ATI PN MENTAL HEALTH PROCTORED EXAM, PN MENTAL ATI
PROCTORED EXAM 2022 COMPLETE QNS & ANS WITH RATIONALES
A+ GUIDE.
1. A nurse is collecting data from a client who is experiencing alcohol withdrawal. Which of the
following findings should the nurse expect?
A. Elevated blood pressure
B. Decreased heart rate
C. Slurred speech
D. Rhinorrhea
Answer: A. Elevated blood pressure
Rationale: Hypertension is an expected finding of alcohol withdrawal and can occur within 4 to
12 hr of cessation of alcohol ingestion.
2. A nurse is caring for a client who recently lost their child in a motor-vehicle crash. The client
is expressing feelings of hopelessness. Which of the following questions is the most important
for the nurse to ask?
A. "Are there times when you feel more upset than others?"
B. "Have you had any thoughts of harming yourself?"
C. "What type of support system do you currently have?"
D. "During difficult times in the past, what did you do to cope?"
Answer: B. "Have you had any thoughts of harming yourself?"
Rationale: The greatest risk to this client is self-injury due to suicide. Asking whether or not the
client has plans to hurt themselves is the most important question for the nurse to ask at this time
because a positive response can alert the nurse to the need for suicide precautions and
intervention.
3. A nurse is reviewing the medical record of a client who has schizophrenia. For which of the
following findings should the nurse withhold the client's medications and notify the provider?
A. Fasting blood glucose
B. Temperature
C. WBC count
D. Heart rate
Answer: C. WBC count
Rationale: The nurse should identify that a WBC count of 3,000/mm2 is below the expected
reference range of 5,000 to 10,000/mm2. The nurse should identify that clozapine can cause
agranulocytosis, a decrease in white blood cells, which can be life threatening.
Therefore, the nurse should withhold the client's medications and notify the provider of this
finding.
4. A nurse is collecting data from a client whose home was destroyed by a fire. Which of the
following responses should the nurse make first?
A. "Are you experiencing feelings of hopelessness?"
B. "Is there someone I can call for you?"
C. "It might be helpful for you to attend a support group."
D. "Now is a good time for you to use relaxation breathing."
Answer: A. "Are you experiencing feelings of hopelessness?"
Rationale: When using Maslow's hierarchy of needs, the priority action for the nurse to take is
to determine if the client is safe. The nurse should collect data about the client's feelings to
determine if the client is having feelings of hopelessness or suicidal ideations.
5. A nurse is collecting data from a client who is taking valproic acid for the treatment of a
bipolar disorder. Which of the following findings is the priority to the provider?
A. Dizziness
B. Weight gain
C. Constipation
D. Yellow sclerae
Answer: D. Yellow sclerae
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding is yellow sclerae because of the risk for hepatotoxicity.
6. A nurse is reinforcing teaching about food that contains tyramine with a client who has a
prescription for phenelzine. Which of the following foods should the nurse instruct the client to
void?
A. Fried chicken
B. Oranges
C. Smoked sausage
D. Lentils
Answer: C. Smoked sausage
Rationale: Smoked sausages are high in tyramine. Clients who are prescribed monoamine
oxidase inhibitors (MAOIs) should avoid food that contain tyramine because consuming them
can cause a hypertensive crisis.
7. A nurse is attempting to resolve an ethical dilemma that involves a client's medical decisions
and their own personal values. After collecting data and identifying the problem, which of the
following actions should the nurse take next?
A. Discuss information about the dilemma with the client's provider.
B. Determine the benefits and consequences of respecting the client's medical decisions.
C. Reflect on the effect of ethical theories on the nurse's personal values.
D. Develop a plan that balances both the nurse's values and the client's medical decisions.
Answer: B. Determine the benefits and consequences of respecting the client's medical
decisions.
Rationale: After the nurse collects the data and identifies the problem, the nurse should
determine the benefits and consequences of respecting the client's medical decisions as the next
step in the ethical decision-making model.
8. A nurse is reinforcing teaching to a client who has a new prescription for phenelzine. The
nurse should instruct the client that eating foods high in tyramine can cause which of the
following adverse reactions with this medication?
A. Hypertensive crisis
B. Serotonin syndrome
C. Hearing loss
D. Urinary incontinence
Answer: A. Hypertensive crisis
Rationale: Tyramine can cause severe hypertension in clients who are taking phenelzine, a
monoamine oxidase inhibitor. Manifestations include palpitations, stiff neck, headache, nausea,
vomiting, and elevated temperature.
9. A nurse is contributing to the plan of care for a client who has antisocial personality disorder.
Which of the following short-term goals should the nurse recommend be included in the plan?
A. The client will participate in assertiveness training.
B. The client will discuss feelings that cause hostility.
C. The client will describe an activity they found enjoyable.
D. The client will dress in a manner appropriate for the setting and temperature.
Answer: B. The client will discuss feelings that cause hostility.
Rationale: Clients who have antisocial personality disorder are frequently aggressive and are at
risk for injuring themselves or others. A short-term goal for these clients should be to discuss
feelings that precipitate aggression or hostility.
10. The nurse is assisting with an admission have a client who has eating disorder. During data
collection, which is the following to the nurse identify as manifestations of bulimia nervosa?
SOA
A. Tooth erosion
B. Hand calluses
C. Lanugo
D. Amenorrhea
E. Hypokalemia
Answer: A. Tooth erosion
B. Hand calluses
E. Hypokalemia
Rationale: Tooth erosion is a manifestation of bulimia nervosa that results from self-induced
vomiting. Hand calluses are a manifestation of bulimia nervosa that results from self- induced
vomiting. Lanugo is a manifestation of anorexia nervosa that results from starvation.
Amenorrhea is a manifestation of anorexia nervosa that results from extreme weight loss.
Hypokalemia is a manifestation of bulimia nervosa that results from volume depletion due to
self-induced vomiting or excessive diuretic and laxative use.
11. A nurse is caring for a client who is taking lithium and reports persistent nausea and vomiting
for 2 days. Which of the following laboratory values should the nurse report to the provider?
A. Potassium 4.0 mEq/L
B. Lithium 0.9 mEq/L
C. BUN 12 mg/dL
D. Sodium 132 mEq/L
Answer: D. Sodium 132 mEq/L
Rationale: The nurse should identify that a sodium level of 132 mEq/L is not within the
expected reference range of 136 to 145 mEq/L. This finding indicates hyponatremia, which can
lead to lithium accumulation and places the client at risk for lithium toxicity. The nurse should
report this finding to the provider.
12. A nurse in a mental health unit is assisting with the plan of care for a newly admitted client
who has anorexia nervosa. Which of the following actions should the nurse include in the plan of
care?
A. Weigh the client at night prior to bedtime.
B. Offer liquid supplements to the client.
C. Encourage the client to gain 2.3 kg (5 lb) per week.
D. Observe the client for up to 30 min after meals.
Answer: B. Offer liquid supplements to the client.
Rationale: The nurse should offer liquid supplements to the client because the client might be
unable to eat solid foods when they are first admitted. The nurse should observe the client for at
least 1 hr after meals to prevent the client from throwing away, hiding, or purging food.
13. A nurse is contributing to plan of care for a school-age child who has attention deficit
hyperactivity disorder. Which of the following interventions should the nurse recommend?
A. Avoid the use of humor when managing the child's disruptive behaviors.
B. Instruct the child to apologize for behavior that negatively affects others.
C. Maintain a scheduled plan of activities regardless of the child's behavior.
D. Administer methylphenidate PRN when the child exhibits disruptive behavior.
Answer: B. Instruct the child to apologize for behavior that negatively affects others.
Rationale: The nurse should recommend performing simple techniques to manage the child's
behavior, including making amends. This technique includes apologizing to others when the
client's behavior has a negative effect.
14. A nurse is reviewing laboratory values for a client who has anorexia nervosa. Which of the
following results should the nurse expect?
A. Potassium 3 mEq/L
B. Phosphorus 3.5 mg/dL
C. Magnesium 1.8 mEq/L
D. Cholesterol 165 mg/dL
Answer: A. Potassium 3 mEq/L
Rationale: The nurse should expect a client who has anorexia nervosa to have hypokalemia,
which is indicated by a decreased potassium level. This value is below the expected reference
range of 3.5 to 5 mEq/L.
15. A nurse is caring for four clients who are displaying the use of defense mechanisms. Which
of the following clients should the nurse identify as using maladaptive defense mechanism?
A. A client who has multiple sclerosis stops taking their medication and says their diagnosis is
wrong.
B. An adolescent client who has difficulty with reading becomes a star athlete.
C. A client admires a high school principal who separated two students who were having a fight.
D. A client who has a gambling disorder volunteers in a head start program.
Answer: A. A client who has multiple sclerosis stops taking their medication and says their
diagnosis is wrong.
Rationale: Suppression is the blocking of thoughts or feelings that a client finds unacceptable.
Denying the presence of an illness is a maladaptive use of a defense mechanism.
16. A nurse is caring for a client who is scheduled for electro conclusive therapy ECT. Which of
the following actions should the nurse take prior to the procedure?
A. Keep the client in a side-lying position.
B. Administer morphine IV.
C. Prepare the client for intubation.
D. Administer atropine sulfate IM.
Answer: D. Administer atropine sulfate IM.
Rationale: In preparation for ECT, the nurse should administer atropine sulfate IM 30 min prior
to the procedure. This will decrease secretions in order to prevent aspiration that can be caused
by the vagal stimulation induced by ECT.
17. A nurse is talking with a client who has borderline personality disorder. The client states they
think that the other nurses avoid them, but they are afraid to share this thought with the other
staff. Which of the following actions should the nurse take?
A. Encourage the use of transference in the nurse-client relationship.
B. Offer to talk to the staff until the client gains an increased level of trust.
C. Encourage the client's verbalization of feeling and perceptions.
D. Ask the client why they think the staff is avoiding them.
Answer: C. Encourage the client's verbalization of feeling and perceptions.
Rationale: The nurse should encourage the client to verbalize their feelings, perceptions, and
fears. Discussing these dynamics can help increase the client's comfort in expressing concerns
directly to other members of staff.
18. A nurse is collecting data from a client who has a history of cocaine use. Which of the
following findings is an indication that the client is experiencing cocaine toxicity?
A. Hypothermia
B. Piloerection
C. Somnolence
D. Seizures
Answer: D. Seizures
Rationale: The nurse should expect a client who is experiencing cocaine toxicity to experience
seizures. Other findings include severe anxiety, hallucinations, and paranoid thoughts.
19. A nurse is caring for a client who has schizophrenia and a prescription for haloperidol. The
nurse should identify that which of the following findings indicates a potential need for a PRN
dose of benztropine?
A. Sore throat
B. Increased mental confusion
C. Urinary retention
D. Shuffling gait
Answer: D. Shuffling gait
Rationale: The nurse should identify that a shuffling gait can be indicative of the presence of
pseudoparkinsonism, which can be treated with a PRN dose of benztropine.
20. A nurse is collecting data from a client who has delirium. The nurse should identify which of
the following conditions as predisposing factor for delirium?
A. Hepatic failure
B. Chronic alcohol use
C. Hypertension
D. Fluid volume overload
Answer: A. Hepatic failure
Rationale: Hepatic failure can be a predisposing factor for the development of delirium. Other
potential predisposing factors include febrile illness, hypoxia, head trauma, and stroke.
21. A nurse is caring for a client who is experiencing opioid withdrawal. Which of he following
medications should the nurse expect to administer?
A. Naltrexone
B. Bupropion
C. Varenicline
D. Phenobarbital
Answer: A. Naltrexone
Rationale: The nurse should expect to administer naltrexone, an opioid antagonist, to a client
who is experiencing opioid withdrawal.
22. A nurse is caring for a client who has depressive disorder and declines electro conclusive
therapy (ECT) despite the provider's recommendation. Which of the following ethical principles
is the nurse demonstrating by supporting the client's decision?
A. Autonomy
B. Nonmaleficence
C. Fidelity
D. Justice
Answer: A. Autonomy
Rationale: The nurse is demonstrating the principle of autonomy by respecting and supporting
the client's right to make decisions about their treatment.
23. A nurse is reinforcing teaching with a client has OCD and performs hand hygiene to decrease
anxiety. Which of the following actions should the nurse take to demonstrate modeling as a
behavioral intervention strategy?
A. Setting a time limit between episodes of hand hygiene
B. Reminding the client to shout "stop" each time they have an urge to perform hand hygiene
C. Demonstrating performing hand hygiene at appropriate times
D. Instructing the client to practice muscle relaxation when they have the urge to perform hand
hygiene
Answer: C. Demonstrating performing hand hygiene at appropriate times
Rationale: This action is an example of modeling, which is a strategy that allows the client to
see another person perform the expected behavior.
24. A nurse on a mental health unit is caring for four clients who have schizophrenia. Which of
the following clients should the nurse see first?
A. A client who has anergia
B. A client who demonstrates blunted affect
C. A client who demonstrates concrete thinking
D. A client who is experiencing command hallucinations
Answer: D. A client who is experiencing command hallucinations
Rationale: Because command hallucinations are a risk factor for violence, the greatest risk to
this client is injury to self or others. Therefore, the nurse should see this client first.
25. A nurse is caring for a client who is undergoing behavioral therapy for PTSD. The nurse
should identify that which of the following findings indicates an improvement in the client's
condition?
A. The client reports about techniques they use to promote sleep.
B. The client shows limited emotion when discussing witnessing a traumatic event.
C. The client states that they no longer feel like they can trust their partner.
D. The client avoids situations that might trigger memories of past trauma.
Answer: A. The client reports about techniques they use to promote sleep.
Rationale: Clients who have PTSD frequently experience disrupted sleep. Therefore, reporting
about techniques they use to promote sleep demonstrates that the client's condition has improved.
26. A nurse in an inpatient mental health unit is supervising a group of clients in the unit's
dayroom. The nurse fails to respond to the escalating, aggressive behavior of a client who
eventually become violent and injures another client. For which of the following is the nurse
liable?
A. Battery
B. Nonmaleficence
C. Negligence
D. Boundary violation
Answer: C. Negligence
Rationale: The nurse is liable for negligence by failing to respond to the client's escalating,
aggressive behavior and prevent harm to others.
27. A nurse is collecting data from a client who has dementia and whose family expresses
concern about their increasing "memory problems". Which of the following findings should the
nurse identify as the priority?
A. The client often forgets people's names.
B. The client avoids social interaction.
C. The client is frequently emotionally labile.
D. The client sometimes wanders from the house.
Answer: D. The client sometimes wanders from the house.
Rationale: The nurse should identify that wandering away from home places the client at
greatest risk for injury due to lack of supervision. Therefore, this is the priority finding.
28. A nurse is caring for a client who has somatic symptom disorder. Which of the following
actions should the nurse take?
A. Obtain the client's vital signs each time the client reports physical illness.
B. Remind the client that their symptoms are not real.
C. Encourage the client to examine how their illness behavior affects their family.
D. Provide adequate time for the client to describe their symptoms.
Answer: C. Encourage the client to examine how their illness behavior affects their family.
Rationale: The nurse should recognize that secondary gains the client might receive are a
reprieve from performing duties related to care of the family. The nurse should encourage the
client to gain insight into how their illness behavior affects their family, which can help restore
family function.
29. A nurse is participating in group therapy for clients who have major depressive disorder.
Which of the following topics should the nurse include in the orientation phase of group therapy?
A. Confidentiality
B. Developing goals
C. Problem solving
D. Identifying the roles of group members
Answer: A. Confidentiality
Rationale: The nurse should establish the expectations of confidentiality during the orientation
phase of group therapy.
30. A nurse is contributing to the plan of care for a client who has an anxiety disorder. Which of
the following interventions should the nurse recommend to be included in the plan?
A. Help the client to identify situations that trigger their anxiety.
B. Change the subject when the client has anxious feelings.
C. detailed explanations of available activities.
D. Encourage the client to determine their own daily schedules.
Answer: A. Help the client to identify situations that trigger their anxiety.
Rationale: The nurse should assist the client in identifying trigger situations to interrupt anxiety
escalation in the future.
31. A nurse is collecting data from a client who has agoraphobia. the nurse should identify that
which of the following situations will increase the client's anxiety?
A. Traveling in an airplane
B. Entering a walk-in closet
C. Taking a bath
D. Picking up a soiled tissue
Answer: A. Traveling in an airplane
Rationale: The nurse should identify that using public transportation, such as traveling in an
airplane, will increase the anxiety of a client who has agoraphobia.
32. A nurse in a mental health facility is caring for a client who has schizophrenia. The client
becomes violent in the dayroom and begins throwing objects at staff and other clients. After
calling for assistance, which of the following actions should the nurse take next?
A. Obtain a prescription for mechanical restraints.
B. Place the client in a monitored seclusion room.
C. Tell the client calmly to sit down.
D. Administer diazepam intramuscularly.
Answer: C. Tell the client calmly to sit down.
Rationale: When providing client care, the nurse should first use the least restrictive
intervention. Therefore, the nurse should use verbal deescalation techniques after calling for
assistance for a client who is aggressive.
33. A nurse is caring for a client who has dementia. Which of the following actions should the
nurse take?
A. Keep the client's room dark at night.
B. Alternate the client's caregivers on a routine basis.
C. Stand in front of the client when speaking.
D. Remove personal belongings from the client's room.
Answer: C. Stand in front of the client when speaking.
Rationale: The nurse should stand in front of the client when speaking to them to maintain eye
contact and maximize the client's understanding of the conversation.
34. A nurse is caring for a client who is experiencing delirium. Which of the following findings
should the nurse expect?
A. A progressive deterioration of memory
B. A sudden onset of disorientation
C. A loss of language ability
D. A loss of bladder control
Answer: B. A sudden onset of disorientation
Rationale: Clients who have delirium experience a sudden onset of disorientation and
disturbances to perception.
35. A nurse is caring for a client with antisocial personality disorder. Which of the following
actions should the nurse take when caring for this client?
A. Persuade the client to demonstrate acceptable behavior.
B. Avoid talking about the client's past display of unacceptable behavior.
C. Use countertransference to develop the therapeutic relationship.
D. Remind the client of the consequences for unacceptable behavior.
Answer: D. Remind the client of the consequences for unacceptable behavior.
Rationale: Clients who have antisocial personality disorder do not respect the rights of others.
Therefore, the nurse should remind the client about which behaviors are acceptable and
unacceptable and be prepared to administer consequences for unacceptable behavior.
36. A nurse is reinforcing teaching with the parent of an adolescent who has amphetamine use
disorder. The nurse should identify that which of the following statements by the parent indicates
an understanding of the teaching?
A. "I should be alert for weight gain in my child because this can indicate amphetamine use."
B. "I can tell my child is using amphetamines because they are drowsy."
C. "Dilated pupils are a sign that my child is using amphetamines."
D. "Increased salivation can indicate that my child is using amphetamines."
Answer: C. "Dilated pupils are a sign that my child is using amphetamines."
Rationale: The nurse should instruct the parent to monitor the adolescent for mydriasis, or
dilated pupils, because this is a manifestation of amphetamine use.
37. A nurse is reinforcing teaching about stress management techniques with a client who has
mild anxiety. Which of the following statements should the nurse make?
A. "You should exercise immediately prior to going to sleep."
B. "You should listen to music when you feel stressed."
C. "Take a 1-hour nap every afternoon."
D. "You should stop drinking caffeine immediately."
Answer: B. "You should listen to music when you feel stressed."
Rationale: The nurse should encourage the client to listen to music to increase relaxation.
38. A nurse is preparing to administer lithium 600 mg PO to a client who has bipolar disorder.
Available is lithium 150 mg capsules. How many capsules should the nurse administer? Round to
the nearest whole number.
Answer: 4 capsules
39. A nurse is assisting in the plan of care for a client who is malnourished due to alcohol use
disorder. Which of the following interventions should the nurse include in the plan?
A. Restrict the client's sodium intake.
B. Encourage the client to eat three large meals per day.
C. Weigh the client weekly.
D. Observe the client for 1 hr after they eat.
Answer: A. Restrict the client's sodium intake.
Rationale: Restrict the client's sodium intake.
A client who is malnourished due to alcohol use disorder is at risk for ascites. Therefore, the
nurse should restrict the client's sodium intake to decrease the risk for fluid retention.
40. A nurse is planning to collect data from a group of clients. The nurse should expect that
which of the following clients is most likely to exhibit speech pattern alterations?
A. A client who has antisocial personality disorder
B. A client who has dependent personality disorder
C. A client who has bulimia nervosa
D. A client who has schizophrenia
Answer: D. A client who has schizophrenia
Rationale: The nurse should expect a client who has schizophrenia to exhibit alterations in
behavior, alterations in perception, and alterations in their speech pattern. Speech pattern
alterations include associative looseness, clang association, neologisms, and echolalia.
41. A nurse is collecting data from a client who has major depressive disorder and is taking
phenelzine. Which of the following findings should the nurse identify as an adverse effect of this
medication?
A. Weight gain
B. Diarrhea
C. Proteinuria
D. Bleeding gums
Answer: A. Weight gain
Rationale: Weight gain, insomnia, and muscle cramps are adverse effects of phenelzine.
42. A nurse is reinforcing teaching with the caregiver of a client who has histrionic personality
disorder. Which of the following manifestations should the nurse tell the caregiver to expect?
A. Emotional detachment
B. Paranoia
C. Attention-seeking behavior
D. Fear of abandonment
Answer: C. Attention-seeking behavior
Rationale: The nurse should identify that attention-seeking behavior, self-centeredness, and
excessive emotionality are expected manifestations in a client who has histrionic personality
disorder.
43. A nurse is caring for a client who states, "I just lost my job. This has been the worst day of
my life." Which of the following responses should the nurse make?
A. "You should focus on positive thoughts."
B. "This job just wasn't a good fit for you."
C. "You'll be able to find a better job soon."
D. "Tell me about your day."
Answer: D. "Tell me about your day."
Rationale: The nurse should encourage the client to discuss the events of their day because this
is a therapeutic communication technique that examines the client's perception of the day's
events.
44. A nurse is assisting with the admission of a client to an acute care mental health facility.
Which of the following activities should the nurse plan for the working phase of the therapeutic
nurse-client relationship?
A. Define the specific responsibilities of the client and the nurse.
B. Assist the client to establish mutual goals.
C. Evaluate the client's progress toward meeting their goals.
D. Discuss how the client can incorporate new strategies into their daily life.
Answer: C. Evaluate the client's progress toward meeting their goals.
Rationale: The nurse should evaluate the progress the client is making toward the goals they
have established as part of the working phase of the therapeutic relationship. During the working
phase, the nurse and the client identify and implement measures to help the client meet their
goals.
45. A nurse is monitoring communication between a client who has alcohol use disorder and their
partner. Which of the following communication patterns of the client's partner should the nurse
identify as being effective?
A. "I can never talk to you because you are always drunk."
B. "I become very angry when you get drunk."
C. "Because of your drinking, we can't have guests in our home."
D. "Don't be mad at the kids. It was my fault that the dishes did not get done."
Answer: B. "I become very angry when you get drunk."
Rationale: The nurse should identify that this statement is an example of a healthy, effective
communication pattern. The partner is discussing personal feelings instead of focusing on the
client's negative behavior.
46. A nurse is reinforcing teaching with an adolescent client who has a history of aggressive
behavior. Which of the following statements should the nurse make?
A. "If you can control your actions this week, I'll talk to your parents about extending your
curfew."
B. "Have you considered participating in a sport to help control your aggression?"
C. "If you become aggressive, your parents will take away privileges."
D. "You're hurting others. Do you understand why that's wrong?"
Answer: B. "Have you considered participating in a sport to help control your aggression?"
Rationale: The nurse should encourage the client to participate in sports and other physical
activities because they can provide a safer outlet for aggression.
47. A nurse is collecting data from a client who says they use alcohol "to cope with stress".
Which of the following questions should the nurse ask?
A. "Do you see how your alcohol consumption affects your employment?"
B. "Is your partner affected by your alcohol consumption?"
C. "What daily activities are disrupted because of your alcohol consumption?"
D. "Would you agree that stressful times in your life lead to increased alcohol consumption?"
Answer: C. "What daily activities are disrupted because of your alcohol consumption?"
Rationale: The nurse is using an open-ended question, which is a therapeutic form of
communication that can encourage the client to share information and to develop a rapport with
the nurse.
48. A nurse is caring for a client who was admitted for major depressive disorder and states that
they do not want to attend group therapy. Which of the following responses should the nurse
make?
A. "Are you experiencing more feelings of depression?"
B. "What are your feelings about going to group therapy?"
C. "I know you'll make the right decision about going to group therapy."
D. "You will feel better after going to group therapy."
Answer: B. "What are your feelings about going to group therapy?"
Rationale: The nurse should ask the client open-ended questions because they are therapeutic
and allow the client to further discuss their feelings. The nurse should allow the client to discuss
their feelings about group therapy in order to involve the client in their own care.
49. A nurse is assisting in the morning hygiene care of a client who is cognitively impaired.
Which of the following statements should the nurse make?
A. "Let me help you get your toothbrush."
B. "Do you want to take a bath or brush your teeth first?"
C. "Do you need help brushing your teeth?"
D. "Let me inspect the inside of your mouth to see if your teeth are clean."
Answer: A. "Let me help you get your toothbrush."
Rationale: A client who is cognitively impaired needs guidance in performing ADLs and should
be given one simple task at a time.
50. A nurse in a mental health unit is reinforcing teaching about informed consent with a newly
licensed nurse. Which of the following statements indicates an understanding of the teaching?
A. "The consent form should be written at a seventh-grade reading level."
B. "If the consent form is signed, I can send a client for a procedure even if they have questions."
C. "I should explain everything to the client about the procedure before the client signs the
consent form."
D. "The consent form should have the name of the provider who is performing the procedure on
the form."
Answer: D. "The consent form should have the name of the provider who is performing the
procedure on the form."
Rationale: The consent form should include the name of the provider who will be performing
the procedure. This should be present on the form before the client signs it. It is the provider's
responsibility to inform the client of the risks, benefits, alternatives, and possible complications
of the procedure.
