ATI MENTAL HEALTH PROCTORED EXAM 2019 WITH NGN
QUESTIONS AND VERIFIED SOLUTIONS/ A+ GRADE
1. A nurse is providing discharge teaching to the parent of an adolescent client who has bulimia
nervosa and has been hospitalized for several weeks. Which of the following statements should
the nurse identify as an indication that the parent understands the teaching?
a. I should allow my child to make independent decisions
b. I should give my child a laxative every morning
c. I should make sure my child takes antipsychotic medication several times daily
d. I should discourage my child from exercising
Answer: a. I should allow my child to make independent decisions
2. Which of the following actions would take place during the working phase of the nurse- client
relationship?
a. introduce concept of client confidentiality
b. establish goals with client
c. define roles of nurse and client
d. facilitate a change in client's behavior
Answer: d. facilitate a change in client's behavior
3. A nurse is assessing a newly admitted client who has GAD and states "I drink alcohol to forget
the pain". The client is exhibiting a maladaptive response to which of the following defense
mechanisms?
a. compensation
b. conversion
c. projection
d. suppression
Answer: a. compensation
Rationale: A person covers up a real or perceived weakness
4. A nurse is providing teaching for a client who has a new prescription for buspirone.
Which of the following statements indicates an understanding of the teaching?
a. watch for signs of dehydration
b. monitor kidney function
c. take on an empty stomach
d. may take several weeks to notice effects
Answer: d. may take several weeks to notice effects
Rationale: Buspirone is an anxiolytic- initial response is a week, and peak response takes
several weeks (should not be given PRN for anxiety)
5. A nurse is teaching a client who has anxiety and a new prescription for buspirone.
Which of the following pieces of information should the nurse include in the teaching?
a. buspirone carries a high potential for abuse
b. avoid consuming grapefruit juice when taking this medication
c. take medication 4x daily
d. peak effects of buspirone occur within 1 week (grapefruit juice can cause levels of the
medication to increase- can cause drowsiness, subjective effects such as dysphoria)
Answer: b. avoid consuming grapefruit juice when taking this medication
6. Which of the following actions should the nurse identify as an intentional tort?
a. administering an incorrect dose of medication
b. informing the client's family member of admission without the client's consent
c. informing the client that an injection will be administered if the client remains agitated
d. failing to recognize suicide risk, resulting in the client's death
Answer: c. informing the client that an injection will be administered if the client remains
agitated
Rationale: example of assault, which is an intentional tort (makes the client fearful of harm or
unwanted touching)
7. A nurse is reviewing lab reports for a client who is taking risperidone. The nurse should
identify that which of the following results indicates a potential adverse reaction to the
medication?
a. elevated blood glucose
b. elevated WBC
c. decreased platelet count
d. decreased AST
Answer: a. elevated blood glucose
Rationale: risperidone is a second-generation antipsychotic- can cause diabetes, weight gain,
and dislipidemia
8. Which of the following is an adverse effect of nicotine gum?
a. itching
b. throat irritation
c. hiccups
d. teary eyes
Answer: b. throat irritation
9. A nurse at an acute care facility is caring for a client receiving IV antibiotic treatments for an
infection. The client reports daily alcohol use at home. On the second day of admission, the
client becomes agitated and has BP of 195/102 and HR of 118/min. Which of the following
actions should the nurse plan to take?
a. administer methadone when agitation increases
b. administer zolpidem before meals
c. request prescription for a different antibiotic
d. request prescription for chlordiazepoxide
Answer: d. request prescription for chlordiazepoxide
Rationale: chlordiazepoxide is med for alcohol withdrawal
10. A nurse is teaching a client who has SAD about the use of light therapy. Which of the
following statements should the nurse make?
a. Light therapy suppresses the natural nighttime release of melatonin
b. You should plan your light therapy session before going to bed
c. You should begin with 2-min therapy sessions and progress to 10-min therapy sessions
d. Light therapy is less effective than medications in treating SAD
Answer: a. Light therapy suppresses the natural nighttime release of melatonin
11. Which is a negative symptom of schizophrenia?
a. hallucinations
b. impaired memory
c. dysphoria
d. social discomfort
Answer: d. social discomfort
Rationale: negative symptoms- absence of something that should normally be present
12. A nurse is caring for a client who has Alzheimer's disease. The client's son states the client
has begun wandering away from her home. Which of the following responses should the nurse
offer?
a. you should plan to move your mother into a home soon
b. place a complex lock at the top of each door that leads outside
c. it is time to place your mother in a LTC facility
d. have you reminded your mother about the dangers of wandering away from home?
Answer: b. place a complex lock at the top of each door that leads outside
Rationale: also encourage son to place a non-removable medical alert bracelet on client that
includes name, address, phone #
13. A nurse is interviewing a client who is seeking help for intimate partner violence. Which of
the following client statements should the nurse identify as an indication that the client is in the
tension-building phase of the cycle of violence?
a. "last night my partner beat me worse than ever before"
b. "it'll be easier just to make my partner mad and get the violence over with"
c. "I believe my partner is remorseful and won't hurt me again"
d. "I only got shoved a bit, and it was my fault for coming home late"
Answer: d. "I only got shoved a bit, and it was my fault for coming home late"
Rationale: During tension-building phase, episodes of violence are often minor, and recipient
might rationalize the episodes by accepting blame
14. A nurse is providing teaching to a client who is scheduled to start taking valproic acid. Which
of the following instructions should the nurse include?
a. the provider will decrease your dosage of valproic acid gradually
b. you should take aspirin for pain
c. you should undergo thyroid function tests every 6 months
d. you should have your liver function levels monitored regularly while taking valproic acid
Answer: d. you should have your liver function levels monitored regularly while taking valproic
acid
15. A nurse is providing discharge teaching for a client who has a new prescription for doxepin
(antidepressant). Which of the following adverse effects is associated with this medication?
a. weight loss
b. diarrhea
c. drowsiness
d. bradycardia
Answer: c. drowsiness
16. A nurse is planning care for a client who has dissociative disorder and is experiencing
flashbacks while in public. Which of the following interventions should the nurse include in the
plan to help the client recognize and counter the flashbacks?
a. encourage reality testing
b. provide opportunities for socialization
c. consistently remind the client of past traumatic events
d. discourage client expressions of negative feelings
Answer: a. encourage reality testing
Rationale: Reality testing involves scanning the surrounding to see if others are afraid and
reorientation to time a place. This can help clients recognize that the flashbacks are not real
17. A nurse is caring for a client who has anxiety disorder. The client states that she forgot her
partner's birthday after they had an argument. The nurse recognizes this action as which of the
following defense mechanisms?
a. repression
b. splitting
c. conversion
d. projection
Answer: a. repression
Rationale: unconscious exclusion of unpleasant or unwanted experiences, emotions, or ideas
from conscious awareness
18. A nurse is caring for a client who is having an acute panic attack. Which of the following
actions should the nurse take?
a. speak to the client in a raised voice
b. walk the client to the dayroom
c. use repetition when speaking with the client
d. secure the client in his room alone
Answer: c. use repetition when speaking with the client
Rationale: When having a panic attack, the client may have a hard time understanding what the
nurse is saying. Simple phrases and repetition are effective methods of communication
19. A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the
following medications should the nurse prepare to administer?
a. carbamazepine
b. clonidine
c. propranolol
d. lorazepam
Answer: d. lorazepam
Rationale: benzodiazepine- first treatment for alcohol withdrawal
Incorrect answers: can be used WITH benzodiazepine for AWS, but not the first choice for
treatment
20. A nurse is caring for a client who has an alcohol use disorder and is currently undergoing
alcohol detoxification. Which of the following interventions should the nurse provide at this
time?
a. administer substitution therapy medications
b. teach the client the physical symptoms of withdrawal
c. provide the client with information about a 12-step program
d. identify the causes of the client's alcohol disorder
Answer: a. administer substitution therapy medications
Rationale: education following acute stage of alcohol use disorder
21. A nurse is assessing a client who is experiencing alcohol withdrawal. For which of the
following findings should the nurse anticipate the administration of lorazepam?
a. decreased pulse rate b. increased BP
c. decreased urinary output
d. increased nausea
Answer: b. increased BP
Rationale: Lorazepam is a benzodiazepine that is given to a client who is experiencing alcohol
withdrawal for stabilizing vital signs, preventing seizures, and treating delirium tremens.
22. A nurse is caring for a client with ADHD who has recently started taking lithium. For which
of the following findings should the nurse monitor when evaluating the effectiveness of the
medication?
a. increased attention span
b. decreased anxiety
c. reduced aggression
d. weight loss
Answer: c. reduced aggression
Rationale: ADHD clients can experience a low tolerance for frustration, leading to aggressive
behaviors. Lithium is a mood stabilizer prescribed to reduced aggression. (monitor for increased
attention span when taking stimulant medication such as methylphenidate)
23. A nurse is evaluating teaching for a client who has bipolar disorder and a new prescription for
lithium. Which of the following statements by the client indicates an understanding of the
teaching?
a. I should take lithium on an empty stomach
b. I can take ibuprofen for headaches while taking lithium
c. I need to limit my salt intake while taking lithium
d. I am likely to gain weight while taking lithium
Answer: d. I am likely to gain weight while taking lithium
Rationale: Nurse should instruct to eat a low-calorie diet because lithium can cause weight gain
Incorrect answers:
• take lithium with food to prevent GI distress
• don't take NSAIDs because they increased risk of lithium toxicity
• maintain balance of water and sodium (decreased sodium can cause lithium toxicity)
24. A home health nurse is providing teaching for the family of a client who has moderate
Alzheimer's disease. The family plans to care for the client in the home. Which of the following
recommendations should the nurse include in the teaching?
a. place non-skid throw rugs over smooth floors
b. install locks at the tops of exterior doors
c. provide clothing that has zippers instead of buttons
d. encourage the client to take frequent naps during the day
Answer: b. install locks at the tops of exterior doors
Rationale: will decrease risk for wandering and getting lost- client with moderate Alzheimer's
disease loses the ability to reach and look upward
25. A nurse is assessing a client who experienced a sexual assault 6 months ago. Which of the
following findings should the nurse report to the provider as an indication of rape- trauma
syndrome?
a. flat affect
b. refusal to accept help from others
c. report of intense guilt
d. denial of the sexual assault
Answer: c. report of intense guilt
Rationale: other findings of rape-trauma syndrome are mood swings intense emotions,
dependence on others
26. A nurse is reviewing the medications of a client who has bipolar disorder and a new
prescription for lithium. Which of the following medications may be administered safely while
the client is taking lithium?
a. ibuprofen
b. haloperidol
c. valproic acid
d. hydrochlorothiazide
Answer: c. valproic acid
Rationale: both indicated for bipolar disorder
27. A nurse is working with a client who exhibits extreme superstition, elaborate speech patterns,
and eccentric behavior. The nurse should identify these features as which of the following
personality disorders?
a. paranoid
b. histronic
c. antisocial
d. schizotypal
Answer: d. schizotypal
28. A nurse is assessing a client who has a history of methamphetamine use. Which of the
following findings indicates that the client is currently under the influence of this drug?
a. paranoia
b. slurred speech
c. marked lethargy
d. bradycardia
Answer: a. paranoia
Rationale: Acute effects of meth use include increased HR and metabolism, mental alter ness,
reduced appetite, and paranoia
29. An ER nurse is assessing a client who has anxiety disorder. The client is flushed, perspiring
profusely, and experiencing palpitations. The client begins to scream, "I am going to die! This is
it! I'm having a heart attack!" The nurse should determine the client's level of anxiety to be:
a. moderate
b. panic
c. severe
d. mild
Answer: b. panic
30. A nurse is teaching a client who has a prescription for a tricyclic antidepressant. Which of the
following instructions should the nurse include in the teaching?
a. take medication within 1 hour of waking each morning
b. limit alcohol to 2 drinks per week
c. it can take 6 weeks to achieve the full therapeutic effect of this medication
d. stop taking the medication if you experience dizziness
Answer: c. it can take 6 weeks to achieve the full therapeutic effect of this medication
Rationale: it can take 6-8 weeks to achieve full therapeutic effect of TCAs
Incorrect answers:
• take TCA at bedtime to decrease sleepiness during the day
• avoid drinking ANY alcohol, it will block therapeutic effects
• TCA can cause dizziness, but this adverse effect is expected to diminish after the first few
weeks
31. A nurse is providing teaching to a client who has a new prescription for disulfiram for
management of alcohol dependence. Which of the following dietary items should the nurse
instruct the client to avoid?
a. peppermint candy
b. pure vanilla extract
c. salt
d. chocolate
Answer: b. pure vanilla extract
Rationale: contains alcohol- make sure to avoid all alcohol-containing substances! (ingesting
alcohol causes hyperventilation, dizziness, vomiting, and hypotension)
32. A nurse is assessing a client in the ED who's friend reported that he inhaled a large amount of
cocaine. Which of the following findings should the nurse expect?
a. depressed mood
b. hallucinations
c. sever hypotension
d. bradycardia
Answer: b. hallucinations
Rationale: Cocaine is a CNS stimulant- hallucinations, delirium, elevated BP, tachycardia,
dilated pupils
33. A nurse is providing teaching to a client who has insomnia. Which of the following
statements should the nurse make?
a. limit daytime napping to an hour maximum
b. watch tv as you fall asleep
c. if you aren't able to sleep, you can get out of bed and read a book
d. track the number of hours that you sleep each night
Answer: c. if you aren't able to sleep, you can get out of bed and read a book
Rationale: Instruct the client to get out of bed a participate in a quiet activity such as reading
until they feel sleepy, then return to bed
Incorrect answers:
• avoid daytime naps whenever possible, if needed limit to 20-30 mins
• monitor quality of sleep rather than number of hours
34. A nurse is assessing a client who has been taking an antipsychotic medication for 6 years.
The provider has started tapering off the client's dosage. The nurse should monitor the client for
which of the following manifestations of tardive dyskinesia?
a. muscular weakness
b. muscle spasms
c. involuntary tongue protrusion
d. uncontrolled rolling of the eyes
Answer: c. involuntary tongue protrusion
Rationale: TD begins with mouth and facial movements and progresses to other muscle groups.
It is irreversible!
35. A nurse is planning care for a client who has vegetative signs of depression. Which of the
following actions should the nurse include in the plan?
a. limit snacking between meals
b. schedule regular nap times during the day
c. weight the client monthly
d. provide decaffeinated beverages
Answer: d. provide decaffeinated beverages
Rationale: no caffeine- since they often have sleep disturbances
Incorrect answers:
• encourage high-protein, high-calorie snacks since they are at risk for malnutrition
• encourage the client to be active during the day, not nap to help with sleep at night-weight
client weekly
36. A nurse on a rehab unit is providing teaching to the partner of a client who is experiencing
stimulant withdrawal. Which of the following statements by the partner indicates an
understanding of the teaching?
a. "increased energy is a sign of withdrawal"
b. "depression is a manifestation of withdrawal"
c. "decreased appetite is a manifestation of withdrawal"
d. "delirium tremens can occur during withdrawal"
Answer: b. "depression is a manifestation of withdrawal"
Rationale: depression and suicidal thoughts are most serious adverse effects of stimulant
withdrawal
37. A nurse in an acute substance disorder unit is assessing a client who received treatment in the
ED for a heroin overdose. Which of the following findings should the nurse anticipate during
heroin withdrawal?
a. excessive sleeping
b. muscle aches
c. pupillary constriction
d. absent bowel sounds
Answer: b. muscle aches
Rationale: Also in heroin withdrawal:
• insomnia
• diarrhea
• pupillary dilation
38. A nurse on an inpatient rehab unit is assessing a client who has a history of opioid use and is
experiencing withdrawal. Which of the following manifestations should the nurse expect?
a. hyperactivity
b. headache
c. rhinorrhea
d. tremulousness
Answer: c. rhinorrhea
Also expect:
• lacrimation
• pupillary dilation
• yawning
• piloerection
39. A nurse is talking with the partner of a client who has alcohol use disorder. Which of the
following statements by the client's partner should the nurse identify as an indication of co
dependence?
a. "My partner is addicted to both alcohol and cocaine"
b. "I have an alcohol problem just like my partner does"
c. "My partner only drinks to deal with her major depression"
d. "I call my partner's boss when she's drunk and can't go to work"
Answer: d. "I call my partner's boss when she's drunk and can't go to work"
Rationale: Codependent individual takes on extra responsibilities and assists the client who has
alcohol use disorder in meeting obligations- affects individual's self-worth and can cause the
individual to put the needs of the client first
40. A nurse is assessing a client who has an anxiety disorder and is taking a benzodiazepine. For
which of the following adverse effects should the nurse monitor the client?
a. seizures
b. dizziness
c. polyuria
d. insomnia
Answer: b. dizziness
Rationale: Dizziness, drowsiness, and sedation are common adverse effects of benzodiazepines
41. A nurse in an acute mental health facility is reviewing the medication records of a group of
patients. The nurse should expect a prescription for memantine for a client who has which of the
following diagnoses?
a. postpartum depression
b. schizophrenia
c. obesity
d. severe Alzheimer's disease
Answer: d. severe Alzheimer's disease
Memantine, NMDA receptor agonist, slows progression of manifestations and improves
cognitive function
42. A nurse is caring for a client with schizophrenia who has been taking chlorpromazine for the
past 2 months. Which of the following findings demonstrates that the chlorpromazine has been
effective?
a. client reports hallucinations occur less frequently
b. client sleeps uninterrupted for 6 hr each night
c. client reports that she is the "most important person on the unit"
d. client demonstrates stereotyped behaviors
Answer: a. client reports hallucinations occur less frequently
Rationale: Chlorpromazine is a first-generation conventional antipsychotic medication- effective
in decreasing delusions, hallucinations, and agitation
43. A nurse in an acute care mental health facility observes a client who has bipolar disorder
begin to shout and use offensive language toward a visitor. Which of the following actions
should the nurse take?
a. give the client two options for ending the situation
b. move quickly to stand directly in front of the client before speaking
c. direct other clients to move toward the client as a show of force
d. tell the client that the conversation will be ended if the shouting continues
Answer: a. give the client two options for ending the situation
Rationale: giving client 2 options (e.g. 2 different locations in which to be away from visitors
and other clients) prevents the client from feeling powerless and gives client some responsibility
for making choices
44. A nurse is teaching a client who has depression and is schedule for TMS (transcranial
magnetic stimulation). The nurse should inform the client that TMS can cause which of the
following adverse effects?
a. retrograde amnesia
b. seizures
c. confusion
d. suicidal ideation
Answer: b. seizures
Rationale: uncommon but potential adverse effect of TMS
45. A nurse is planning an in-service about involuntary commitment to mental health facilities
for a group of newly licensed nurses. Which of the following pieces of information should the
nurse include?
a. the client can challenge hospitalization following emergency treatment
b. involuntary commitment requires the hospitalization of the client
c. a client who is competent but committed involuntarily is unable to make treatment decisions
d. court hearings should be held 7 days after emergency commitment
Answer: a. the client can challenge hospitalization following emergency treatment
46. A nurse is providing teaching to a client who has social anxiety disorder and a new
prescription for paroxetine. Which of the following statements should the nurse include in the
teaching?
a. you can take this medication when needed
b. the medication takes a few weeks to build up in your system
c. you should plan to take this medication for 6 months
d. relapsing after withdrawing from this medication is rare
Answer: b. the medication takes a few weeks to build up in your system
Rationale: Paroxetine is a SSRI- takes about 4 weeks for initial effects to develop, optimal
effects seen in 8-12 weeks
Incorrect answers:
• should not be taken PRN
• treatment should continue for at least 1 year
• withdrawal frequently results in relapse of anxiety disorder
47. A nurse is a provider's office is reviewing the medical history of a client who asks about the
use of varenicline for smoking cessation. Which of the following items in the client's medical
history indicates a precaution for the use of varenicline?
a. client have type 1 diabetes
b. client has a history of depression
c. client has rheumatoid arthritis
d. client has history of GERD
Answer: b. client has a history of depression
Rationale: Varenicline can cause mood changes and thoughts of suicide-contraindicated in
clients with history of psychiatric disease
48. A nurse is evaluating the plan of care for a client who has antisocial personality disorder.
Which of the following actions indicate that the client is making progress with treatment? (Select
all that apply)
a. helping another client who has depression fill out a menu
b. nominating himself to chair the client government meeting
c. requesting a weekend pass to go home
d. serving as the judge for a unit talent show
e. informing the nurse that the staff provides excellent care to clients
Answer: a. helping another client who has depression fill out a menu (trying to connect, help
others) c. requesting a weekend pass to go home (willingness to follow unit rules)
Incorrect answers:
• assuming position of power does not indicate progress
• may use flattery as a form of manipulation
49. A nurse is reviewing the medical record of a client who has a new prescription for
tranylcypromine. The client still has a current prescription for sertraline. The nurse should notify
the provider because taking these medications concurrently increases the risk of which of the
following adverse effects?
a. increased intracranial pressure
b. serotonin syndrome
c. acute kidney injury
d. hypertensive crisis
Answer: b. serotonin syndrome tranylcypromine is a MAOI and sertraline is a SSRI
50. A nurse on an acute care unit is providing post-op care to an older adult client who develops
delirium. Which of the following actions should the nurse take?
a. request a prescription for an antianxiety medication
b. provide the client with a stimulating activity prior to bedtime
c. dim the lights in the client's room at night
d. encourage the client to make decisions about her daily routine
Answer: a. request a prescription for an antianxiety medication
51. A nurse is caring for a client who has schizophrenia and started taking a first generation
antipsychotic medication 3 weeks ago. The client reports a feeling of inner restlessness, rocks
back and forth when sitting down, and paces frequently. The nurse should identify that the client
is experiencing which of the following adverse effects of antipsychotic medications?
a. neuroleptic malignant syndrome
b. akathisia
c. anticholinergic toxicity
d. opisthotonos
Answer: b. akathisia
52. A nurse is caring for a client with bipolar disorder who is experiencing mania. Which of the
following actions is the nurse's priority?
a. offer the client finger foods every 2 hours
b. determine if the client is a danger to herself
c. monitor the client's vital signs q2h
d. move the client to a quiet area
Answer: b. determine if the client is a danger to herself
Rationale: Greatest risk to a client is injury from hyperactivity or life-threatening exhaustion
53. A nurse is establishing a therapeutic relationship with a client who has hallucinations. Which
of the following actions should the nurse take during the orientation phase?
a. identify the client's perception of the reason for therapy
b. ask the client to provide a detailed description of the hallucinations
c. assist the client with the development of problem-solving skills
d. explore the client's relationship with family members
Answer: a. identify the client's perception of the reason for therapy
Rationale: nurse should establish rapport and confidentiality with client- to do this, nurse should
assess client's beliefs about the reason for therapy
54. A nurse is updating the plan of care for a client who has major depression and a new
prescription for amitriptyline. The nurse should plan to monitor the client for which of the
following adverse effects?
a. hypertension
b. drowsiness
c. panic attacks
d. diarrhea
Answer: b. drowsiness
Rationale: drowsiness is an expected side effect of amitriptyline and other TCAs. sedation is
most likely to be present during the first few weeks of treatment and can increase risk of falls.
Incorrect answers:
• OH is common (not hypertension)
• suicidal thoughts is common (not panic attacks)
• anticholinergic effects = constipation not diarrhea
55. A nurse is assessing a client who is experiencing PTSD following a traumatic event. Which
of the following medications should the nurse expect the provider to prescribe?
a. bupropion
b. phenelzine
c. mirtazapine
d. paroxetine
Answer: d. paroxetine
Rationale: SSRI, first-line treatment for PTSD
Incorrect answers:
• Buproprion = antidepressant for smoking cessation, depression, ADHD
• Phenelzine = MAOI, can be prescribed for PTSD but not first-line
• Mirtazapine = TCA, also can be used for PTSD but not first-line
56. A nurse is providing teaching to a client who has a new prescription for clozapine. Which of
the following statements should the nurse include in the teaching?
a. "you should have your WBC count checked once per week for 6 months"
b. "you should check yourself every 3 days for weight loss"
c. "you might experience frequent loose stools"
d. "you might experience ringing in your ears"
Answer: a. "you should have your WBC count checked once per week for 6 months"
Rationale: antipsychotic, can cause agranulocytosis
Incorrect answers:
• causes weight gain, not weight loss
• constipation
• tinnitus not an adverse effect of clozapine
57. A nurse on a psychiatric unit is talking with a client when the client makes a sexual advance
toward the nurse. Which of the following responses should the nurse make?
a. "It's normal to have sexual feelings toward the staff"
b. "You need to stop any type of sexual advances"
c. "This behavior is unacceptable while I am your nurse"
d. "What would your family think of this type of behavior?"
Answer: b. "You need to stop any type of sexual advances"
Rationale: Nurse should not suggest that this type of behavior might be acceptable upon
termination of the nurse-client relationship
58. A nurse is caring for a client who has schizophrenia and a history of aggression. The client is
observed continually pacing in the hallway in an agitated manner over the past hour. Which of
the following responses should the nurse make?
a. "It's a beautiful day outside. Let's take a walk together"
b. "Sit down and we'll try out a relaxation exercise"
c. "Would you like your ant-anxiety medication now?"
d. "You are pacing back and forth. Can you tell me what you are feeling?"
Answer: d. "You are pacing back and forth. Can you tell me what you are feeling?"
Rationale: Assess first collect data from client- then determine intervention
59. A nurse is providing teaching to a client who recently completed detoxification from alcohol
and has a new prescription for acamprosate. Which of the following statements should the nurse
make?
a. "you will get very sick if you drink alcohol while taking this medication"
b. "the medication will be administered as a SQ injection"
c. "you should take this medication on an empty stomach"
d. "the medication might cause you to have episodes of diarrhea"
Answer: d. "the medication might cause you to have episodes of diarrhea"
Rationale: This is an adverse effect of acamprosate.
This does NOT function as aversion therapy, instead reduces the unpleasant feelings associated
with abstinence such as anxiety, dysphoria, and tension
60. A nurse is providing teaching to a client who has a new prescription for diazepam. Which of
the following instructions should the nurse include in the teaching?
a. expect this medication to make you anxious
b. this medication can be habit-forming
c. take this medication on an empty stomach
d. this medication needs to be taken for 2-3 weeks to reach the full therapeutic effect
Answer: b. this medication can be habit-forming
Rationale: diazepam is a benzodiazepine, can cause physical dependence are controlled
substances
Incorrect answers:
• take with food - benzos take effect immediately
61. A nurse is caring for a client who is undergoing ECT. Following the procedure, which of the
following actions should the nurse take?
a. administer oxygen
b. administer an anticonvulsant
c. administer an opioid antagonist
d. administer IV fluids
Answer: a. administer oxygen
Rationale: In preparation for ECT, the anesthesiologist administers succinylcholine, which
paralyzes respiratory muscles. Clients require oxygen administration until their respiratory status
is stable
62. A nurse in the ED is assessing a client with heroin intoxication. Which of the following
findings should the nurse expect?
a. seizure activity
b. respiratory depression
c. hypersensitivity to pain
d. increased mental alertness
Answer: b. respiratory depression
Rationale: heroin is an opioid
• reduces pain, decreased mental alertness, no seizures (impaired coordination)
63. A nurse is caring for a client with OCD who has been taking fluoxetine for 3 months. The
client states, "This medication isn't working. I want to stop taking it." Which of the following
responses should the nurse make?
a. "It is best to discontinue the medication slowly over 1-2 months"
b. "If the medication hasn't helped you in 3 months, it's not going to"
c. "You will likely gain weight if you stop taking this medication"
d. "This medication is the only treatment available for your condition"
Answer: a. "It is best to discontinue the medication slowly over 1-2 months"
Rationale: Fluoxetine is an SSRI, discontinuing medication slowly reduces manifestations of
withdrawal
Incorrect answers:
• effects of fluoxetine take several months to peak, therapy should continue for over a year
before discontinuation - weight gain may occur ON medication
• Other SSRI meds and treatments available
64. A nurse is assessing a client who has adjustment disorder. Which of the following statements
by the client should the nurse recognize as a manifestation of the disorder?
a. "I am unable to remember my address"
b. "I feel like I am living in a fog"
c. "I sometimes cannot remember large blocks of time"
d. "I could have done something to prevent my cousin's death"
Answer: d. "I could have done something to prevent my cousin's death"
Rationale: Occurs as a response to a stressful event. manifestations include guilt, depression,
anxiety, anger
65. A nurse in the ED is assessing a client who reports recent cocaine use. Which of the
following should the nurse expect?
a. hypertension
b. drowsiness
c. bradycardia
d. pinpoint pupils
Answer: a. hypertension
Rationale: cocaine is CNS stimulant (mental alertness, tachycardia, dilated pupils
66. A nurse is reviewing the medical record of a client who has a new prescritiption for
benzodiazepine. For which of the following findings should the nurse question the provider's
prescription?
a. skeletal muscle injury
b. history of status epilepticus
c. hypotension
d. insomnia
Answer: c. hypotension
Rationale: Benzos can cause severe hypotension and increase the client's risk of cardiac arrest
67. A nurse caring for a client who has a new diagnosis of colon cancer. Shortly after the client
receives the diagnosis, the nurse enters the client's room. The client begins yelling "I've received
terrible care here, and no one bothers to help me" The nurse should recognize that the client is
demonstrating which of the following defense mechanisms?
a. Denial
b. Displacement
c. Reaction formation
d. Projection
Answer: b. displacement
Rationale: Redirection of thoughts feelings from an object that causes anxiety to a safer, more
acceptable one Projection occurs when the client attributes undesired impulses to another person
68. A nurse is planning care for a client who has completed detoxification from opioid use
disorder. The nurse should plan to teach about which of the following medications?
a. methadone
b. naltrexone
c. buprenorphine
d. disulfiram
Answer: b. naltrexone
Rationale: Opioid antagonist used for the long-term maintenance of opioid use disorder. It is the
usual med of choice following detox from opioids (Methadone is an opioid agonist that is
prescribed as a substitute for opioids prior to detox)
69. A nurse is assessing a client who has been using a nicotine transdermal patch for smoking
cessation. The client reports itching of the skin where the patch is applied. Which of the
following statements should the nurse make?
a. you should change the location of the patch on your body
b. decreasing the strength of the patch should stop the itching
c. you should discontinue using the patch
d. this is an adverse effect of the patch that will subside in time
Answer: c. you should discontinue using the patch
Rationale: Stop using the patch is persistent local reactions occur such as erythema, itching, or
edema are experienced
70. A nurse is creating a plan of care for a group of clients. Which of the following interventions
is the priority for the nurse to include?
a. offering high-calorie beverages to a client who is in the manic phase of bipolar disorder
b. practicing relaxation techniques with a client who has an anxiety disorder
c. assisting a client who has a depressive disorder with decision-making regarding group
activities
d. providing teaching to a client who has schizophrenia about a new prescription for clozapine
Answer: a. offering high-calorie beverages to a client who is in the manic phase of bipolar
disorder
Rationale: Maslow's hierarchy- physiological needs first. Education about meds is important,
but not a priority need (administering meds would be!)
71. A nurse is providing teaching to a client about cannabis use disorder. Which of the following
statements indicates an understanding of the teaching?
a. withdrawal of cannabis occurs 3 days after cessation"
b. there are no physical manifestations of withdrawal from cannabis"
c. "drug screens can detect cannabis for up to 8 weeks after use"
d. cannabis use can produce effects resembling the effects of alcohol use"
Answer: d. cannabis use can produce effects resembling the effects of alcohol use"
Rationale:
• also a CNS depressant
• physical manifestations of withdrawal include abdominal pain, shakiness, sweating, fever,
chills, headaches
• cannabis can be detected in drug screens for up to 4 weeks
72. A nurse is providing teaching to a client who has generalize anxiety disorder and a new
prescription for buspirone. Which of the following manifestations is a common adverse effect of
this medication?
a. confusion
b. bradycardia
c. dizziness
d. insomnia
Answer: c. dizziness
Rationale: Buspirone is a anxiolytic. Dizziness is a common side effect. Client should avoid
driving and operating heavy machinery until presence of adverse effects have been determined
73. Which of the following is a negative symptoms of schizophrenia?
a. hallucinations
b. impaired memory
c. dysphoria
d. social discomfort
Answer: d. social discomfort
Rationale: Something normal that is not present in person with schizophrenia (dysphoria is an
affective symptom = those that involve the expression of emotions
74. A nurse is assessing a client who has Stage 4 Alzheimer's disease. Which of the following
findings should the nurse expect?
a. client requires assistance with eating
b. client independently manages personal finances
c. client has bladder incontinence
d. client is able to identify the names of family members
Answer: d. client is able to identify the names of family members
Rationale: Clients with AD maintain this ability until stage 6 (incontinence also stage 6,
requiring assistance eating is stage 7)
75. A nurse is assessing a client who takes phenelzine for the treatment of depression. Which of
the following findings is the priority for the nurse to report to the provider?
a. elevated BP
b. weight gain
c. muscle twitching
d. 2+ peripheral edema
Answer: a. elevated BP
Rationale: Phenelzine is a MAOI, increased BP increases risk of hypertensive crisis
76. Which of the following findings should the nurse expect during alcohol withdrawal?
a. low body temp
b. insomnia
c. muscle flaccidity
d. bradycardia
Answer: b. insomnia
Rationale: insomnia and restlessness
• elevated temp
• muscle tremors
• tachycardia
77. A nurse is caring for a client who has excoriation disorder. Which of the following statements
by the client should the nurse expect?
a. "I pick my face when I am nervous"
b. "I have bald patched from pulling out my hair"
c. "I inspect my body in the mirror several times a day"
d. "I am unable to part with any of my belongings"
Answer: a. "I pick my face when I am nervous"
78. A nurse is caring for a client who has acute delirium. Which of the following findings should
the nurse expect?
a. progressive deterioration of cognitive function
b. rapid fluctuation in LOC
c. loss of language ability
d. absence of contributing factors to pinpoint the cause of delirium
Answer: b. rapid fluctuation in LOC
Incorrect answers:
• Progressive deterioration of cognitive function, loss of language = dementia
79. A nurse is assessing a client who has panic disorder and has been taking paroxetine. Which of
the following assessments should the nurse identify as an adverse effect of the medication?
a. peripheral edema
b. chest congestion
c. shuffling gait
d. weight gain
Answer: d. weight gain
Rationale: Paroxetine is an SSRI- expected adverse effects are weight gain, nausea, headaches,
insomnia, and sexual dysfunction
80. A nurse is providing teaching to a client who has a new prescription for buspirone to treat
anxiety. Which of the following statements should the nurse include in the teaching?
a. use buspirone with caution because it raises risk of suicidal thoughts
b. you can minimize adverse effects by taking buspirone with grapefruit juice
c. buspirone enhances the depressant effects of alcohol
d. buspirone cause nausea in some people
Answer: d. buspirone cause nausea in some people
Rationale: Buspirone is a anxiolytic. Can cause nausea
81. A nurse is providing teaching to a new client who has anxiety and a new prescription for
diazepam. Which of the following statements should the nurse make?
a. "feelings of sedation should resolve in about 1 week"
b. "there is no risk of physical dependence with this medication"
c. "you can increase the dose when you feel especially anxious"
d. "it will take several months for you to feel the maximum benefit of the medication"
Answer: a. "feelings of sedation should resolve in about 1 week"
Rationale:
• Diazepam = benzodiazepine. Sedation and psychomotor slowing should subside in 7- 10 days
• Are at risk for dependence
• NOT to increase dose with approval of provider
• immediate onset of action
82. A nurse is caring for a client who has Wernicke-Korsakoff syndrome due to alcohol use
disorder. Which of the following findings should the nurse report?
a. increased arousal
b. arrhythmias
c. confusion
d. esophageal pain
Answer: c. confusion
Rationale: Neurological and cognitive manifestations due to thiamine (B1) deficiency
83. A nurse is providing teaching to a client who has a new prescription for chlorpromazine.
Which of the following statements should the nurse make?
a. "this medication is a TCA and will improve your mood"
b. "this medication is an opioid antagonist that blocks the pleasurable effects of alcohol"
c. "this medication is an antipsychotic that controls manifestations of schizophrenia"
d. "this medication is a cholinesterase inhibitor that slows the progression of dementia"
Answer: c. "this medication is an antipsychotic that controls manifestations of schizophrenia"
84. A nurse is assessing a client prior to administering lithium. The client began taking lithium 1
week ago for the treatment of mania. For which of the following findings should the nurse
withhold the dose?
a. report of nausea with frequent episodes of emesis
b. weight gain of 4 lbs since start of treatment
c. fine hand tremors in both hands
d. serum lithium level of 1.1 mEq/L
Answer: a. report of nausea with frequent episodes of emesis
Rationale: GI upset with nausea and emesis is an early indicator of lithium toxicity (should
withhold dose and obtain a serum lithium level)
• weight gain of up to 5 lbs in first week is normal finding
• fine hand tremors normal (coarse tremors concerning?)
85. A home health nurse is talking with the partner of a client who has dementia. Which of the
following statements by the partner indicates that the client is displaying signs of apraxia?
a. "yesterday my partner put on a jacket upside down"
b. "my partner has trouble reading the newspaper"
c. "my partner often repeats words"
d. "last week, my partner did not recognize the sound of the alarm clock"
Answer: a. "yesterday my partner put on a jacket upside down"
Rationale: apraxia = lack of ability to accomplish once-known tasks
86. A nurse is caring for. A client who has bipolar disorder. Which of the following
manifestations is the priority finding for the nurse to identify?
a. inability to concentrate
b. poor hygiene
c. hyperactivity
d. pressured speech
Answer: c. hyperactivity
Rationale: risk for injury- constant activity can lead to exhaustion and even death
87. A nurse is providing teaching to a client who has panic disorder and a new prescription for
clomipramine. Which of the following adverse effects should the nurse include in the teaching?
a. diarrhea
b. sedation
c. hypertension
d. urinary frequency
Answer: b. sedation
Rationale: Adverse effects of Clomipramine (TCA) include sedation, orthostatic hypotension,
anticholinergic effects
88. A nurse is assessing a client who is taking lithium to treat bipolar disorder and has a lithium
level of 2.2 mEq/L. Which of the following findings should the nurse expect?
a. muscle weakness
b. oliguria
c. vomiting
d. blurry vision
Answer: d. blurry vision
Manifestations of lithium toxicity with levels between 2 and 2.5 include blurry vision, ataxia,
clonic twitching, severe hypotension, and polyuria
89. A nurse working in the ED is caring for a client following an overdose of pentobarbital
sodium. For which of the following findings should the nurse assess first?
a. cerebrovascular accident
b. dysrhythmias
c. liver failure
d. respiratory depression
Answer: d. respiratory depression
Pentobarbital sodium is a barbiturate- most dangerous adverse effect of med is respiratory
depression that can be fatal
90. A nurse is providing teaching to a client who has a new prescription for varenicline for
smoking cessation. Which of the following statements by the client indicates an understanding of
the teaching?
a. "if I fail to stop smoking after 12 weeks, I will have to try another product"
b. "I will take the medication for 7 days before I try to stop smoking"
c. "the medication will cause me to lose weight as I stop smoking"
d. "I will take the medication after eating a meal"
Answer: d. "I will take the medication after eating a meal"
Rationale: Taking with a meal will minimize the associated nausea
91. A nurse is monitoring a client who has schizophrenia and receiving treatment with
fluphenazine hydrochloride. Which of the following findings is an indication of neuroleptic
malignant syndrome that the nurse should report to the provider?
a. blurred vision
b. urinary retention
c. muscle flaccidity
d. elevated temp
Answer: d. elevated temp
Rationale: Other symptoms include rigidity, sweating, dysrhythmias, and changes in BP
92. A nurse is assessing a client who is taking buspirone to treat GAD. Which of the following
findings should the nurse identify as an adverse effect of this medication?
a. arthralgia
b. photophobia
c. xerostomia
d. bradycardia
Answer: c. xerostomia
Rationale: Buspirone is a benzodiazepine- can cause xerostomia, headaches, nausea, and
insomnia
93. A nurse is assessing a client who has been taking thioridazine hydrochloride for several days.
The client reports hand tremors, drooling, and rigid extremities. Which of the following actions
should the nurse take?
a. reassure the client that these effects are expected
b. administer diazepam
c. encourage deep breathing and relaxation
d. administer benztropine
Answer: d. administer benztropine
Rationale: Client is experiencing EPS, which includes pseudo parkinsonism. Benztropine is a
medication that counteracts these adverse effects (anti parkinson's drug)
94. A nurse is assessing a client who has ADHD and reports abruptly discontinuing his
amphetamine treatment. Which of the following assessments indicates that the client is
physically dependent on the amphetamine?
a. client exhibits paranoia
b. client reports having insomnia
c. client reports eating excessively
d. client has an increased heart rate
Answer: c. client reports eating excessively
Rationale: indications of physical dependence include excessive eating, exhaustion, depression,
prolonged sleep, and craving for more amphetamine
95. A nurse is obtaining a client's medical history prior to scheduling the client for ECT. Which
of the following findings should the nurse identify as a potential complication of the procedure?
a. severe depression
b. cardiac arrhythmia
c. bipolar disorder
d. Parkinson's disease
Answer: b. cardiac arrhythmia
Rationale: Needs further evaluation, since greatest risk of death due to ECT is related to cardiac
complications
96. A nurse is teaching a parent who has admitted to verbally abusing his children about stress
management techniques. Which of the following strategies is the nurse providing?
a. tertiary prevention
b. individual psychotherapy
c. family psychotherapy
d. primary prevention
Answer: a. tertiary prevention
Rationale: Tertiary prevention methods occur AFTER abuse as occurred (can be for victim or
perpetrator)
• Secondary acute
• Primary preventative
97. A nurse is caring for a newly admitted client who is experiencing alcohol withdrawal. Which
of the following findings should the nurse expect?
a. bradycardia
b. increased somnolence
c. slurred speech
d. headache
Answer: d. headache
Rationale: Other findings include hand tremors, nausea, vomiting, sweating, depression, or
irritability
98. A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following
clinical manifestations should the nurse expect?
a. sedation
b. rhinorrhea
c. bradycardia
d. hypothermia
Answer: b. rhinorrhea (runny nose)
Rationale: flu-like symptoms- yawning, sneezing, abdominal pain
99. A nurse in an outpatient facility is assessing a 3-month-old infant who has lost weight and has
injuries that indicate physical abuse. When preparing to interview the parent, which of the
following actions should the nurse take?
a. insist that the parent tell the nurse how the child was injured
b. tell the parent that a child protection agency must be notified
c. show disapproval to the parent regarding the infant's condition
d. call at least 2 other staff members to sit in the room during the interview
Answer: b. tell the parent that a child protection agency must be notified
100. A nurse is caring for a client with alcohol use disorder who has undergone detox. Which of
the following medications should the nurse expect the provider to prescribe to assist the client
with maintaining sobriety?
a. varenicline
b. clonidine
c. buprenorphine
d. disulfiram
Answer: d. disulfiram
Rationale: Aversion therapy
Incorrect answers:
a. varenicline- reduces nicotine cravings b. clonidine- heroin withdrawal c. buprenorphine- treats
opioid withdrawal
101. A nurse is providing teaching to a client who has a new prescription for phenelzine. Which
of the following OTC meds can cause a hypertensive crisis when taking concurrently with
phenelzine?
a. acetaminophen
b. ranitidine
c. naproxen
d. pseudoephedrine
Answer: d. pseudoephedrine (Sudafed- decongestant)
Rationale: Interacts with MAOI medications and is therefore contraindicated
102. A nurse is providing teaching to a client with ADHD and a new prescription for a
transdermal methylphenidate patch. Which of the following statements by the client indicates an
understanding of the teaching?
a. "I will rotate placing the patch on different parts of my upper body"
b. "I can take showers with the patch in place"
c. "If the patch bothers my skin, I will switch to the oral form of the medication"
d. "I will apply a patch each night at bedtime"
Answer: b. "I can take showers with the patch in place"
Rationale: Can be worn during showers, bathing, and swimming
• apply to hips, not upper body
• if reaction to transdermal, may have reaction to oral form
• apply patch each morning, leave in place for no more than 9 hours
103. A nurse is caring for a client who has schizophrenia. The client states, "Aliens came into my
room last night and took a sample of my blood" Which of the following responses should the
nurse make:
a. aliens do not exist
b. has your daughter had her baby?
c. do you mean to say that a lab technician drew your blood last night?
d. that does not sound real
Answer: d. that does not sound real
104. A nurse asks an older adult client, "Did you have any visitors yesterday?" The client
responds, "Yes, several members of my church choir came to see me." The nurse knows that only
the client's daughter visited the day before. Which of the following cognitive impairments is the
client demonstrating?
a. perseveration
b. confabulation
c. apraxia
d. agnosia
Answer: b. confabulation
Rationale: Filling in gaps in memory by fabrication. Client unconsciously makes up responses
that are inaccurate to avoid the embarrassment of memory loss
105. A nurse is preparing to apply wrist restraints on a client who is threatening to harm others
and has not responded to less invasive interventions. Which of the following actions should the
nurse plan to take?
a. obtain a PRN prescription for restraints from the client's provider
b. visually observe the client every 10 mins until restraints are removed
c. ensure 3 fingers can fit between the restraint and the client's wrist
d. document the client's behavior every 15 min while restraints are in place
Answer: d. document the client's behavior every 15 min while restraints are in place
Rationale:
• prescription needed, CANNOT be PRN though
• one-on-one observation needed for restraints
• 2 fingers, not 3
Meth Drug Effects - stimulant
• paranoia
• high HR and metabolism
• mental alterness
• decreased appetite
Cocaine Drug Effects - stimulant
• hallucinations
• delirium
• increased BP, HR
• dilated pupils
Stimulant Withdrawal Symptoms - depression and suicidal thoughts
Heroin Withdrawal Symptoms - opposite of opioid effect
• muscle aches
• insomnia
• diarrhea
• pupillary dilation
Alcohol Withdrawal Symptoms - headache
• insomnia
• hand tremors
• sweating
• depression
• irritability
First-line treatment for alcohol withdrawal - Benzodiazepines
e.g. Lorazepam, Diazepam
Opioid Withdrawal Symptoms - rhinorrhea (runny nose)
• flu-like symptoms: sneezing, yawning, lacrimation, pupillary dilation, piloerection
Varenicline - for nicotine cessation
• take with meals to avoid nausea
• can cause suicidal ideation, caution in those with depression
Acamprosate - lessens symptoms of alcohol abstinence
• may cause diarrhea
MAOIs - antidepressants
Phenelzine,
Tranylcypromine
• elevated BP = hypertensive crisis
• Pseudo epinephrine contraindicated
Barbituates - anticonvulsant
Pentobarbital sodium
• respiratory depression is priority!
Valproic Acid - anticonvulsant, use in treatment of bipolar liver- hepatotoxicity (LFTs)
Benzodiazepines - "tranquilizers" Lorazepam, Diazepam
Adverse effects: dizziness, drowsiness, sedation most common. can cause severe hypotension
(leading to cardiac arrest)
• first-line treatment for alcohol withdrawal (stabilizes VS, prevents seizures, treats DTs)
• feelings of sedation should resolve in 1 week
• immediate onset of action
• highly addictive
First-Gen Antipsychotics (Typical) - treats POSITIVE S/S Chlorpromazine
• EPS side effects
Antiparkinson Agents - used to treat EPS symptoms in antipsychotics Benztropine
Anxiolytics - anti-anxiety Buspirone
Common adverse effects: xerostomia, dizziness avoid grapefruit juice
• may take several weeks to notice effects
• causes nausea in some people
Tricyclic Antidepressants - Amitriptyline, Clomipramine
SE: drowsiness sedation, orthostatic hypotension, anticholinergic effects dizziness expected to
diminish after 1st few weeks
• takes 6-8 weeks to achieve full therapeutic effect
• take @ bedtime (sleepiness)
• no alcohol
Lithium - bipolar med (mood stabilizer)
• causes weight gain
• take with food (GI distress)
• balance water and sodium
• no NSAIDs
Nausea and emesis early signs of toxicity
Therapeutic range = 0.6-1.2 (1.5 and over is toxicity)
Second-Gen Antipsychotics (Atypical) - treat NEGATIVE
Symptoms Risperidone
Clozapine = agranulocytosis
SE: weight gain, metabolic syndrome
SSRIs - antidepressants
Paroxetine = 1st line for
PTSD Fluoxetine, Sertraline
Adverse effects: weight gain, nausea, headaches, insomnia, sexual dysfunction
Onset of action = 4 weeks for initial effect, 8-12 weeks for optimal effect
