client breathe into a paper bag
14. 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. Repression
B. Displacement
C. Rationalization
D. Denial
Answer: A. Repression
15. A nurse is caring for a client who has anorexia nervosa. Which of the following findings
requires immediate intervention by the nurse?
A. +2 edema of the lower extremities
B. BUN 21 mg/dL
C. Lanugo covering the body
D. Blood pH 7.60
Answer: C. Lanugo covering the body
16. A nurse is caring for a client in a mental facility. The client is educated and threatens to
harm herself and others. Which of the following is a nurse's priority intervention?
A. Place the client in restraints
B. Administer and anti-anxiety medication to the client

C. Put the client in seclusion
D. Set limits on the client's behavior
Answer: D. Set limits on the client's behavior
17. A nurse is preparing to administer haloperidol 7 mg IM to a client who is severely
agitated. Available as Haloperidol injection 5mg/ml. How many ml should the nurse
administer? (Round to the nearest tenth)
Answer: 1.4 ml
18. A nurse is caring for a client who was involuntarily committed and is scheduled to receive
electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why
the healthcare team would. Which of the following actions should the nurse take?
A. Ask the client's family to encourage the client to receive ECT
B. Inform the client that ECT does not require client consent
C. Document the client’s refusal of the treatment in the medical record
D. Tell the client he cannot refuse the treatment because he was involuntarily committed
Answer: C. Document the client’s refusal of the treatment in the medical record
19. A nurse in 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. Request a mental health consult for the client
B. Ask the client if she has thought about harming herself
C. Encourage the client to attend a grief support group
D. Discuss the client's coping skills
Answer: B. Ask the client if she has thought about harming herself
20. A nurse is caring for a client who has borderline personality disorder and has been
engaging in self-mutilation. The nurse should encourage decline to participate in which of the
following groups?
A. Dual diagnosis treatment group
B. Dialectical behavior treatment group
C. For client who exhibit self-injurious behavior
D. Desensitization therapy

E. Co-dependents support group
Answer: B. Dialectical behavior treatment group
21. A nurse is reviewing the medication administration record of a client who has
schizophrenia. The nurse should plan to initiate abnormal involuntary movement scale to
monitor for adverse effects of which of the following medications?
A. Amantadine
B. Diphenhydramine
C. Benztropine
D. Haloperidol
Answer: D. Haloperidol
22. 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 am so sorry for the times I was angry with my partner
B. I find myself thinking about my partner often
C. I still don't feel up to returning to work
D. I like looking at his personal items in the closet
Answer: C. I still don't feel up to returning to work
23. 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 report a decrease in hallucinations
B. The client will communicate needs
C. The client will verbalize improved mood
D. The client will attend to personal hygiene
Answer: C. The client will verbalize improved mood
24. A nurse is caring for a client who is prescribed the massage therapy to treat panic disorder.
The client states, “I can't stand to be touched by another person.” Which of the following
responses should the nurse make?
A. Why don't you like to be touched by others?
B. Don't worry about it. Your anxiety will lessen once a massage begins
C. I will tell your provider that you would like a treatment other than massage

D. I will request that the massage therapist wear gloves during the treatment
Answer: C. I will tell your provider that you would like a treatment other than massage
25. 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 physical activity for the client during the day
B. Discourage the client from expressing feelings of anger
C. Keep a bright light on in the client’s room at night
D. Identify and schedule alternate group activities for the client
Answer: A. Encourage physical activity for the client during the day
26. 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 a role of monopoliser?
A. The mother who expresses hostility toward her spouse
B. The adolescent son who refuses to share personal feelings
C. The father who intervenes whenever two siblings argue
D. The adolescent daughter who attempts to dominate the discussion
Answer: D. The adolescent daughter who attempts to dominate the discussion
27. 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 plan?
A. The client might have a headache after treatment
B. The client will experience a seizure during treatment
C. The client will require intubation after treatment
D. The client is at risk for aspiration during treatment
Answer: A. The client might have a headache after treatment
28. 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? SATA
A. You will need to take the medication once-daily
B. You will receive treatment in an inpatient setting
C. You should avoid using mouthwash that contains alcohol

D. You should avoid drinking carbonated beverages while taking the medication - caffeine?
E. You can expect to develop a physical dependence to the medication
Answer: A. You will need to take the medication once-daily
C. You should avoid using mouthwash that contains alcohol
D. You should avoid drinking carbonated beverages while taking the medication - caffeine?
29. 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. Avoid power struggles by remaining neutral
B. Allow the client to set limits for his behavior
C. Provide in-depth explanation of nursing expectations
D. Encourage the client to participate in group activities
Answer: A. Avoid power struggles by remaining neutral
30. 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. Environmental stress
B. Gender
C. Depression
D. Birth order
Answer: C. Depression
31. 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 exhibits an inflated sense of self
B. The client develops an inability to concentrate
C. The client increases participation in social activities - impaired social
D. The client begins sleeping more than usual - can’t sleep
Answer: A. The client exhibits an inflated sense of self
32. A nurse is assessing a client who is restless and constantly mutters to himself. Which of
the following findings should the nurse to suspect delirium?
A. The client unable to recognize objects

B. The clients manifestations developed suddenly
C. The client has a flat affect
D. The client speech is slow and repetitious
Answer: B. The clients manifestations developed suddenly
33. A nurse is caring for a client and 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. You know that's not true, because it is against the law for others to read your mail
B. All of your letters come sealed, so that seems unlikely
C. It must be frightening that someone is reading your mail
D. Why do you think the government wants to read your mail?
Answer: C. It must be frightening that someone is reading your mail
34. A nurse is assessing a client who has Neuroleptic malignant syndrome. Which of the
following clinical findings should the nurse expect?
A. Heart rate 48/min
B. Temperature 104 F - sudden high fever
C. WBC 3,000/mm3
D. Hypotonicity
Answer: B. Temperature 104 F - sudden high fever
35. 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?
EXHIBIT
A. WBC count
B. Blood glucose level
C. Report of photosensitivity
D. Heart rate
Answer: A. WBC count
36. A nurse is caring for a client who has a personality disorder and is using transference to
cope. Which of the following behaviours should the nurse expect?
A. Talking negatively about other staff members

B. Expressing frustration regarding unit rules
C. Reacting to the nurse as though she were his mother
D. Refusing to participate in group activities
Answer: C. Reacting to the nurse as though she were his mother
37. A nurse in a mental health facility is caring for a newly admitted client. Which of the
following resources should the nurse recommend to help the client adapt to the health care
setting?
A. A community meeting
B. A medication group
C. A self-help meeting
D. A symptom Management Group
Answer: A. A community meeting
38. A nurse is assisting with obtaining informed consent for a client who has been declared
legally incompetent. Which of the following actions should the nurse take?
A. Request of the client’s Guardian sign the consent
B. Ask the charge nurse to obtain informed consent
C. Contact the social worker to obtain the consent
D. Explain implied consent to the client’s family
Answer: A. Request of the client’s Guardian sign the consent
39. A nurse is caring for a client who has cocaine use disorder. Which of the following
manifestations should the nurse expect the client to have during the withdrawal?
A. Hand tremors
B. Rapid speech
C. Fatigue
D. Seizures
Answer: C. Fatigue
40. A nurse is providing teaching about this order management for a client who has PTSD.
Which of the following statements should the nurse include in the teaching?
A. Avoiding stimuli that trigger memories of the trauma can help you overcome your PTSD
B. Talking about the traumatic experience is recommended

C. Response prevention is an effective treatment for PTSD
D. You should try to limit the number of hours that you sleep each day
Answer: A. Avoiding stimuli that trigger memories of the trauma can help you overcome
your PTSD
41. 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. Thyroid stimulating hormone TSH 4.0 microunits/ml
B. Alanine transaminase ALT 20 IU/L
C. Skin rash
D. Epistaxis
Answer: C. Skin rash
42. A nurse is caring for a client who has schizophrenia and display severe negative
symptoms of the disorder. Which of the following actions should the nurse take?
A. Manage the clients loud, rambling, and incoherent communication patterns
B. Direct the client to perform her own daily hygiene and grooming tasks
C. Assist the client to identify somatic and thought broadcasting delusions
D. Use medication to decrease frequency of auditory and visual hallucination
Answer: B. Direct the client to perform her own daily hygiene and grooming tasks
43. 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. Inform the client about confidentiality rights
B. Establish boundaries between the nurse and the client
C. Set short and long-term objectives for the future
D. Evaluate progress toward predetermined goals
Answer: C. Set short and long-term objectives for the future
44. A nurse in a mental health facility is making plans for client discharge. Which of the
following interdisciplinary team members should the nurse contact to assist a client with
housing placement?
A. Clinical nurse specialist
B. Recreational therapist

C. Occupational therapist
D. Social worker
Answer: D. Social worker
45. A nurse is caring for a client who reports that he's 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 a client
demonstrating?
A. Denial
B. Displacement
C. Compensation
D. Rationalization
Answer: B. Displacement
46. 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. The client needs to accept responsibility for his substance use
C. The client generally shares his feelings during group therapy sessions
D. The client asked me to go on a date with him, but I refused
Answer: A. The client is just like my brother who finally overcame his habit
47. 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. Establish a rapport to foster trust
B. Implement continuous one to one observation
C. Ask the client to sign a no suicide contract
D. Encourage the client to participate in group therapy
Answer: B. Implement continuous one to one observation
48. 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 student who is upset with her teacher writes a story about an excellent student
B. A school-age child whose mother died two years ago talks about her and present tense
C. A woman who has a health concern postpones a medical appointment until after the
vacation
D. An adult who was sexually abused as a child is unable to remember the incident
Answer: A. A student who is upset with her teacher writes a story about an excellent student
49. A nurse in an inpatient mental health facility is assessing a client who has schizophrenia
and is taking haloperidol. Which of the following clinical findings is the nurse’s priority?
A. High fever
B. Urinary hesitancy
C. Insomnia
D. Headache
Answer: A. High fever
50. 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 recognizes the importance of others
B. The client conforms to social norms regarding clothing choices
C. The client reduces self-dramatization
D. The client treats others with respect
Answer: D. The client treats others with respect
51. 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. Negotiate with the client how much weight she should gain each week
B. Decrease the client's daily intake of fibre
C. Weigh the client weekly for the first month
D. Notify the client about designated times for meals
Answer: D. Notify the client about designated times for meals
52. A nurse is fearful of driving and enters a behavioral therapy program to help him
overcome his anxiety. Using systematic desensitization, he's 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. Therapist modelling
B. Positive reinforcement
C. Frequent practice
D. Biofeedback
Answer: B. Positive reinforcement
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 judgement
Answer: A. Request permission from the client to take photographs of the injuries
54. 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. Ranitidine
B. Pseudoephedrine
C. Ibuprofen
D. Docusate sodium
Answer: B. Pseudoephedrine
55. A nurse is caring for a client who is experiencing active auditory hallucinations. Which of
the following actions should the nurse take?
A. Avoid asking direct questions about the clients experiences
B. Convey sympathy for the clients experience
C. Tell the client her experience is not real
D. Focus the client on reality-based activities
Answer: D. Focus the client on reality-based activities
56. caring for a client who has just returned to the unit after receiving an electroconvulsive
therapy treatment. Which of the following assessments is a nurse's priority?

A. First voiding
B. Short-term memory
C. Presence of gag reflex
D. Return of bowel sounds
Answer: C. Presence of gag reflex
57. 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. I think you should ignore the comment
B. You sound upset about today’s session
C. Why do you think that he said that to you?
D. I agree that the comment was inappropriate
Answer: B. You sound upset about today’s session
58. A nurse is assessing a client who is experiencing acute alcohol withdrawal. Which of the
following findings should the nurse expect?
A. Hypotension
B. Insomnia
C. Bradycardia
D. Diminished reflexes
Answer: B. Insomnia
59. 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 should drink at least 6 liters of water per day
B. I should be on a low sodium diet
C. I will call my doctor if I have diarrhoea (bc Na imbalance)
D. I will see my doctor to check my lithium levels annually
Answer: C. I will call my doctor if I have diarrhoea (bc Na imbalance)

60. 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 should the nurse collaborate
with a clinical psychologist?
A. The client needs a prescription for medication to promote nighttime sleep while in the
facility
B. The client needs to find a place to live after discharge
C. The client needs group therapy program prior to discharge
D. The client needs to relearn how to perform skills that require fine motor coordination (OT)
Answer: C. The client needs group therapy program prior to discharge
61. A nurse is reviewing the lab report of a client who is taking carbamazepine for bipolar
disorder. Which of the following lab results should the nurse report to the provider?
A. Urine specific gravity 1.029
B. Platelets 90,000/mm3
C. Urine pH 5.6
D. RBC 4.7/mm3
Answer: B. Platelets 90,000/mm3
62. 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 ensure the bedroom is dark while he's sleeping at night x
B. I will place a sliding bolt lock just above the door knob x
C. I will notify law enforcement within 2 hours if he cannot be found
D. I will give his most recent photo to the police (y give an old pic lol)
Answer: D. I will give his most recent photo to the police (y give an old pic lol)
63. teaching a client who has a new prescription for phenelzine to treat depression. The nurse
instruct the client to avoid foods with tyramine to prevent which of the following?
A. Hypertensive crisis
B. Cardiac toxicity
C. Serotonin syndrome
D. Urinary retention
Answer: A. Hypertensive crisis

64. A nurse in an outpatient clinic is assessing a client who has anorexia nervosa. Which of
the following findings indicates a need for hospitalization?
A. Potassium 3.8
B. HR 56/min
C. Temperature 96.1 F
D. Weight 10% below ideal weight
Answer: C. Temperature 96.1 F
65. 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 a client's
history should the nurse report to the provider?
A. Hep B infection
B. Hypothyroidism
C. Knee arthroplasty 1 month ago
D. Recent head injury
Answer: D. Recent head injury
66. A nurse is providing Crisis Intervention for a client who was involved in violent mass
casualty situation in the community. Which of the following actions should the nurse take
during the initial session with a client?
A. Help the client focus on a wide variety of topics regarding the crisis
B. Identify the client’s usual coping style
C. Tell the client that his life will soon return to normal
D. Encourage the client to display anger toward the cause of the crisis
Answer: B. Identify the client’s usual coping style
67. 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. Rationalization
B. Displacement
C. Dissociation
D. Repression

Answer: A. Rationalization
68. 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. Sit on the side of the bed for a few minutes before standing (ortho hypo)
B. Decrease the prescribed dose by half when mood improves
C. Avoid over the counter magnesium when taking the medication
D. Eat a snack before going to bed.
Answer: A. Sit on the side of the bed for a few minutes before standing (ortho hypo)
69. 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. Confront the client when he exhibits inappropriate behavior
C. Provide finger foods to enhance caloric intake
D. Remove clocks from the client’s room
Answer: C. Provide finger foods to enhance caloric intake
70. 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. Discuss appropriate use of assertive behavior with the client
B. Encourage the client to attend weekly support group meetings
C. Assist the client to maintain awareness over thoughts and feelings
D. Implement measures to prevent intentional self-inflicted injury
Answer: D. Implement measures to prevent intentional self-inflicted injury

PRACTICE ASSESSMENT: RN Mental Health Online Practice 2019 B
1. 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. Encourage the parents to avoid discussing the death of their other children to protect their
feelings
B. Recommend each parent grieve in a private to avoid hindering each other’s healing
C. Suggest forming a weekly support group for parents who have experienced the death of a
child.
D. Advise the parents to begin counseling if they are still grieving in a few months
Answer: C. Suggest forming a weekly support group for parents who have experienced the
death of a child.
2. A nurse in a community Health Centre 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. Response prevention
B. Guided imagery
C. Aversion therapy
D. Light therapy
Answer: B. Guided imagery
3. 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 phenytoin 30 min prior to procedure
B. Instruct the client to expect a headache following the procedure
C. Place the client in a four-point restraint prior to the procedure
D. Monitor the client’s cardiac rhythm during the procedure
Answer: D Monitor the client’s cardiac rhythm during the procedure
4. 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. Provide teaching about the use of positive coping mechanisms
B. Establish screening programs to identify at risk clients
C. Refer survivors to intimate partner abuse to a legal advocacy program
D. Organize rehabilitation therapy for clients who have experienced intimate partner abuse
Answer: B. Establish screening programs to identify at risk clients

5. A nurse in a mental health facility is caring for a client who has schizophrenia. Which of
the following findings places the client at a greater risk for self-directed injury or injuring
others?
A. Inability to communicate with others
B. Feelings of absence of self-worth
C. Lack of motivation to perform daily tasks
D. Command hallucinations
Answer: D. Command hallucinations
6. A nurse is caring for a child who is taking methylphenidate. The nurse should monitor the
child for which of the following findings as an adverse effect of methylphenidate?
A. Weight gain
B. Tinnitus
C. Tachycardia
D. Increased salivation
Answer: C. Tachycardia
7. A nurse observes a client on a mental health unit pushing on the locked unit door. Which of
the following statements should the nurse make?
A. “It appears as though you would like to open the door.”
B. “You will feel more comfortable after you've been here for a while.”
C. “It is ok to not want to be here.”
D. “You really shouldn't be pushing on the door.”
Answer: A. “It appears as though you would like to open the door.”
8. A nurse is assisting a client who has a terminal illness adjust to progressive loss of
independence. Which of the following statements by the client indicates acceptance of her
illness?
A. “I am going to order a wheelchair for when I'm unable to walk.”
B. “I am going to stop paying my bills since I won't be around much longer.”
C.“I wish you would go take care of somebody who actually needs you.”
D.“I am sure I'm going to be able to continue to care for myself without help.”
Answer: A. “I am going to order a wheelchair for when I'm unable to walk.”

9. A nurse is preparing to participate in an interdisciplinary conference or client who has
bipolar disorder. Which of the following behaviours is the priority for the nurse to report to
the treatment team?
A. Calling family members
B. Spending time alone
C. Giving away possessions
D. Excessive crying
Answer: C. Giving away possessions
10. A nurse is teaching the partner of a client who has bipolar disorder how to identify
manifestations of acute mania. Which of the following findings should the clients partner
report to the provider?
A. Obsessive attention to detail
B. Inability to sleep
C. Reports of fatigue
D. Isolation from others
Answer: B. Inability to sleep
11. A nurse on an acute mental health facility is receiving change of shift report for four
clients which of the following clients should the nurse assess first?
A. A client who does not recognize familiar people
B. A client who cannot verbalize their needs
C. A client who is awake and disoriented at night
D. A client who is experiencing delusions of persecution
Answer: D. A client who is experiencing delusions of persecution
12. A nurse is counseling and adolescent who has anorexia nervosa and reports excessive
laxative use and a fear of gaining weight. The client states “I'm so fat I can't even stand to
look at myself.” Which of the following therapeutic responses demonstrate the nurses use of
summarizing?
A. “You've discussed several concerns about your weight let's go back and talk about your
belief that you are fat.”
B. “You are saying that you think you are fat and are using laxatives because you are afraid of
gaining weight.”

C. “You don't want to look at yourself because you think you are fat.”
D. “You and I can work together to overcome your fears of gaining weight.”
Answer: B. “You are saying that you think you are fat and are using laxatives because you
are afraid of gaining weight.”
13. A nurse in a mental health clinic is caring for a client who has post-traumatic stress
disorder (PTSD) after returning from military deployment which of the following is the
priority action for the nurse to take?
A. Assist the client to identify personal areas of strength
B. Encourage the client to talk about experiences during the deployment
C. Stay with the client when flashbacks occur
D. Teach the client stress management techniques
Answer: C. Stay with the client when flashbacks occur
14. A nurse is discussing a 12-step-program with a client who has alcohol use disorder and is
in an acute care facility undergoing detoxification. Which of the following information
should the nurse include in the teaching?
A. The program will help the client accept responsibility for the disorder
B. the client should obtain a sponsor before discharge for an increased chance of recovery
C. the client will need to identify individuals who have contributed to the disorder
D. The program will need a prescription for the clients provider prior to attendance
Answer: B. the client should obtain a sponsor before discharge for an increased chance of
recovery
15. 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. Move the client who has bipolar disorder to a private room
B. administer sleep medication to the client who has bipolar disorder
C. move the client who has severe depression to a private room
D. administer sleep medication to the client who has severe depression
Answer: A. Move the client who has bipolar disorder to a private room

16. 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 this admission is confidential
B. Introduce the client to other clients in the dayroom
C. Assist the client in facilitating behavioral change
D. Determine coping strategies that the client has used in the past
Answer: A. Inform the client that this admission is confidential
17. A nurse is teaching coping strategies to a client who is experiencing depression related to
partner violence. Which of the following statements by the client indicates an understanding
of the teaching?
A. I will spend extra time at work to keep from feeling depressed
B. I will talk about my feelings with a close friend
C. I will be able to learn how to prevent my partner's attacks
D. I will use meditation instead of taking my anti-depressants
Answer: B. I will talk about my feelings with a close friend
18. A nurse is assessing a school age child who experienced the traumatic loss of a parent 8
months ago. Which of the following findings should the nurse identify as an indication of the
child is it is experiencing post-traumatic stress disorder (PTSD)?
A. Clinging behaviours directed toward a teacher
B. Increased time spending sleeping
C. Intense focus on schoolwork
D. Lack of interest in an upcoming holiday
Answer: D. Lack of interest in an upcoming holiday
19. A nurse on a mental health unit is caring for a group of clients. Which of the following
actions by the nurse is an example of the ethical principle of justice?
A. Allowing a client to choose which unit activities to attend
B. Attempting alternative therapies instead of restraints for a client who is combative
C. Providing a client with accurate information about their prognosis
D. Spending adequate time with a client who is verbally abusive
Answer: D. Spending adequate time with a client who is verbally abusive

20. A nurse is performing a cognitive assessment to distinguish delirium from dementia in a
client whose family reports episodes of confusion. Which of the following assessment
findings support the nurse’s suspicion of delirium?
A. Slow onset
B. Aphasia
C. Confabulation
D. Easily distracted
Answer: D. Easily distracted
21. A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of
the following findings?
A. Amenorrhea
B. Lanugo
C. Cold extremities
D. Tooth erosion
Answer: D. Tooth erosion
22. A nurse is teaching the guardians of a client about their adolescent child's diagnosis of
bulimia nervosa. Which of the following statements made by the guardian indicates an
understanding of their child's illness?
A. “The disease will increase our child's risk of high blood pressure.”
B. “It is important for our child to have regular dental checkups.”
C. “We need to weigh our child daily for several weeks then once per week.”
D. “Bleeding during our child's periods will increase because of this disease.”
Answer: B. “It is important for our child to have regular dental checkups.”
23. A nurse any providers office is interviewing older adult which of the following action
should the nurse plan to take? (Click on exhibit button for additional information about the
client there are 3 tabs that contain separate categories of data).
A. Use a screening tool to evaluate the client for depression
B. ask the provider to decrease the dosage of the client’s blood pressure medication
C. instruct the client to decrease intake of vitamin B12
D. suggest the client go for brisk walk 20 minutes just before bedtime

Answer: A. Use a screening tool to evaluate the client for depression
24. A nurse is caring for an older adult client who is experiencing delirium. Which the
following intervention should the nurse include in the client's plan of care?
A. Offer the client various choices for milk selection
B. Assign different nursing personnel for each shift
C. Permit the client to perform daily rituals to decrease anxiety
D. Maintain an environment that has low lighting
Answer: C. Permit the client to perform daily rituals to decrease anxiety
25. 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. Tell the client to talk less or risk being removed from the meeting
B. Ask the group members to discuss their feelings about the client’s monopolizing behavior
C. End the group meeting and take the client aside to discuss the disruptive behavior
D. Focus on the group members and ignore the client who is doing all the talking
Answer: B. Ask the group members to discuss their feelings about the client’s monopolizing
behavior
26. A nurse is assessing a family’s dynamics during a counseling session. The nurse should
recognize which of the following findings as an indication of a boundary issue?
A. An adolescent family member who questions parental authority
B. A family with three generations in the same household
C. Older children who are responsible for their younger siblings
D. Two adults and their children from prior relationships in the same household
Answer: C. Older children who are responsible for their younger siblings
27. A nurse is admitting a client who has a major depressive disorder and a new prescription
for tranylcypromine. Which of the following over-the-counter medications that the client
report staking should alert the nurse to a potential adverse reaction?
A. Lansoprazole
B. Naproxen
C. Magnesium hydroxide

D. Phenylephrine
Answer: D. Phenylephrine
28. The nurse is receiving change of shift report for four clients. Which of the following
client should the nurse plan to see first?
A. A client who has avoidant personality and refuses to attend group therapy
B. A client who has bipolar disorder in reports being kidnapped by aliens overnight
C. A client who's taking bupropion and reports having insomnia the past 2 nights
D. A client who is taking clozapine and reports of sore throat and chills
Answer: D. A client who is taking clozapine and reports of sore throat and chills
29. A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following
laboratory findings should the nurse expect?
A. Increased creatine phosphokinase (CPK)
B. Increased low density lipoproteins (LDL)
C. Decreased fasting blood sugar
D. Decreased aspartate aminotransferase (AST)
Answer: A. Increased creatine phosphokinase (CPK)
30. A nurse is caring for a client who is experiencing a panic attack. Which of the following
actions should the nurse take?
A. Orient the client to person place and time
B. Assist the client with deep breathing exercises
C. Calm the client by using therapeutic touch
D. Have the client sit alone in a quiet room
Answer: B. Assist the client with deep breathing exercises
31. The charge nurse on a mental health unit is discussing client’s rights with a newly
licensed nurse. Which of the following statements should the charge nurse make?
A. “Clients can't refuse to take medications if they are admitted involuntarily”.
B. “You can notify a client’s family if they are admitted involuntarily”.
C. “Clients who are admitted involuntarily maintain the right to give informed consent for
procedures.”

D. “You can remove a client's privileges if they are admitted involuntarily and refused to
attend therapy sessions.”
Answer: C. “Clients who are admitted involuntarily maintain the right to give informed
consent for procedures.”
32. Nurse is planning discharge teaching for a client who has a severe schizoaffective
disorder. The nurse should identify which of the following treatment options can offer
interdisciplinary services for the client at home?
A. Community mental Health Centre
B. Mental health day program
C. Partial hospitalization program
D. Assertive community treatment
Answer: D. Assertive community treatment
33. A nurse on a mental health unit observes a client who has acute mania hit another client.
Which of the following action should the nurse take first?
A. Call the provider to obtain an immediate prescription for restraint
B. Prepare to administer benzodiazepine I am
C. Call for a team of staff members to help with the situation
D. Check the client who was hit for injuries
Answer: C. Call for a team of staff members to help with the situation
34. A nurse is planning care for a client who has bipolar disorder and is experiencing mania.
Which of the following interventions should the nurse include in the plan of care?
A. Encourage the client to participate in Group therapy
B. Instruct the client to avoid napping during the day
C. Offer the client high calorie finger foods frequently
D. Decrease the client's daily fibre intake
Answer: C. Offer the client high calorie finger foods frequently
35. A nurse is caring for a child who has conduct disorder and is behaving in a destructive
manner, throwing objects, and kicking others. Which of the following therapeutic nursing
interventions is the priority?
A. Encourage expression of feelings

B. Support the child's attendance at an assertiveness training group
C. Assist the child to perform relaxation breathing
D. Reduce environmental stimuli
Answer: D. Reduce environmental stimuli
36. A nurse on a medical surgical unit is assessing a client who sustained injuries 12 hours
ago following a motor vehicle crash the client's admission blood alcohol level was 325
mg/dL. Which of the following findings should indicate to the nurse that the client is
experiencing alcohol withdrawal?
A. Somnolence
B. Blood pressure 154 /96 mm Hg
C. Pinpoint pupils
D. Blood glucose 210 mg/dL
Answer: B. Blood pressure 154 /96 mm Hg
37. A nurse is assessing a client who is experiencing opioid withdrawal. Which of the
following manifestations should the nurse expect?
A. Sedation
B. Rhinorrhoea
C. Bradycardia
D. Hypothermia
Answer: B. Rhinorrhoea
38. A nurse in a community Health Centre is teaching families of clients who have posttraumatic stress disorder (PTSD) about expected clinical manifestations which of the
following manifestation should the nurse include?
A. Repeatedly talks about the traumatic incident
B. Sleeps excessively
C. Experiences feelings of isolation
D. Uses repetitive speech
Answer: C. Experiences feelings of isolation

39. A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above
their ideal body weight. Which of the following interventions should the nurse include in the
plan?
A. Include a liquid supplement with meals
B. Identify the clients trigger foods
C. Allow the client at least 1 hour for each meal
D. Weigh the client at bedtime each day
Answer: B. Identify the clients trigger foods
40. Nurse is educating a parent of a child who has a new diagnosis of autism spectrum
disorder. Which of the following manifestations of the of this disorder should the nurse
include in the teaching?
A. Fear of abandonment
B. Motor and verbal tics
C. Hostile behavior
D. Language delay
Answer: D. Language delay
41. A nurse is caring for an older adult 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. “Why do you think you deserve this punishment?”
B. “Don't worry about being punished by God.”
C. “Let's talk about what is upsetting you.”
D. “You shouldn't say things that will upset you so much.”
Answer: C. “Let's talk about what is upsetting you.”
42. 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. WBC count 2,500/mm3
B. Hgb 11.5 mg/dL
C. Platelets 150,000/mm3
D. RBC count 3.5 million/mm3

Answer: A. WBC count 2,500/mm3
43. Nurse in a mental health clinic is planning care for four clients. Which of the following
tasks should the nurse delegate to an assistive personnel (AP)?
A. Discuss outpatient resources with a client who has post-traumatic stress disorder
B. Create a plan of care for a client who is experiencing alcohol withdrawal
C. Explain sleep hygiene to a client who has insomnia
D. Stay with a client who has anorexia nervosa for 1 hour after mealtimes
Answer: D. Stay with a client who has anorexia nervosa for 1 hour after mealtimes
44. Nurse is teaching a group of newly licensed nurses about the use of mechanical restraints.
Which of the following information should the nurse include in the teaching?
A. Complete documentation about the client status every hour while they are in restraints
B. Maintain the client in restraints for a minimum of 4 hour
C. Apply restraints when other means of managing a client's behavior have failed
D. Request the provider assess the client with an 8 hour of application of restraints
Answer: C. Apply restraints when other means of managing a client's behavior have failed
45. Nurse is planning discharge teaching with a family member of a client who has a new
diagnosis of depression. Which of the following information about relapse should the nurse
include?
A. Additional acute episodes of depression are unlikely following in patient care
B. Early identification of changes such as decrease social involvement is important
C. Medication compliance will prevent further need for inpatient hospitalization
D. It is helpful to regularly reinforce to the client that things will get better
Answer: B. Early identification of changes such as decrease social involvement is important
46. Nurse is caring for a client who is in an abusive relationship and is assisting in the
development of a safety plan. Which of the following actions is the first component of a
safety plan?
A. Develop a code word that means “time to go.”
B. Identify signs of escalation of violence
C. Have a predetermined place to go in an event of violence
D. Keep a hidden packed bag of necessities

Answer: B. Identify signs of escalation of violence
47. Nurse is planning care for a client who has generalized anxiety disorder. Which of the
following levels of anxiety should the nurse plan to teach the client relaxation techniques?
A. Panic
B. Moderate
C. Severe
D. Mild
Answer: D. Mild
48. Nurse is assessing a client who has major depressive disorder and has been receiving
amitriptyline for 1 week which of the following outcomes should the nurse expect?
A. Rapid improvement in effect with 30 to 60 minutes after taking the medication
B. Greater risk of attempting suicide as affect and energy improve
C. Onset of frequent loose stools
D. Development of physiologic dependence on the medication
Answer: B. Greater risk of attempting suicide as affect and energy improve
49. A nurse is caring for four clients in an emergency department. The nurse should identify
that which of the following clients can give informed consent?
A. A 17- year- old client who lives with friends
B. a 50- year- old client who has a blood alcohol level of 80 milligrams per deciliter
C. a 35- year- old client who has major depressive disorder
D. a 65 -year- old client who just received a dose of morphine
Answer: C. a 35- year- old client who has major depressive disorder
50. A nurse in an emergency department is caring for a female adolescent who has a diagnosis
of bulimia nervosa and had a fainting episode during a ballet performance. Which of the
following statements by the parent acknowledges the client’s diagnosis?
A. “She works so hard at ballet. Will she still be able to perform?”
B. “She won't let me take the trash from her room I'm concerned about what she has in there.”
C. “She told me she was tired, so I did her chores for her today.”
D. “She is happier with her appearance now that she's lost some weight.”

Answer: B. “She won't let me take the trash from her room I'm concerned about what she has
in there.”
51. Nurse is preparing to discharge to hold an older adult client who attempted suicide. The
client lives alone and passed difficulty performing ADL’s. Which of the following referrals
should the nurse initiate (select all that apply)
A. Occupational therapy
B. Meal delivery services
C. Speech language pathologist
D. Physical therapy
E. Home health services
Answer: A. Occupational therapy
B. Meal delivery services
D. Physical therapy
E. Home health services
52. The nurse is reviewing the medication administration record for a client who is
experiencing adverse effects of chlorpromazine. The nurse should administer benztropine and
to relieve which of the following adverse effects?
A. blurred vision
B. orthostatic hypotension
C. dry mouth
D. acute dystonia
Answer: D. acute dystonia
53. The nurse is creating a plan of care for a client who has been placed in seclusion after
threatening to harm others on the unit which of the following interventions should the nurse
include in the plan?
A. Document the client’s behavior every 8 hours
B. Limit the client’s fluid intake to 50 mL/hr
C. Renew the prescription for the client every 4 hour
D. Toilet the client every 4 hour
Answer: C. Renew the prescription for the client every 4 hour

54. The nurse is teaching a newly licensed nurse about nursing care plans for clients who
have depressive disorders. Which of the following statements by the newly licensed nurse
indicates an understanding of the teaching?
A. “I will use the same plan of care and interventions for each client who has depression.”
B. “Each nurse will develop a separate plan of care for each client who has depression.”
C. “I will update the plan of care as a client’s manifestations of depression change.”
D. “An assistive - personnel can use the plan of care for client teaching.”
Answer: C. “I will update the plan of care as a client’s manifestations of depression change.”
55. The nurse is preparing to administer diazepam 7.5 IV bolus to a client for alcohol
withdrawal. Available is diazepam injection 5 mg/mL. How many mL should the nurse
administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not
use a trailing zero.
Answer: 1.5 ml
56. A nurse is providing teaching to the partner of a client who is in a rehabilitation program
for alcohol use disorder. The nurse should identify that which of the following statements by
the client's partner indicates an understanding of the teaching?
A. “I will avoid social events until my partner has completed treatment.”
B. “It is important for me to focus my attention on my partner's addiction.”
C. “I will not take charge of my partners or responsibilities.”
D. “I want my partner to promise to change addictive behaviours.”
Answer: C. “I will not take charge of my partners or responsibilities.”
57. A nurse in the emergency department is caring for four clients. Which of the following
clients is the nurse required to report as a potential victim of abuse?
A. High school age child who has bruises on the knees
B. An older adult client who is bed bound and has a stage IV pressure ulcer
C. An adolescent who has a vaginal candida infection
D. A young adult who is pregnant and has a sprained ankle
Answer: B. An older adult client who is bed bound and has a stage IV pressure ulcer
58. Nurse is caring for a client who gave birth to a stillborn baby. Which of the following
statements should the nurse make?

A. “You probably want to hold your baby.”
B. “I’ll stay with you just in case you want to talk.”
C. “I know how you must be feeling.”
D. “It hurts now but things will be better soon.”
Answer: B. “I’ll stay with you just in case you want to talk.”
59. A nurse is planning care for a client who has made repeated physical threats toward others
on the unit. Although the client does not want to leave the unit, the nurse requests the
provider to transfer the client to a unit that is equipped to manage my behavior. Which of the
following ethical principles should the nurse apply in this situation?
A. Nonmaleficence
B. Veracity
C. Justice
D. Autonomy
Answer: A. Nonmaleficence
60. 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 an increased risk for
depression?
A. The client is married
B. The client recently received a promotion at work
C. The client has COPD
D. The client is male
Answer: C. The client has COPD

ATIMENTAL MENTAL HEALTH C ATI HEALTH C PROCTORED
EXAM
1. A nurse is reviewing the medication administration record of a client who has major
depressive disorder and a new prescription for selegiline. The nurse should recognize that
which of the following client medications is contraindicated when taken with selegiline?
A. Warfarin
B. Fluoxetine

C. Calcium carbonate
D. Acetaminophen
Answer: B. Fluoxetine
2. A nurse in a long-term care facility is assessing a client who has dementia. Which of the
following findings should the nurse identify as a risk for this client?
A. Outside doors have locks
B. The bed is in the low position
C. Hallways are long distances
D. The room has an area rug
Answer: D. The room has an area rug
3. A nurse is providing behavioral 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. “Ask a family member to check the locks for you at night”
B. “Keep a journal of how often you check the locks each night”
C. “Snap a rubber band on your wrist when you think about checking the locks”
D. “Focus on abdominal breathing whenever you go to check the locks”
Answer: C. “Snap a rubber band on your wrist when you think about checking the locks”
4. A nurse in an inpatient mental health facility is assessing a client who has schizophrenia
and is taking haloperidol. Which of the following clinical findings is the nurse’s priority?
A. Insomnia
B. Urinary hesitancy
C. Headache
D. High fever
Answer: D. High fever
5. A nurse is caring for a client who has Alzheimer’s disease. Which of the following findings
should the nurse expect?
A. Failure to recognize familiar objects
B. Altered level of consciousness

C. Excessive motor activity
D. Rapid mood swings
Answer: A. Failure to recognize familiar objects
6. A nurse in a mental health facility is interviewing a new client. Which of the following
outcomes must occur if the nurse is to establish a therapeutic nurse-client relationship?
A. The nurse is seen as an authority figure
B. A written contract is established to clarify the steps of the treatment plan
C. The nurse maintains confidentiality unless the client’s safety is compromised
D. The nurse is seen as a friend
Answer: C. The nurse maintains confidentiality unless the client’s safety is compromised
7. A nurse is teaching a client who has a new prescription for disulfiram. Which of the
following statements by the client indicates an understanding of the teaching?
A. “If I cut myself, I can clean the wound with isopropyl alcohol”
B. “I can wear my cologne on special occasions”
C. “When I bake my favourite cookies, I can use pure vanilla extract for flavouring”
D. “I can continue to eat aged cheese and chocolate”
Answer: D. “I can continue to eat aged cheese and chocolate”
8. A nurse is planning care for a client who has narcissistic personality disorder. Which of the
following actions is appropriate for the nurse to include in the plan of care?
A. Ask the client to sign a no-suicide contract
B. Remain neutral when communicating with the client
C. Request an antipsychotic medication from the provider
D. Provide the client with high-calorie finger foods
Answer: B. Remain neutral when communicating with the client
9. 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. Urine specific gravity 1.029
B. Platelets 90,000/mm3
C. Urine pH 5.6

D. RBC 4.7/mm3
Answer: B. Platelets 90,000/mm3
10. A nurse is providing teaching about relapse prevention to a client who has schizophrenia.
Which of the following statements by the client indicates an understanding of the teaching?
A. “I should avoid being around others if I think I’m having a relapse”
B. “I should let my counsellor know if I am having trouble sleeping”
C. “I shouldn’t worry about the voices because they are a part of my illness”
D. “I should increase my carbohydrate intake to maintain my energy level”
Answer: B. “I should let my counsellor know if I am having trouble sleeping”
11. A nurse is assessing a client for negative manifestations of schizophrenia. Which of the
following findings should the nurse expect?
A. Echopraxia
B. Delusions
C. Anergia
D. Tangentiality
Answer: C. Anergia
12. A nurse is preparing for an interprofessional team meeting regarding a newly admitted
client who has major depressive disorder. Which of the following findings obtained during
the initial assessment is the priority to report to other disciplines?
A. Poor problem-solving skills
B. Markedly neglected hygiene
C. Significant weight loss
D. Psychomotor retardation
Answer: D. Psychomotor retardation
13. A nurse is preparing to administer methylphenidate 25 mg PO to a school age child who
has ADHD. Available is methylphenidate 10mg/5mL liquid. How many mL should the nurse
administer? (Round to nearest tenth)
Answer: 12.5

14. A nurse is caring for a school age child who has a fractured arm. The child has other
injuries that cause the nurse to suspect abuse. Which of the following actions is appropriate
for the nurse to take when assessing the child’s situation?
A. Ask the parents directly if the child’s fracture is due to physical abuse
B. Direct the parents to the waiting room before interviewing the child
C. Interview the child with the provider and social worker present
D. Ask clarifying questions as the child explains how the injuries occurred
Answer: D. Ask clarifying questions as the child explains how the injuries occurred
15. A nurse is assisting with obtaining consent for a client who has been declared legally
incompetent. Which of the following actions should the nurse take?
A. Ask the charge nurse to obtain informed consent
B. Contact the facility social worker to obtain consent
C. Request that the client’s guardian sign the consent
D. Explain implied consent to the clients family
Answer: C. Request that the client’s guardian sign the consent
16. A nurse in a mental health facility is reviewing a client’s medical record. Which of the
following actions should the nurse take first? (Click on the exhibit button for additional
information about the client. There are 3 tabs that contain separate categories of data)
A. Teach the client about nutritional needs
B. Initiate 0.9% sodium chloride with 40 mEq potassium chloride
C. Administer acetaminophen 500 mg PO
D. Encourage the client to attend group therapy sessions
Answer: B. Initiate 0.9% sodium chloride with 40 mEq potassium chloride
17. A nurse is assessing a client who has delirium. Which of the following findings requires
immediate intervention by the nurse?
A. Rapid mood swings
B. Command hallucinations
C. Impaired memory
D. Inappropriate speech patterns
Answer: A. Rapid mood swings

18. A nurse is developing a teach 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 n the teaching plan?
A. The client is at risk for aspiration during treatment
B. The client will experience a seizure during treatment
C. The client will require intubation after treatment
D. The client might have a headache after treatment
Answer: D. The client might have a headache after treatment
19. 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. Recent head injury
B. Hypothyroidism
C. Knee arthroplasty 1 month ago
D. Hepatitis B infection
Answer: A. Recent head injury
20. A nurse is developing a plan of care for a client who has paranoid personality disorder.
Which of the following actions should the nurse include in the plan?
A. Provide written information about the client’s treatment plan
B. Monitor the client for splitting behaviours
C. Encourage countertransference when developing the nurse-client relationship
D. Isolate the client from social or group interactions
Answer: D. Isolate the client from social or group interactions
21. A nurse is caring for a client who receives lamotrigine daily for bipolar disorder and
reports a rash on his arm. Which of the following actions should the nurse take?
A. Ask the client about a recent change in laundry detergent
B. Explain that the medication causes a temporary rash
C. Apply hydrocortisone cream on the client’s rash
D. Withhold the next dose of the medication
Answer: D. Withhold the next dose of the medication

22. A nurse is caring for a client who begins yelling and pacing around the room. Which of
the following actions should the nurse take? (select all that apply)
A. Stand directly in front of the client
B. Identify the client’s stressors
C. Request that security guards restrain the client
D. Talk to the client using short, simple sentences
E. Speak to the client in a loud voice
Answer: B. Identify the client’s stressors
D. Talk to the client using short, simple sentences
23. A nurse is developing a plan of care for a school-age child who has autism spectrum
disorder. Which of the following interventions should the nurse include in the plan?
A. Allow flexibility in the child’s daily schedule
B. Assign the child to a room with another child of the same age
C. Discourage the child from making eye contact with caregivers
D. Use a reward system for appropriate behavior
Answer: D. Use a reward system for appropriate behavior
24. A nurse is caring for a client who has post-traumatic stress disorder. Which of the
following clinical findings is associated with this disorder?
A. Depersonalization
B. Pressured speech
C. Hypervigilance
D. Compulsive behavior
Answer: A. Depersonalization
25. A nurse is teaching a client about the use of cognitive reframing for stress management.
Which of the following statements by the client indicates an understanding of the teaching?
A. “I will focus on a mental image while concentration on my breathing.”
B. “I will practice replacing negative thoughts with positive self-statements.”
C. “I will progressively relax each of my muscle groups when feeling stressed.”
D. “I will learn how to voluntarily control my blood pressure and heart rate.”
Answer: B. “I will practice replacing negative thoughts with positive self-statements.”

26. A nurse is caring for a client who has schizophrenia and has been taking chlorpromazine
for 5 years. Which of the following assessment tools should the nurse use to determine if the
client is experiencing adverse effects of the medication?
A. Addiction Severity Index (ASI)
B. Mood Disorder Questionnaire (MDQ)
C. Abnormal Involuntary Movement Scale (AIMS)
D. Hamilton Depression Scale
Answer: C. Abnormal Involuntary Movement Scale (AIMS)
27. A nurse in a mental health facility is assessing a client for suicide risk factors using the
SAD PERSONS scale. Which of the following finding indicates a risk suicide?
A. The client is married
B. The client has diabetes mellitus
C. The client is 50 years of age
D. The client is female
Answer: B. The client has diabetes mellitus
28. 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. Help the client focus on a wide variety of topics regarding the crisis
C. Tell the client that his life will soon return to normal
D. Encourage the client to display anger toward the cause of the crisis
Answer: A. Identify the client’s usual coping style
29. A nurse is caring for a client who has schizophrenia and is experiencing auditory
hallucinations. Which of the following actions should the nurse take first?
A. Encourage the client to listen to music
B. Monitor the client for indications of anxiety
C. Ask the client what she is missing
D. Focus the client on reality-based topics
Answer: D. Focus the client on reality-based topics

30. A nurse is planning to lead a support group for clients who have alcohol use disorder. One
of the group members is a client who speaks a different language than the nurse. The nurse
should ask which of the following individuals to assist with communication?
A. A family member of the client
B. Another client who speaks the same language as the client
C. A translator of the same gender as the client
D. A unit secretary who speaks the same language as the client
Answer: C. A translator of the same gender as the client
31. A nurse in an emergency department is assessing a client who reports recently using
cocaine. Which of the following clinical manifestations should the nurse expect?
A. Lethargy
B. Hypothermia
C. Hypertension
D. Bradycardia
Answer: C. Hypertension
32. A nurse is caring for a client who has severe depression and is scheduled to receive
electroconvulsive therapy. The nurse should recognize that the client will receive
succinylcholine to prevent which of the following adverse effects?
A. Muscle distress
B. Aspiration
C. Elevated blood pressure
D. Decreased heart rate
Answer: A. Muscle distress
33. 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. Heart rate 56/min
C. Weight 10% below ideal weight
D. Potassium 3.8 mEq/L
Answer: A. Temperature 35.6 C (96.1 F)

34. A nurse is caring for a client who is under observation for suicidal ideations and has
verbalized a suicide plan. The client demands privacy and to be left alone. Which of the
following statements should the nurse make?
A. “Since you are trying to follow the treatment plan, we can submit your request to the
provider.”
B. “We are concerned about you and need to keep you safe.”
C. “Until your medication has reached therapeutic levels, you will need constant
observation.”
D. “If you complete a contract that states you will not harm yourself, you can be alone.”
Answer: B. “We are concerned about you and need to keep you safe.”
35. A nurse on a mental health unit is leading a therapy session for a group of clients. One
client challenges the nurse and shows no empathy for others in the group. Which of the
following actions should the nurse take?
A. Request that the client leave the therapy session immediately
B. Place the client in seclusion
C. Reassign the client to another group
D. Ask the client privately what is causing the anger
Answer: D. Ask the client privately what is causing the anger
36. A nurse in a mental health clinic is assessing a client who has borderline personality
disorder. Which of the following findings should the nurse expect?
A. Inability to maintain employment
B. Intense efforts to avoid abandonment
C. Avoidance of interpersonal relationships
D. Reluctance to discard worthless objects
Answer: B. Intense efforts to avoid abandonment
37. A nurse in a long-term care facility is assessing an older adult client for depression.
Which of the following findings should the nurse expect?
A. Rapid mood swings
B. Sun downing
C. Insomnia
D. Rambling speech

Answer: C. Insomnia
38. A nurse is assessing a client who has been taking thioridazine for 2 weeks. The client
reports an inability to be still. Which of the following adverse effects should the nurse
suspect?
A. Tardive dyskinesia
B. Pseudo parkinsonism
C. Akathisia
D. Acute dystonia
Answer: C. Akathisia
39. 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. Clinical nurse specialist
B. Social worker
C. Occupational therapist
D. Recreational therapist
Answer: B. Social worker
40. A nurse is interviewing a client who was recently sexually assaulted. The client cannot
recall the attack. The nurse should identify that the client is using which of the following
defense mechanisms?
A. Sublimation
B. Reaction formation
C. Suppression
D. Repression
Answer: D. Repression
41. A nurse is assessing a client who has antisocial personality disorder. Which of the
following client behaviours should the nurse expect?
A. Attention-seeking
B. Anxious
C. Projects blame

D. Manipulative
Answer: D. Manipulative
42. A nurse is caring for a client who has physical restraints applied. The nurse determines
that the restraints should be removed when which of the following occurs?
A. The client states that he will harm himself unless the restraints are removed
B. The client refuses to take his medication unless he is released
C. The client demonstrates that he is oriented to person, place, and time
D. The client is able to follow commands
Answer: D. The client is able to follow commands
43. A nurse is caring for a client who states, “Things will never work out.” Which of the
following responses should the nurse make?
A. “Why do you feel like things will never work?”
B. “Have you been thinking about harming yourself?”
C. “You should try to focus on yourself for a change.”
D. “Maybe an antidepressant will make you feel better.”
Answer: B. “Have you been thinking about harming yourself?”
44. A nurse in an emergency department is caring for a client who reports a recent sexual
assault by her partner. Which of the following statements is the priority for the nurse make?
A. “I want you to know that you are in a safe place here.”
B. “I can contact a support person for you.”
C. “A trained sexual-assault nurse will be assigned to your care.”
D. “I can provide information about an advocacy group in your area”
Answer: A. “I want you to know that you are in a safe place here.”
45. After assessing a client in a crisis situation, a nurse determines the client is safe. Which of
the following actions should the nurse take first?
A. Help the client identify social support
B. Involve the client in planning interventions
C. Assist the client to lower his anxiety level
D. Teach the client specific coping skills to handle stressful situations
Answer: C. Assist the client to lower his anxiety level

46. A nurse is assessing a client who has bulimia nervosa. Which of the following findings
should the nurse expect?
A. Acrocyanosis
B. Amenorrhea
C. Lanugo
D. Hyponatremia
Answer: A. Acrocyanosis
47. A nurse is caring for client who reports smoking marijuana several times per day. The
client tells the nurse, “ I don’t know what the big deal is marijuana is a harmless herb” The
nurse should identify that the client is displaying which of the following mechanisms?
A. Rationalization
B. reaction formation
C. compensation
D. suppression
Answer: A. Rationalization
48. 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. identify and schedule alternative group activities for the client
B. encourage physical activity for the client during the day
C. discourage the client from expressing feelings of anger
D. keep a bright light on in the client’s room at night.
Answer: B. encourage physical activity for the client during the day
49. A nurse is teaching the family of a client who has Alzheimer’s disease about the safety
interventions for nighttime wandering, which of the following interventions should the nurse
include?
A. place rubber backed throw rugs on tile floors
B. encourage the client to take naps during the day
C. install locks at the bottom of exit doors
D. place the clients mattress on the floor.
Answer: C. install locks at the bottom of exit doors

50. A nurse in a mental health facility is reviewing the lab results of a client who is taking
lithium carbonate. Which of the following findings places the client at risk for lithium
toxicity.
A. calcium 10.0
B. WBC 6,0000
C. sodium 132 mEq/L
D. aspartate aminotransferase 40 units/L
Answer: C. sodium 132 mEq/L
51. a nurse in an acute care facility is planning care for a client who has a history of alcohol
use disorder and is admitted while intoxicated. Which of the following interventions should
the nurse plan for the client
A. monitor for orthostatic hypotension
B. administer methadone hydrochloride
C. implement seizure precautions
D. acidify the client’s urine
Answer: C. implement seizure precautions
52. a nurse is developing a safety plan for a client who has experienced intimate partner
abuse. Which of the following items should the nurse include in the plan that will provide
immediate safety for the client and her children?
A. the phone numbers for law enforcement agencies
B. a code phrase to use when it is time to leave the house
C. the phone number of the local shelter
D. a referral to a support group
Answer: C. the phone number of the local shelter
53. 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. Denial
B. Rationalization

C. displacement
D. compensation
Answer: C. displacement
54. A nurse is observing a newly licensed nurse administer an IM medication to a client who
is manic and refuses the medication. Which of the following actions should the nurse take
first?
A. stop the newly licensed nurse from administering the medication
B. call the provider for an alternate medication route
C. report the occurrence to the nurse manager
D. talk to the newly licensed nurse about the incident
Answer: A. stop the newly licensed nurse from administering the medication
55. A nurse is planning care for a client who demonstrates prolonged depression related to the
loss of her partner 6 months ago. Which of the following actions should the nurse take?
A. explain that it can take a year or more to learn to live with loss
B. discourage the client from reliving the events surrounding her loss
C. suggest that the client avoid social interactions that remind her of her partner
D. direct the client to maintain an unstructured daily routine
Answer: A. explain that it can take a year or more to learn to live with loss
56. A nurse is caring for a client who has bipolar disorder. The client is walking in and out of
rooms, speaking inappropriately, and giggling. Which of the following actions should the
nurse take?
A. tell the client there will be negative consequences for her behavior
B. take the client to the day room to watch a movie with the other clients
C. have the client return to her room to read a book
D. lead the client outside for a walk
Answer: D. lead the client outside for a walk
57. A nurse is admitting a client who has a new diagnosis of schizophrenia and a history of
aggression. Which of the following actions should the nurse include in the clients initial plan
of care?
A. agree with the client when he is upset until he can calm down

B. provide physical exercise activity for the client
C. avoid eye contact with the client for the first few days
D. ignore the clients hallucinations
Answer: B. provide physical exercise activity for the client
58. a nurse is caring for a client who has bipolar disorder and is exhibiting mania. Which of
the following findings should the nurse expect?
A. disorganized speech
B. heightened concentration
C. hypersomnia
D. agoraphobia
Answer: A. disorganized speech
59. a nurse is caring for a client who has schizophrenia. The client’s employer calls to discuss
the client’s condition. Which of the following is the appropriate nursing action?
A. consult the client
B. consult the client’s family
C. contact the provider
D. contact the facility legal department
Answer: A. consult the client
60. A nurse is providing teaching to a client who is prescribed methylphenidate for ADHD.
Which of the following statements by the client indicates accurate understanding of this
medications effects?
A. I know that I will be able to think more clearly now
B. this medicine will help me relax and feel less anxious
C. I’ll take my medicine at bedtime because it will make my drowsy
D. I need to tell my doctor if I start gaining weight
Answer: A. I know that I will be able to think more clearly now
61. 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 very uninterested in routine activities. The
daughter states “ I’m so worried that my mother is depressed” Which of the following
responses should the nurse take?

A. “you shouldn’t worry about this, because depressive disorder is easily treated”
B. older adults are usually diagnosed with depressive disorder as they age
C. tell me the reasons you think your mother is depressed
D. everyone gets depressed from time to time.
Answer: C. tell me the reasons you think your mother is depressed
62. A nurse is providing teaching to a client who has a new prescription for tranylcypromine.
Which of the following over the counter medications should the nurse instruct the client to
avoid taking due to adverse interactions?
A. Ranitidine
B. Pseudoephedrine
C. Ibuprofen
D. magnesium hydroxide
Answer: B. Pseudoephedrine
63. A nurse in the ED is admitting a client who has a history of alcohol use disorder. The
client has a blood alcohol level of 0.26 g/dl. The nurse should anticipate a prescription for
which of the following medications?
A. Disulfiram
B. Chlordiazepoxide
C. Naltrexone
D. Acamprosate
Answer: B. Chlordiazepoxide
64. A nurse is building a therapeutic relationship with a client who has an eating disorder.
Which of the following activities should the nurse initiate during the relationships orientation
phase?
A. Mutually deciding and agreeing on the goals of the relationship
B. using memories to validate the relationship experience
C. discussing the incorporation of new strategies into daily life
D. teaching and encouraging the use of problem solving skills
Answer: A. Mutually deciding and agreeing on the goals of the relationship

65. A nurse is assessing a client who has schizophrenia. The client tells the nurse, “My heart
exploded and my blood is draining out” The nurse should interpret this statement as which of
the following manifestations?
A. concrete thinking
B. a visual hallucination
C. a somatic delusion
D. paranoia
Answer: C. a somatic delusion
66. A nurse is interviewing a client who has schizophrenia. The client states, “aliens are going
to abduct me at midnight tonight” Which of the following responses should the nurse make?
A. why are the aliens going to abduct you?
B. you are safe from aliens here
C. believing that aliens will abduct you must be scary
D. have you ever been abducted by aliens before?
Answer: C. believing that aliens will abduct you must be scary
67. A nurse is caring for a client who has generalized anxiety disorder and a history of
substance abuse use disorder. Which of the following medications would the nurse expect the
provider to prescribe?
A. Chlordiazepoxide
B. Clonazepam
C. Buspirone
D. Alprazolam
Answer: C. Buspirone
68. A nurse in an ED is creating a plan of care for a client who reports experiencing intimate
partner violence. Which of the following interventions should the nurse include as the
priority?
A. teach the client stress reduction techniques
B. help the client devise a safety plan
C. refer the client to a support group
D. follow the facilities protocol for reporting the abuse
Answer: D. follow the facilities protocol for reporting the abuse

69. A nurse in a mental health facility is caring for a client who is being aggressive toward
other clients. Which of the following actions is the priority for the nurse to take?
A. Assist the client to explore techniques to reduce stress
B. Ask the client if he intends to harm others,
C. role model healthy ways to express anger
D. suggest the client make a list of things that make him angry.
Answer: B. Ask the client if he intends to harm others,
70. A nurse in the ED is caring for a client who has serotonin syndrome. The nurse should
assess the client for which of the following manifestations?
A. Hyperpyrexia
B. Priapism
C. Parathesisa
D. bradycardia
Answer: A. Hyperpyrexia
1. 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. Use therapeutic hold technique
C. Apply wrist restraints
D. Administer risperidone
Answer: A. Place the child in seclusion
2. 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. Chest x-ray
B. ECG
C. Coagulation studies
D. Liver function test
Answer: B. ECG

3. A nurse is caring for a client who exhibits excessive compliance, passivity, and self-denial.
The nurse should recognize that these findings are associated with which of the following
personality disorders?
A. Dependent
B. Paranoid
C. Borderline
D. Histrionic
Answer: A. Dependent
4. 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. Inform the client that he does not have the right to refuse medication
B. Administer the medication to the client via IM injection
C. Offer the client the medication at the next scheduled dose time
D. Implement consequences until the client take the medication
Answer: C. Offer the client the medication at the next scheduled dose time
5. A nurse is caring for a client in the emergency department who states she was beaten and
sexually assault by her partner. After a rapid assessment, which of the following actions
should the nurse plan to take next?
A. Conduct a pregnancy test
B. Requests mental health consultation for the client
C. Provide a trained advocate to stay with the client
D. Offer prophylactic medication to prevent STI’s
Answer: D. Offer prophylactic medication to prevent STI’s
6. 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. Request that the client’s partner sign the consent form
B. Cancel the scheduled ECT procedure
C. Proceed with the preparation for ECT based on implied consent

D. Inform the client about the risks of refusing the ECT
Answer: B. Cancel the scheduled ECT procedure
7. 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. Rationalization
B. Denial
C. Compensation
D. Displacement
Answer: D. Displacement
8. A nursing 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. Please don’t take what the client said seriously when she is depressed
B. It’s important that the client feel safe verbalizing how she is feeling
C. Everybody feels that way about this client so don’t worry about it
D. I’ll change your assignment to someone who doesn’t have depressive disorder
Answer: B. It’s important that the client feel safe verbalizing how she is feeling
9. A nurse is assessing a child in the emergency department. Which of the following findings
places the child at the greatest risk for physical abuse?
A. The child is 10years old
B. The child is homeschooled
C. The has no siblings
D. The child has cystic fibrosis
Answer: D. The child has cystic fibrosis
10. A nurse is providing behavioral 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. Keep a journal of how often you check the locks each night
B. Snap a rubber band on your wrist when you think about checking the locks
C. Ask a family member to check the lock for you at night
D. Focus on abdominal breathing whenever you go to check the locks
Answer: B. Snap a rubber band on your wrist when you think about checking the locks
11. A nurse is assessing a client who is experiencing alcohol withdrawal. For which of the
following findings should the nurse anticipate administration of lorazepam
A. Bradycardia
B. Stupor
C. Afebrile
D. Hypertension
Answer: A. Bradycardia
12. A nurse is creating a plan of care of a client who has anorexia nervosa. Which of the
following intervention should the nurse include in the plan?
A. Weigh the client twice per day
B. Prepare the client for electroconvulsive therapy
C. Set a weight gain goal of 2.2kg (5lbs) per week
D. Encourage the client to participate in family therapy
Answer: D. Encourage the client to participate in family therapy
13. A nurse is planning care for a 3-year-old child who has autism spectrum disorder. Which
of the following finding should the nurse expect?
A. Readily initiates conversation
B. Enjoys imaginative play
C. Strong relationship with sibling and peers
D. Attachment to objects that spin
Answer: d. Attachment to objects that spin
14. A nurse is planning care for a client who has bipolar disorder. The client reports not
sleeping for 3 days and is exhibiting a euphoric mood. The nurse should identify which of the
following as the priority intervention.
A. Secure the client’s valuable possessions

B. Limit loud noises in the client’s environment
C. Encourage the client to participate in structured solitary activities
D. Provide high calorie snacks to the client
Answer: B. Limit loud noises in the client’s environment
15. A nurse is evaluating the medication response of a client who takes naltrexone for the
treatment of alcohol use disorder. The nurse should identify that which of the following is a
therapeutic effect of this medication.
A. Blocks aldehyde dehydrogenase
B. Prevents the anxiety of abstinence
C. Reduces substance craving
D. Decreases the likelihood of seizures
Answer: C. Reduces substance craving
16. 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 come it is to drink.” The nurse should recognize that the
client is displaying which of the following defense mechanisms?
A. Repression
B. Rationalization
C. Introjection
D. Intellectualization
Answer: B. Rationalization
17. 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. How does this situation affect your life?
B. Do you see your current situation affecting your future?
C. Can you describe how you are currently feeling?
D. How have you dealt with similar situations in the past
Answer: C. Can you describe how you are currently feeling?
18. 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
intervention is the nurse’s priority at this time?

A. Contact the adolescent’s parents
B. Suggest the adolescent join support groups
C. Ask the adolescent if he is considering hurting himself
D. Determine when the adolescent’s change in behavior began
Answer: D. Determine when the adolescent’s change in behavior began
19. A nurse is assessing a client who is withdrawing from heroin. Which of the following
manifestations should the nurse expect?
A. Slurred speech
B. Hypotension
C. Bradycardia
D. Hyperthermia
Answer: A. Slurred speech
20. A nurse is assessing a client who has histrionic personality disorder. Which of the
following finds should the nurse expect?
A. Lack of remorse
B. Attention seeking
C. Splitting of staff
D. Identity disturbance
Answer: B. Attention seeking
21. 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 provide my mother with detailed instructions about how to perform self-care
C. I will wake my mother up a couple of times in the night to check on her
D. I will discourage my mother from talking about physical complaints
Answer: A. I will limit my mother’s clothing choices when she is getting dressed
22. 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. Self-mutation

B. Pacing back and forth
C. Preoccupation with details
D. Disorganized speech
Answer: A. Self-mutation
23. A nurse is reviewing the laboratory results on adolescent who has anorexia nervosa.
Which of the following findings should the nurse expect?
A. Blood glucose 100 mg/dL
B. T4 11 mcg/dL
C. Potassium 3.7 mEq/L
D. Hgb 10 g/dL
Answer: D. Hgb 10 g/dL
24. A nurse is teaching about benztropine to a client who has schizophrenia. Which of the
following statements should the nurse include in the teaching?
A. This medication is given to help with extrapyramidal side effects
B. This medication is given to help with your depression
C. Benztropine helps alleviate your hallucinations
D. Benztropine is used to counteract your tachycardia
Answer: A. This medication is given to help with extrapyramidal side effects
25. A nurse is planning care for a client with acute delirium. Which of the following
instructions should the nurse include in the plan?
A. Reinforce the clients orientation with the calendar
B. Refute the clients perception of visual hallucinations
C. Teach the client assertive techniques
D. Assigned the client to a different caregiver each shift
Answer: A. Reinforce the clients orientation with the calendar
26. 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. Discouraged client from expressing feelings of anger
B. Identify and schedule alternative group activities for the client
C. Encourage physical activity for the client during the day

D. Keep a bright light on in the clients room at night
Answer: C. Encourage physical activity for the client during the day
27. A nurse is caring for a client who has posttraumatic stress disorder related to military
service. Which of the following actions should the nurse take?
A. Encourage the client to suppress feelings of trauma
B. Assign the same staff to care for the client each day
C. Address the client in an authoritative manner
D. Limit the amount of time spent with the client
Answer: B. Assign the same staff to care for the client each day
28. A nurse is providing teaching for school age child and his parents regarding a new
prescription for risperidone. Which of the following statements by the parent indicates an
understanding of the teaching?
A. I will provide a low sodium diet for my son
B. I will make sure my son takes the last dose of the day by 4 PM
C. I should expect my son to develop hand tremors
D. I should contact my doctor if my son urinates excessively
Answer: C. I should expect my son to develop hand tremors
29. A nurse is caring for a client who has a lithium level of 0.8 mEq/L. Which of the
following actions should the nurse take?
A. Withhold the next does of lithium
B. Repeat the lithium level test
C. Administer the next does of lithium
D. Recommended a low sodium diet
Answer: C. Administer the next does of lithium
30. A nurse in a community mental health clinic is caring for a group of clients. The nurse
should encourage participation in cognitive behavioral family therapy in response to which of
the following client statements.
A. I want to learn how to change the way I react to problems within my family
B. I want to understand why my past experiences are affecting my family relationships
C. I want to improve my family’s understanding of each other’s boundaries

D. I want each of my family members to be more aware of each other’s feelings
Answer: D. I want each of my family members to be more aware of each other’s feelings
31. A nurse is providing teaching to the caregiver of an older adult client who has
Alzheimer’s disease and is being cared for at home. The client wonders at night and has a
history of previous falls. Which of the fund instructions should nurse including? (select all) in
the teaching
A. position the mattress on the floor
B. Install sensor devices on outside doors
C. Encourage physical activity prior to bedtime
D. put locks at top of doors
E. place the client in a reclining chair
Answer: D. put locks at top of doors
32. A nurse is reviewing laboratory values for a client who has bipolar disorder and a
prescription for lithium. The nurse should identify that which of the following laboratory
results places the client at risk for lithium toxicity?
A. Calcium 9.0 mg/dL
B. sodium 130 mEq/L
C. chloride 98 mEq/L
D. potassium 5.0 mEq/L
Answer: B. sodium 130 mEq/L
33. A nurse is assisting with obtaining informed consent from client who has been declared
legally incompetent. Which of the following actions should the nurse take?
A. Contact the facility social worker to obtain the consent
B. Explain implied consent to the clients family
C. Request that the clients Guardian signed the consent
D. Ask the charge nurse to obtain an informed consent
Answer: C. Request that the clients Guardian signed the consent
34. A nurse is giving a presentation about intimate partner abuse for community group.
Which of the following statements buy a group member indicates understanding of teaching?
A. Survivors of abuse often feel guilty

B. abusers often have high self-esteem
C. the honeymoon stage of violence usually gets longer over time
D. as abuse continues, victims become more determined to be independent
Answer: A. Survivors of abuse often feel guilty
35. A nurse is planning care for a client who has experienced intimate partner abuse. The
nurse should identify which of the following outcomes as the priority?
A. The client joins a support group
B. the client identifies techniques to reduce her stress
C. The client develops a safety plan
D. The client identify support systems
Answer: C. The client develops a safety plan
36. A nurse is developing a behavioral contract with the client who has antisocial personality
disorder. Which of the following client goals should the nurse include in the contract?
A. Use projection during group therapy
B. increase self-esteem
C. use bargaining skills for behavioral consequences
D. Decrease the number of verbal outbursts
Answer: D. Decrease the number of verbal outbursts
37. A nurse is caring for a client who has schizophrenia and takes clozapine. Which of the
following findings is a priority for the nurse to report to the provider?
A. Nausea
B. Random blood glucose 130 mg/dL
C. Heart rate 104 per minute
D. sore throat
Answer: D. sore throat
38. A nurse is counseling and adult client whose parent just died. The client states, “My son is
4, and I don’t know how he’ll react when he finds out that grandpa died.” The nurse should
inform the client that the preschool age child commonly has which of the following concepts
of death?
A. Death is not permanent and the loved one may come back to life

B. Death is contagious and can cause other people he loves to die
C. Death creates an interest in the physical aspects of dying
D. Death is a part of life that eventually happens to everyone
Answer: A. Death is not permanent and the loved one may come back to life
39. A nurse is reviewing the medical records for clients. Which of the following findings
should the nurse identified as a risk factor for violent behavior?
A. Schizoid personality disorder
B. Alcohol intoxication
C. Dysthymic disorder
D. long-term isolation
Answer: B. Alcohol intoxication
40. A nurse in a provider’s office is assessing a school age child who has a spiral fracture. The
parent of the child provides different accounts for the cause of the injury. Which of the
following actions should the nurse take first?
A. Request that the parent leaves the room while you interview the child
B. Report suspected abuse to child protective services
C. Ask the child how the injury occurred d.
D. Determine the immediate safety needs of the child
Answer: D. Determine the immediate safety needs of the child
41. An older adult client is brought to the mental 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. Older adults are usually diagnosed with depressive disorder as they age
B. everyone gets depressed from time to time
C. you shouldn’t worry about this, because depressive disorder is easily treated
D. tell me the reasons you think your mother is depressed
Answer: D. tell me the reasons you think your mother is depressed
42. A nurse in a mental health facility is caring for a client. Which of the following actions
the nurse take during though working phase of the nurse-client relationship?

A. Summarize goals and objectives
B. Address confidentiality c.
C. promote problem-solving skills
D. establish a participation contract
Answer: C. promote problem-solving skills
43. a nurse is caring for a client who suddenly directs profanities at her, then abruptly hangs
his head and says, “please forgive me, I’m not sure what came over me I don’t know why
said those things.” The nurse interprets this behavior as which of the following?
A. Emotional lability
B. Confabulation
C. flight of ideas
D. Neologism
Answer: A. Emotional lability
44. A nurse is providing teaching for the family of a client who has dementia. Which of the
following should the nurse include in the teaching as a contributing factor for this disorder?
A. Hypotension
B. alcohol use disorder
C. Dehydration
D. change in environment
Answer: B. alcohol use disorder
45. A nurse is caring for a client who has been taking valproic acid. Which of the following is
expected outcome of the medication?
A. The client reports improved short-term memory
B. the client has a decreased euphoric mood
C. the client reports absence of auditory hallucinations
D. the client has decreased anxiety
Answer: D. the client has decreased anxiety
46. A nurse is teaching a client who has major depressive disorder about electroconvulsive
therapy. Which of the phone information should the nurse include?
A. This therapy works as a cure for major depressive disorders

B. You will be awake and alert during the procedure
C. You might experience confusion for a few hours after treatment
D. This therapy will stimulate the vagus nerve to improve your mood
Answer: C. You might experience confusion for a few hours after treatment
47. A nurse emergency department is assessing a client who has major depressive disorder.
Which of the following actions should the nurse take? (Exhibit question)
A. ask the client if she has eaten foods containing tyramine
B. Give regular insulin subcutaneously to the client
C. Prepare the client for electroconvulsive therapy
D. administer dantrolene IV bolus to the client
Answer: A. ask the client if she has eaten foods containing tyramine
48. 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. Urine specific gravity 1.029
B. Platelets 90,000/mm3
C. urine pH 5.6
D. RBC 4.7/mm3
Answer: B. Platelets 90,000/mm3
49. A nurse is caring for a client who has schizophrenia and started taking clozapine two
months ago. Which of the following laboratory results should the nurse report to the
provider?
A. WBC 3,000/mm3
B. Potassium 4.2 mEq/L
C. Hgb 16 g/dL
D. Platelets 300,000/mm3
Answer: A. WBC 3,000/mm3
50. A nurse is assessing the boundaries of a client’s family one of the family members says to
the client, “ I know exactly what you’re thinking right now.” The nurse should recognize that
the following family boundaries?

A. Rigid
B. Inconsistent
C. Enmeshed
D. Clear
Answer: D. Clear
51. A nurse is assessing a client who requires bupropion for smoking cessation. Which of the
following findings in the client’s history should the nurse recognized as a contraindication for
taking this medication?
A. Seizures
B. Anaemia
C. Migraines
D. Asthma
Answer: A. Seizures
52. A nurse is caring for a client with Alzheimer’s disease. Which of the following actions
should the nurse take?
A. Seat the client at a dining table with six or more residents
B. provide the client with several choices for meal selection
C. give complete directions before starting client care
D. use symbols to assist the client in locating rooms
Answer: D. use symbols to assist the client in locating rooms
53. A nurse is assessing a newly admitted client who has schizophrenia and takes
thioridazine. Which of the following findings should the nurse document as an adverse effect
of this medication?
A. Anhedonia
B. Waxy flexibility
C. contractions of the jaw
D. incongruent affect
Answer: B. Waxy flexibility
54. A nurse in an inpatient mental health facility is assessing a client who has schizophrenia
and is taking haloperidol. Which of the following clinical findings is the nurse’s priority?

A. High fever
B. Insomnia
C. Urinary hesitancy
D. Headache
Answer: A. High fever
55. A nurse is speaking with a client. Which of the following responses by the nurse
demonstrates the communication technique of reflection?
A. “I would like to sit with you for a while”
B. “You feel upset when this happens?”
C. “Let’s work together to try to solve your problem”
D. “Can you tell me what is happening now?”
Answer: B. “You feel upset when this happens?”
56. A nurse is leading grief support group for bereaved clients. Which of the following client
statements should the nurse report to the provider as an indication of clinical depression?
A. “I don’t know how I could cope if I didn’t have my family’s support”
B. “It’ll be a long time before I’m happy again”
C. “I don’t feel anything but numbness anymore”
D. “I feel like I’m angry at the whole world right now”
Answer: C. “I don’t feel anything but numbness anymore”
57. A nurse is preparing to administer chlorpromazine hydrochloride 25 mg PO to an older
adult client. Available is chlorpromazine hydrochloride syrup 10 mg/5 mL. How many mL
should the nurse administer? (Round to nearest tenth)
Answer: 12.5
58. A nurse is teaching the parent of a school age child who has ADHD and a prescription for
atomoxetine 40 mg daily. Which of the following information should the nurse include in the
teaching?
A. Expect the child to gain weight while taking this medication
B. Crush the medication and mix it with 120 mL (4 oz) of juice
C. Therapeutic effects will occur within 24 hr of starting treatment
D. Administer the medication before the child goes to school in the morning

Answer: D. Administer the medication before the child goes to school in the morning
59. 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. Place the client in a group therapy session
B. Rotate staff members who work with the client
C. Encourage the client to participate in physical activities
D. Distract the client with increased environmental stimuli
Answer: C. Encourage the client to participate in physical activities
60. A nurse in a mental facility is assessing a client for suicide risk factors using the SAD
PERSONS scale. Which of the following findings indicates a risk for suicide?
A. The client is married
B. The client is female
C. The client is 50 years of age
D. The client has diabetes mellitus
Answer: D. The client has diabetes mellitus
61. A nurse is performing a mental status examination for a client who has schizophrenia. The
nurse should recognize that which of the following actions requires the client to think
abstractly?
A. Explain what to do if he misses the bus
B. Determine the meaning of a proverb
C. Name the last three presidents of the United States of America
D. Count by adding sevens consecutively
Answer: B. Determine the meaning of a proverb
62. A nurse is developing a plan of care for a school age child who has ADHD. Which of the
following interventions should the nurse include in the plan?
A. Administer olanzapine
B. Institute consequences for deliberate behaviours
C. Provide a stimulating environment
D. Encourage thought stopping techniques
Answer: C. Provide a stimulating environment

63. 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. Clinical nurse specialist
B. Recreational therapist
C. Social worker
D. Occupational therapist
Answer: C. Social worker
64. 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. Encourage the client to display anger toward the cause of the crisis
B. Tell the client that his life will soon return to normal
C. Identify the client’s usual coping style
D. Help the client focus on a wide variety of topics regarding the crisis
Answer: C. Identify the client’s usual coping style
65. A nurse is planning to conduct a support group for adolescents who have cancer. Which of
the following actions should the nurse include during the orientation phase?
A. Manage conflict within the group
B. Establish rapport with group members
C. Encourage the use of problem-solving skills
D. Maintain the group’s focus on identified issues
Answer: B. Establish rapport with group members
66. A nurse is assessing a client who recently started antidepressant therapy for the treatment
of major depressive disorder. Which of the following findings indicates the client is at an
increased risk for suicide?
A. Increased energy
B. Hypersomnia
C. Unkempt appearance
D. Psychomotor retardation

Answer: C. Unkempt appearance
67. A nurse in a rehabilitation unit is caring for a client who has a traumatic brain injury. To
which of the following members of the client’s interprofessional team should the nurse refer
the client in order to help him relearn how to use eating utensils?
A. Neuropsychiatrist
B. Occupational therapist
C. Physical therapist
D. Social worker
Answer: B. Occupational therapist
68. A nurse is caring for a group of clients on a mental health unit. For which of the following
clients is the nurse mandated to report to the appropriate agency?
A. A client who reports that she took $20 from the cash register where she works
B. A client who reports that her partner ties their child to a bed as punishment
C. A client who reports that he enjoys smoking marijuana on weekends
D. A client who reports lying to his provider about having suicidal ideation
Answer: B. A client who reports that her partner ties their child to a bed as punishment
69. 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. Recent head injury
B. Hepatitis B infection
C. Hypothyroidism
D. Knee arthroplasty 1 month ago
Answer: A. Recent head injury
70. A charge nurse is orienting a newly licensed nurse and observes the newly licensed nurse
imitating her behaviours. The nurse should recognize this behavior as which of the following
defense mechanisms?
A. Suppression
B. Reaction formation
C. Identification

D. Compensation
Answer: C. Identification
1. 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. Use therapeutic hold technique
C. Apply wrist restraints
D. Administer risperidone
Answer: A. Place the child in seclusion
2. 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. Chest x- ray
B. ECG
C. Coagulation studies
D. Liver function test
Answer: B. ECG
3. A nurse is caring for a client who exhibits excessive compliance, passivity, and self-denial.
The nurse should recognize that these findings are associated with which of the following
personality disorders?
A. Dependent
B. Paranoid
C. Borderline
D. Histrionic
Answer: A. Dependent
4. 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. Inform the client that he does not have the right to refuse medication

B. Administer the medication to the client via IM injection
C. Offer the client the medication at the next scheduled dose time
D. Implement consequences until the client take the medication
Answer: C. Offer the client the medication at the next scheduled dose time
5. A nurse is caring for a client in the emergency department who states she was beaten and
sexually assault by her partner. After a rapid assessment, which of the following actions
should the nurse plan to take next?
A. Conduct a pregnancy test
B. Requests mental health consultation for the client
C. Provide a trained advocate to stay with the client
D. Offer prophylactic medication to prevent STI’s
Answer: D. Offer prophylactic medication to prevent STI’s
6. 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. Request that the client’s partner sign the consent form
B. Cancel the scheduled ECT procedure
C. Proceed with the preparation for ECT based on implied consent
D. Inform the client about the risks of refusing the ECT
Answer: B. Cancel the scheduled ECT procedure
7. 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. Rationalization
B. Denial
C. Compensation
D. Displacement
Answer: D. Displacement

8. A nursing 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. Please don’t take what the client said seriously when she is depressed
B. It’s important that the client feel safe verbalizing how she is feeling
C. Everybody feels that way about this client so don’t worry about it
D. I’ll change your assignment to someone who doesn’t have depressive disorder
Answer: B. It’s important that the client feel safe verbalizing how she is feeling
9. A nurse is assessing a child in the emergency department. Which of the following findings
places the child at the greatest risk for physical abuse?
A. The child is 10years old
B. The child is homeschooled
C. The has no siblings
D. The child has cystic fibrosis
Answer: D. The child has cystic fibrosis
10. A nurse is providing behavioral 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. Keep a journal of how often you check the locks each night
B. Snap a rubber band on your wrist when you think about checking the locks
C. Ask a family member to check the lock for you at night
D. Focus on abdominal breathing whenever you go to check the locks
Answer: B. Snap a rubber band on your wrist when you think about checking the locks
11. A nurse is assessing a client who is experiencing alcohol withdrawal. For which of the
following findings should the nurse anticipate administration of lorazepam
A. Bradycardia
B. Stupor
C. Afebrile
D. Hypertension
Answer: A. Bradycardia

12. A nurse is creating a plan of care of a client who has anorexia nervosa. Which of the
following intervention should the nurse include in the plan?
A. Weigh the client twice per day
B. Prepare the client for electroconvulsive therapy
C. Set a weight gain goal of 2.2kg (5lbs) per week
D. Encourage the client to participate in family therapy
Answer: D. Encourage the client to participate in family therapy
13. A nurse is planning care for a 3-year-old child who has autism spectrum disorder. Which
of the following finding should the nurse expect?
A. Readily initiates conversation
B. Enjoys imaginative play
C. Strong relationship with sibling and peers
D. Attachment to objects that spin
Answer: D. Attachment to objects that spin
14. A nurse is planning care for a client who has bipolar disorder. The client reports not
sleeping for 3 days and is exhibiting a euphoric mood. The nurse should identify which of the
following as the priority intervention.
A. Secure the client’s valuable possessions
B. Limit loud noises in the client’s environment
C. Encourage the client to participate in structured solitary activities
D. Provide high calorie snacks to the client
Answer: B. Limit loud noises in the client’s environment
15. A nurse is evaluating the medication response of a client who takes naltrexone for the
treatment of alcohol use disorder. The nurse should identify that which of the following is a
therapeutic effect of this medication.
A. Blocks aldehyde dehydrogenase
B. Prevents the anxiety of abstinence
C. Reduces substance craving
D. Decreases the likelihood of seizures
Answer: C. Reduces substance craving

16. 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 come it is to drink.” The nurse should recognize that the
client is displaying which of the following defense mechanisms?
A. Repression
B. Rationalization
C. Introjection
D. Intellectualization
Answer: B. Rationalization
17. 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. How does this situation affect your life?
B. Do you see your current situation affecting your future?
C. Can you describe how you are currently feeling?
D. How have you dealt with similar situations in the past
Answer: C. Can you describe how you are currently feeling?
18. 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
intervention is the nurse’s priority at this time?
A. Contact the adolescent’s parents
B. Suggest the adolescent join support groups
C. Ask the adolescent if he is considering hurting himself
D. Determine when the adolescent’s change in behavior began
Answer: D. Determine when the adolescent’s change in behavior began
19. A nurse is assessing a client who is withdrawing from heroin. Which of the following
manifestations should the nurse expect?
A. Slurred speech
B. Hypotension
C. Bradycardia
D. Hyperthermia
Answer: A. Slurred speech

20. A nurse is assessing a client who has histrionic personality disorder. Which of the
following finds should the nurse expect?
A. Lack of remorse
B. Attention seeking
C. Splitting of staff
D. Identity disturbance
Answer: B. Attention seeking
21. 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 provide my mother with detailed instructions about how to perform self- care
C. I will wake my mother up a couple of times in the night to check on her
D. I will discourage my mother from talking about physical complaints
Answer: A. I will limit my mother’s clothing choices when she is getting dressed
22. 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. Self-mutation
B. Pacing back and forth
C. Preoccupation with details
D. Disorganized speech
Answer: A. Self-mutation
23. a nurse is reviewing the laboratory results on adolescent who has anorexia nervosa.
Which of the following findings should the nurse expect?
A. Blood glucose 100 mg/dL
B. T4 11 mcg/dL
C. Potassium 3.7 mEq/L
D. Hgb 10 g/dL
Answer: D. Hgb 10 g/dL

24. A nurse is teaching about benztropine to a client who has schizophrenia. Which of the
following statements should the nurse include in the teaching?
A. This medication is given to help with extrapyramidal side effects
B. This medication is given to help with your depression
C. Benztropine helps alleviate your hallucinations
D. Benztropine is used to counteract your tachycardia
Answer: A. This medication is given to help with extrapyramidal side effects
25. A nurse is planning care for a client with acute delirium. Which of the following
instructions should the nurse include in the plan?
A. Reinforce the clients orientation with the calendar
B. Refute the clients perception of visual hallucinations
C. Teach the client assertive techniques
D. Assigned the client to a different caregiver each shift
Answer: A. Reinforce the clients orientation with the calendar
26. 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. Discouraged client from expressing feelings of anger
B. Identify and schedule alternative group activities for the client
C. Encourage physical activity for the client during the day
D. Keep a bright light on in the clients room at night
Answer: C. Encourage physical activity for the client during the day
27. A nurse is caring for a client who has posttraumatic stress disorder related to military
service. Which of the following actions should the nurse take?
A. Encourage the client to suppress feelings of trauma
B. Assign the same staff to care for the client each day
C. Address the client in an authoritative manner
D. Limit the amount of time spent with the client
Answer: B. Assign the same staff to care for the client each day

28. A nurse is providing teaching for school age child and his parents regarding a new
prescription for risperidone. Which of the following statements by the parent indicates an
understanding of the teaching?
A. I will provide a low sodium diet for my son
B. I will make sure my son takes the last dose of the day by 4 PM
C. I should expect my son to develop hand tremors
D. I should contact my doctor if my son urinates excessively
Answer: C. I should expect my son to develop hand tremors
29. A nurse is caring for a client who has a lithium level of 0.8 mEq/L. Which of the
following actions should the nurse take?
A. Withhold the next does of lithium
B. Repeat the lithium level test
C. Administer the next does of lithium
D. Recommended a low sodium diet
Answer: C. Administer the next does of lithium
30. A nurse in a community mental health clinic is caring for a group of clients. The nurse
should encourage participation in cognitive behavioral family therapy in response to which of
the following client statements.
A. I want to learn how to change the way I react to problems within my family
B. I want to understand why my past experiences are affecting my family relationships
C. I want to improve my family’s understanding of each other’s boundaries
D. I want each of my family members to be more aware of each other’s feelings
Answer: D. I want each of my family members to be more aware of each other’s feelings
31. A nurse is providing teaching to the caregiver of an older adult client who has
Alzheimer’s disease and is being cared for at home. The client wonders at night and has a
history of previous falls. Which of the fund instructions should nurse including? (select all) in
the teaching
A. position the mattress on the floor
B. Install sensor devices on outside doors
C. Encourage physical activity prior to Bedtime
D. put locks at top of doors

E. place the client in a reclining chair
Answer: A. position the mattress on the floor
B. Install sensor devices on outside doors
D. put locks at top of doors
32. A nurse is reviewing laboratory values for a client who has bipolar disorder and a
prescription for lithium. The nurse should identify that which of the following laboratory
results places the client at risk for lithium toxicity?
A. Calcium 9.0 mg/Dl
B .sodium 130 mEq/L
C. chloride 98 mEq/L
D. potassium 5.0 mEq/L
Answer: B .sodium 130 mEq/L
33. A nurse is assisting with obtaining informed consent from client who has been declared
legally incompetent. Which of the following actions should the nurse take?
A. Contact the facility social worker to obtain the consent
B. Explain implied consent to the clients family
C. Request that the clients Guardian signed the consent
D. Ask the charge nurse to obtain an informed consent
Answer: C. Request that the clients Guardian signed the consent
34. A nurse is giving a presentation about intimate partner abuse for community group.
Which of the following statements buy a group member indicates understanding of teaching?
A. Survivors of abuse often feel guilty
B. abusers often have high self-esteem
C. the honeymoon stage of violence usually gets longer over time
D. as abuse continues, victims become more determined to be independent
Answer: A. Survivors of abuse often feel guilty
35. A nurse is planning care for a client who has experienced intimate partner abuse. The
nurse should identify which of the following outcomes as the priority?
A. The client joins a support group
B. the client identifies techniques to reduce her stress

C. The client develops a safety plan
D. The client identify support systems
Answer: C. The client develops a safety plan
36. A nurse is developing a behavioral contract with the client who has antisocial personality
disorder. Which of the following client goals should the nurse include in the contract?
A. Use projection during group therapy
B. increase self-esteem
C. use bargaining skills for behavioral consequences
D. Decrease the number of verbal outbursts
Answer: D. Decrease the number of verbal outbursts
37. A nurse is caring for a client who has schizophrenia and takes clozapine. Which of the
following findings is a priority for the nurse to report to the provider?
A. Nausea
B. Random blood glucose 130 mg/dL
C. Heart rate 104 per minute
D. sore throat
Answer: D. sore throat
38. A nurse is counseling and adult client whose parent just died. The client states, “My son is
4, and I don’t know how he’ll react when he finds out that grandpa died.” The nurse should
inform the client that the preschool age child commonly has which of the following concepts
of death?
A. Death is not permanent and the loved one may come back to life
B. Death is contagious and can cause other people he loves to die
C. Death creates an interest in the physical aspects of dying
D. Death is a part of life that eventually happens to everyone
Answer: A. Death is not permanent and the loved one may come back to life
39. A nurse is reviewing the medical records for clients. Which of the following findings
should the nurse identified as a risk factor for violent behavior?
A. Schizoid personality disorder
B. Alcohol intoxication

C. Dysthymic disorder
D. long-term isolation
Answer: B. Alcohol intoxication
40. A nurse in a provider’s office is assessing a school age child who has a spiral fracture. The
parent of the child provides different accounts for the cause of the injury. Which of the
following actions should the nurse take first?
A. Request that the parent leaves the room while you interview the child
B. Report suspected abuse to child protective services
C. Ask the child how the injury occurred
D. Determine the immediate safety needs of the child
Answer: D. Determine the immediate safety needs of the child
41. An older adult client is brought to the mental 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. Older adults are usually diagnosed with depressive disorder as they age
B. everyone gets depressed from time to time
C. you shouldn’t worry about this, because depressive disorder is easily treated
D. tell me the reasons you think your mother is depressed
Answer: D. tell me the reasons you think your mother is depressed
42. A nurse in a mental health facility is caring for a client. Which of the following actions
the nurse take during though working phase of the nurse- client relationship?
A. Summarize goals and objectives
B. Address confidentiality
C. promote problem-solving skills
D. establish a participation contract
Answer: C. promote problem-solving skills
43. a nurse is caring for a client who suddenly directs profanities at her, then abruptly hangs
his head and says, “please forgive me, I’m not sure what came over me I don’t know why
said those things.” The nurse interprets this behavior as which of the following?

A. Emotional lability
B. Confabulation
C. flight of ideas
D. Neologism
Answer: A. Emotional lability
44. A nurse is providing teaching for the family of a client who has dementia. Which of the
following should the nurse include in the teaching as a contributing factor for this disorder?
A. Hypotension
B. alcohol use disorder
C. Dehydration
D. change in environment
Answer: B. alcohol use disorder
45. A nurse is caring for a client who has been taking valproic acid. Which of the following is
expected outcome of the medication?
A. The client reports improved short-term memory
B. the client has a decreased euphoric mood
C. the client reports absence of auditory hallucinations
D. the client has decreased anxiety
Answer: D. the client has decreased anxiety
46. A nurse is teaching a client who has major depressive disorder about electroconvulsive
therapy. Which of the phone information should the nurse include?
A. This therapy works as a cure for major depressive disorders
B. You will be awake and alert during the procedure
C. You might experience confusion for a few hours after treatment
D. This therapy will stimulate the vagus nerve to improve your mood
Answer: C. You might experience confusion for a few hours after treatment
47. A nurse emergency department is assessing a client who has major depressive disorder.
Which of the following actions should the nurse take? (Exhibit question)
A. ask the client if she has eaten foods containing thyramine
B. Give regular insulin subcutaneously to the client

C. Prepare the client for electroconvulsive therapy
D. administer dantrolene IV bolus to the client
Answer: C. Prepare the client for electroconvulsive therapy
48. 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. Urine specific gravity 1.029
B. Platelets 90,000/mm3
C. urine pH 5.6
D. RBC 4.7/mm3
Answer: B. Platelets 90,000/mm3
49. A nurse is caring for a client who has schizophrenia and started taking clozapine two
months ago. Which of the following laboratory results should the nurse report to the
provider?
A. WBC 3,000/mm3
B. Potassium 4.2 mEq/L
C. Hgb 16 g/dL
D. Platelets 300,000/mm3
Answer: A. WBC 3,000/mm3
50. A nurse is assessing the boundaries of a client’s family one of the family members says to
the client, “ I know exactly what you’re thinking right now.” The nurse should recognize that
the following family boundaries?
A. Rigid
B. Inconsistent
C. Enmeshed
D. Clear
Answer: D. Clear
51. A nurse is assessing a client who requires bupropion for smoking cessation. Which of the
following findings in the client’s history should the nurse recognized as a contraindication for
taking this medication?

A. Seizures
B. Anaemia
C. Migraines
D. Asthma
Answer: A. Seizures
52. A nurse is caring for a client with Alzheimer’s disease. Which of the following actions
should the nurse take?
A. Seat the client at a dining table with six or more residents
B. provide the client with several choices for meal selection
C. give complete directions before starting client care
D. use symbols to assist the client in locating rooms
Answer: D. use symbols to assist the client in locating rooms
53. A nurse is assessing a newly admitted client who has schizophrenia and takes
thioridazine. Which of the following findings should the nurse document as an adverse effect
of this medication?
A. Anhedonia
B. Waxy flexibility
C. contractions of the jaw
D. incongruent affect
Answer: B. Waxy flexibility
54. A nurse in an inpatient mental health facility is assessing a client who has schizophrenia
and is taking haloperidol. Which of the following clinical findings is the nurse’s priority?
A. High fever
B. Insomnia
C. Urinary hesitancy
D. Headache
Answer: A. High fever
55. A nurse is speaking with a client. Which of the following responses by the nurse
demonstrates the communication technique of reflection?
A. “I would like to sit with you for a while”

B. “You feel upset when this happens?”
C. “Let’s work together to try to solve your problem”
D. “Can you tell me what is happening now?”
Answer: B. “You feel upset when this happens?”
56. A nurse is leading grief support group for bereaved clients. Which of the following client
statements should the nurse report to the provider as an indication of clinical depression?
A. “I don’t know how I could cope if I didn’t have my family’s support”
B. “It’ll be a long time before I’m happy again”
C. “I don’t feel anything but numbness anymore”
D. “I feel like I’m angry at the whole world right now”
Answer: C. “I don’t feel anything but numbness anymore”
57. A nurse is preparing to administer chlorpromazine hydrochloride 25 mg PO to an older
adult client. Available is chlorpromazine hydrochloride syrup 10 mg/5 mL. How many mL
should the nurse administer? (Round to nearest tenth)
Answer: 12.5
58. A nurse is teaching the parent of a school age child who has ADHD and a prescription for
atomoxetine 40mg daily. Which of the following information should the nurse include in the
teaching?
A. Expect the child to gain weight while taking this medication
B. Crush the medication and mix it with 120 mL (4 oz) of juice
C. Therapeutic effects will occur within 24 hr of starting treatment
D. Administer the medication before the child goes to school in the morning
Answer: D. Administer the medication before the child goes to school in the morning
59. 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. Place the client in a group therapy session
B. Rotate staff members who work with the client
C. Encourage the client to participate in physical activities
D. Distract the client with increased environmental stimuli
Answer: C. Encourage the client to participate in physical activities

60. A nurse in a mental facility is assessing a client for suicide risk factors using the SAD
PERSONS scale. Which of the following findings indicates a risk for suicide?
A. The client is married
B. The client is female
C. The client is 50 years of age
D. The client has diabetes mellitus
Answer: D. The client has diabetes mellitus
61. A nurse is performing a mental status examination for a client who has schizophrenia. The
nurse should recognize that which of the following actions requires the client to think
abstractly?
A. Explain what to do if he misses the bus
B. Determine the meaning of a proverb
C. Name the last three presidents of the United States of America
D. Count by adding sevens consecutively
Answer: B. Determine the meaning of a proverb
62. A nurse is developing a plan of care for a school age child who has ADHD. Which of the
following interventions should the nurse include in the plan?
A. Administer olanzapine
B. Institute consequences for deliberate behaviours
C. Provide a stimulating environment
D. Encourage thought stopping techniques
Answer: C. Provide a stimulating environment
63. 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. Clinical nurse specialist
B. Recreational therapist
C. Social worker
D. Occupational therapist
Answer: C. Social worker

64. 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. Encourage the client to display anger toward the cause of the crisis
B. Tell the client that his life will soon return to normal
C. Identify the client’s usual coping style
D. Help the client focus on a wide variety of topics regarding the crisis
Answer: C. Identify the client’s usual coping style
65. A nurse is planning to conduct a support group for adolescents who have cancer. Which of
the following actions should the nurse include during the orientation phase?
A. Manage conflict within the group
B. Establish rapport with group members
C. Encourage the use of problem-solving skills
D. Maintain the group’s focus on identified issues
Answer: B. Establish rapport with group members
66. A nurse is assessing a client who recently started antidepressant therapy for the treatment
of major depressive disorder. Which of the following findings indicates the client is at an
increased risk for suicide?
A. Increased energy
B. Hypersomnia
C. Unkempt appearance
D. Psychomotor retardation
Answer: C. Unkempt appearance
67. A nurse in a rehabilitation unit is caring for a client who has a traumatic brain injury. To
which of the following members of the client’s interprofessional team should the nurse refer
the client in order to help him relearn how to use eating utensils?
A. Neuropsychiatrist
B. Occupational therapist
C. Physical therapist
D. Social worker

Answer: B. Occupational therapist
68. A nurse is caring for a group of clients on a mental health unit. For which of the following
clients is the nurse mandated to report to the appropriate agency?
A. A client who reports that she took $20 from the cash register where she works
B. A client who reports that her partner ties their child to a bed as punishment
C. A client who reports that he enjoys smoking marijuana on weekends
D. A client who reports lying to his provider about having suicidal ideation
Answer: B. A client who reports that her partner ties their child to a bed as punishment
69. 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. Recent head injury
B. Hepatitis B infection
C. Hypothyroidism
D. Knee arthroplasty 1 month ago
Answer: A. Recent head injury
70. A charge nurse is orienting a newly licensed nurse and observes the newly licensed nurse
imitating her behaviours. The nurse should recognize this behavior as which of the following
defense mechanisms?
A. Suppression
B. Reaction formation
C. Identification
D. Compensation
Answer: C. Identification