2019 ATI Mental Health Proctored Exam With Answers-163 Solved Questions

ATI MENTAL HEALTH PROCTORED EXAM 2019
1. A charge nurse is discussing mental status exams with a newly licensed nurse. Which
of the following statements by the newly licensed nurse indicates an understanding of
the teaching? (Select all that apply)
A. "To assess cognitive ability, I should ask the patient to count backward by sevens."
B. "To assess affect, I should observe the patient's facial expression."
C "To assess language ability, I should instruct the patient to write a sentence."
D. "To assess remote memory, I should have the patient repeat a list of objects."
E. "To assess the patient's abstract thinking, I should ask the patient to identify our most
recent presidents."
Answer: A. "To assess cognitive ability, I should ask the patient to count backward by
sevens."
B. "To assess affect, I should observe the patient's facial expression."
C "To assess language ability, I should instruct the patient to write a sentence."
Rationale:
• Counting backward by sevens assesses cognitive ability and attention.
• Observing facial expressions effectively evaluates a patient's affect.
• Instructing a patient to write a sentence tests language skills and coherence.
• Repeating a list assesses short-term memory, not remote memory.
• Identifying recent presidents tests factual recall rather than abstract thinking.
2. A nurse is planning care for a patient who has a mental health disorder. Which of the
following actions should the nurse include as a psychobiological intervention?
A. Assist the patient with systematic desensitization therapy.
B. Teach the patient appropriate coping mechanisms.
C. Assess the patient for comorbid health conditions.
D. Monitor the patient for adverse effects of the medications.
Answer: D. Monitor the patient for adverse effects of the medications.
Rationale:

Monitoring a patient for adverse effects of medications is a key psychobiological
intervention in mental health care. Psychobiological interventions focus on the
biological aspects of mental health disorders, including the effects of pharmacological
treatments. By observing for side effects, the nurse ensures the patient's safety, assesses
medication effectiveness, and can collaborate with the healthcare team to adjust
treatment as necessary. This proactive approach is essential for optimizing therapeutic
outcomes and minimizing risks associated with medication use.
3. A nurse in an outpatient mental health clinic is preparing to conduct an initial patient
interview. When conducting the interview, which of the following actions should the
nurse identify as the priority?
A. Coordinate holistic care with social services.
B. Identify the patient's perception of her mental health status.
C. Include the patient's family in the interview.
D. Teach the patient about her current mental health disorder.
Answer: B. Identify the patient's perception of her mental health status.
Rationale:
Understanding the patient's perception of her mental health status is crucial during the
initial interview. This insight provides a foundation for building rapport, guiding the
therapeutic relationship, and tailoring the care plan to meet the patient's specific needs
and concerns. By prioritizing the patient's perspective, the nurse can better assess the
severity of symptoms, identify areas of distress, and understand the patient's goals for
treatment, which are essential for effective and personalized care. Other actions, while
important, should follow this foundational understanding.
4. A nurse is told during change of shift report that a patient is stuporous. When
assessing the patient, which of the following findings should the nurse expect?
A. The patient arouses briefly in response to a sternal rub.
B. The patient has a Glasgow coma scale score less than 7.
C. The patient exhibits decorticate rigidity.
D. The patient is alert but disoriented to time and place.

Answer: A. The patient arouses briefly in response to a sternal rub.
Rationale:
A stuporous patient is in a state of altered consciousness, where they may be difficult to
arouse but can respond to strong stimuli, such as a sternal rub. This indicates that the
patient has some level of responsiveness, albeit limited.
5. A nurse is planning a peer group discussion about the DSM-5. Which of the following
information is appropriate to include in the discussion? (Select all that apply)
A. The DSM-5 includes patient education handouts for mental health disorders.
B. The DSM-5 establishes diagnostic criteria for individual mental health disorders.
C. The DSM-5 indicates recommended pharmacological treatment for mental health
disorders.
D. The DSM-5 assists nurses in planning care for patient's who have mental health
disorders.
E. The DSM-5 indicates expected assessment findings of mental health disorders.
Answer: B. The DSM-5 establishes diagnostic criteria for individual mental health
disorders.
D. The DSM-5 assists nurses in planning care for patient's who have mental health
disorders.
E. The DSM-5 indicates expected assessment findings of mental health disorders.
Rationale:
• The DSM-5 provides specific criteria for diagnosing mental health disorders, making it
a crucial tool for clinicians.
• By understanding the diagnoses and criteria outlined in the DSM-5, nurses can better
plan individualized care based on patients' specific needs.
• The DSM-5 does not provide patient education materials; it is primarily a diagnostic
tool for professionals.
6. A nurse in an emergency mental health facility is caring for a group of patients. The
nurse should identify that which of the following patients requires a temporary
emergency admission?

A. A patient who has schizophrenia with delusions of grandeur
B. A patient who has manifestations of depression and attempted suicide a year ago
C. A patient who has borderline personality disorder and assaulted a homeless man with
a metal rod
D. A patient who has bipolar disorder and paces quickly around the room while talking
to himself
Answer: C. A patient who has borderline personality disorder and assaulted a homeless
man with a metal rod
Rationale:
This patient poses an immediate risk to others due to their aggressive behavior,
indicating a potential danger to themselves or others. Emergency admissions are often
necessary when a patient's behavior presents an imminent threat.
7. A nurse decides to put a patient who has a psychotic disorder in seclusion overnight
because the unit is very short-staffed, and the patient frequently fights with other
patients. The nurse's actions are an example of which of the following torts?
A. Invasion of privacy
B. False imprisonment
C. Assault
D. Battery
Answer: B. False imprisonment
Rationale:
False imprisonment occurs when a person is confined or restrained against their will
without legal justification. In this scenario, placing a patient in seclusion overnight
solely due to short staffing, rather than a clinical necessity or established protocol,
constitutes an unlawful restriction of the patient's freedom.
8. A patient tells a nurse, "Don't tell anyone but I hid a sharp knife under my mattress in
order to protect myself from my roommate, who is always yelling at me and threatening
me." Which of the following actions should the nurse take?

A. Keep the patient's communication confidential, but talk to the patient daily, using
therapeutic communication to convince him to admit to hiding the knife.
B. Keep the patient's communication confidential, but watch the patient and his
roommate closely.
C. Tell the patient that this must be reported to the health care team because it concerns
the health and safety of the patient and others.
D. Report the incident to the health care team, but do not inform the patient of the
intention to do so.
Answer: D. Report the incident to the health care team, but do not inform the patient of
the intention to do so.
Rationale:
The nurse has a duty to maintain the safety of all patients, and the patient's disclosure
about hiding a sharp knife poses a significant risk to both themselves and their
roommate. It is essential to inform the patient that this information cannot remain
confidential due to safety concerns. This approach prioritizes the safety of all involved
while maintaining transparency with the patient about the actions being taken.
9. A nurse is caring for a patient who is in mechanical restraints. Which of the following
statements should the nurse include in the documentation? (Select all that apply)
A. "patient was offered 8 oz of water every hr."
B. "patient shouted obscenities at assistive personnel."
C. "patient received chlorpromazine 15 mg by mouth at 1000."
D. "patient ate most of his breakfast."
E. “patient acted out after lunch ”
Answer: A. "patient was offered 8 oz of water every hr."
B. "patient shouted obscenities at assistive personnel."
C. "patient received chlorpromazine 15 mg by mouth at 1000."
Rationale:
It is essential to document that the patient was provided with hydration, as this is part of
ensuring their basic needs are met while in restraints.

Documenting the patient's behavior is important for understanding their mental state and
the context of their restraints. This provides insight into the need for continued restraint.
10. A nurse hears a newly licensed nurse discussing a patient's hallucinations in the
hallway with another nurse. Which of the following actions should the nurse take first?
A. Notify the nurse manager.
B. Tell the nurse to stop discussing the behavior.
C. Provide an in-service program about confidentiality.
D. Complete an incident report.
Answer: B. Tell the nurse to stop discussing the behavior.
Rationale:
The first action the nurse should take is to immediately address the breach of
confidentiality. Discussing a patient’s hallucinations in a public area violates the
patient’s privacy rights and can undermine trust in the healthcare setting. By telling the
newly licensed nurse to stop discussing the behavior, the nurse is taking direct action to
protect the patient’s confidentiality and ensure that sensitive information is not shared
inappropriately.
11. A nurse is caring for the parents of a child who has demonstrated changes in behavior
and mood. When the mother of the child asks the nurse for reassurance about her son's
condition, which of the following responses should the nurse make?
A. "I think your son is getting better. What have you noticed."
B. "I'm sure everything will be okay. It just takes time to heal."
C. "I'm not sure what’s wrong. Have you asked the doctor about your concerns?"
D. "I understand you're concerned. Let's discuss what concerns you specifically."
Answer: D. "I understand you're concerned. Let's discuss what concerns you
specifically."
Rationale:
This response is empathetic and invites the mother to share her specific concerns,
allowing for a more open and supportive dialogue. It validates her feelings and

encourages communication, which is essential in addressing parental anxiety and
providing appropriate reassurance.
12. A nurse is caring for a patient who smokes and has lung cancer. The patient reports,
"I'm coughing because I have that cold that everyone has been getting." The nurse
should identify that the patient is using which of the following defense mechanisms?
A. Reaction formation
B. Denial
C. Displacement
D. Sublimation
Answer: B. Denial
Rationale:
Denial is a defense mechanism where a person refuses to accept reality or facts, thereby
blocking external events from awareness. In this case, the patient attributes their
coughing to a cold rather than acknowledging the possibility that it could be related to
their lung cancer. This avoidance reflects a denial of the severity of their condition and
the potential implications it carries.
13. A nurse is providing preoperative teaching for a patient who was just informed that
she requires emergency surgery. The patient has a respiratory rate 30/min and says,
"This is difficult to comprehend. I feel shaky and nervous." The nurse should identify
that the patient is experiencing which of the following levels of anxiety?
A. Mild
B. Moderate
C. Severe
D. Panic
Answer: B. Moderate
Rationale:
Moderate anxiety is characterized by increased physical symptoms and an inability to
fully concentrate on the situation at hand. In this scenario, the patient's respiratory rate is
elevated at 30 breaths per minute, and she expresses feelings of shakiness and

nervousness, indicating that her anxiety is affecting her ability to process information.
While she is not completely overwhelmed, her symptoms suggest she is in a state of
moderate anxiety.
14. A nurse is caring for a patient who is experiencing moderate anxiety. Which of the
following actions should the nurse take when trying to give necessary information to the
patient? (Select all that apply.)
A. Reassure the patient that everything will be okay.
B. Discuss prior use of coping mechanisms with the patient.
C. Ignore the patient's anxiety so that she will not be embarrassed.
D. Demonstrate a calm manner while using simple and clear directions.
E. Gather information from the patient using closed-ended questions.
Answer: B. Discuss prior use of coping mechanisms with the patient.
D. Demonstrate a calm manner while using simple and clear directions.
Rationale:
• This approach helps the patient feel understood and encourages them to use strategies
that have worked for them in the past, promoting a sense of agency and reducing
anxiety.
• A calm demeanor from the nurse can help to soothe the patient’s anxiety, and using
simple, clear directions is essential for effective communication, especially when a
patient is anxious.
15. A nurse is talking with a patient who is at risk for suicide following the death of his
spouse. Which of the following statements should the nurse make?
A. "I feel very sorry for the loneliness you must be experiencing."
B. "Suicide is not the appropriate way to cope with loss."
C. "Losing someone close to you must be very upsetting."
D. "I know how difficult it is to lose a loved one."
Answer: C. "Losing someone close to you must be very upsetting."
Rationale:

This statement acknowledges the patient’s feelings and validates their experience
without making assumptions or minimizing their grief. It opens the door for further
discussion about their emotions and provides an opportunity for the patient to express
themselves.
16. A charge nurse is discussing the characteristics of a nurse-patient relationship with a
newly licensed nurse. Which of the following characteristics should the nurse include in
the discussion? (Select all that apply)
A. The needs of both participants are met.
B. An emotional commitment exists between the participants.
C. It is goal-directed.
D. Behavioral change is encouraged.
E. A termination date is established.
Answer: C. "Losing someone close to you must be very upsetting."
Rationale:
The nurse-patient relationship is focused on achieving specific health-related goals, such
as improving the patient's well-being or facilitating recovery. The relationship aims to
promote positive behavioral changes that support the patient's health and coping
mechanisms. While the nurse's needs may be considered, the primary focus is on the
patient's needs, making this statement less appropriate.
17. A nurse is in the working phase of a therapeutic relationship with a patient who has
methamphetamine use disorder. Which of the following actions indicates transference
behavior?
A. The patient asks the nurse whether she will go out to dinner with him.
B. The patient accuses the nurses of telling him what to do just like his ex-girlfriend.
C. The patient reminds the nurse of a friend who died from a substance overdose.
D. The patient becomes angry and threatens to harm himself.
Answer: B. The patient accuses the nurses of telling him what to do just like his exgirlfriend.
Rationale:

Transference is a phenomenon where a patient projects feelings, attitudes, or experiences
from past relationships onto the healthcare provider. In this case, the patient is
associating the nurse's guidance or authority with negative feelings toward his exgirlfriend, indicating that he is transferring emotions from that past relationship onto the
nurse.
18. A nurse is planning care for the termination phase of a nurse-patient relationship.
Which of the following actions should the nurse include in the plan of care?
A. Discussing ways to use new behaviors
B. Practicing new problem-solving skills
C. Developing goals
D. Establishing boundaries
Answer: A. Discussing ways to use new behaviors
Rationale:
In the termination phase of a nurse-patient relationship, the focus is on helping the
patient consolidate their learning and plan for the future. Discussing ways to use new
behaviors allows the patient to reflect on their progress and consider how to apply what
they have learned in their daily life after the relationship ends.
19. A nurse is orienting a new patient to a mental health unit. When explaining the unit's
community meetings, which of the following statements should the nurse make?
A. "You and a group of other patients will meet to discuss your treatment plans."
B. "Community meetings have a specific agenda that is established by staff."
C. "You and the other patients will meet with staff to discuss common problems."
D. "Community meetings are an excellent opportunity to explore your personal mental
health issues."
Answer: C. "You and the other patients will meet with staff to discuss common
problems."
Rationale:
This statement accurately describes the purpose of community meetings on a mental
health unit. These meetings typically provide a platform for patients to come together to

share experiences, discuss common challenges, and collaborate on solutions, all while
involving staff for guidance and support.
20. A nurse is caring several patients who are attending community-based mental health
programs. Which of the following patients should the nurse plan to visit first?
A. A patient who recently burned her arm while using a hot iron at home.
B. A patient who requests that her antipsychotic medication be changed due to some new
adverse effects.
C. A patient who says he is hearing a voice that tells him he is not worth living anymore.
D. A patient who tells the nurse he experienced manifestations of severe anxiety before
and during a job interview.
Answer: C. A patient who says he is hearing a voice that tells him he is not worth living
anymore.
Rationale:
This patient is expressing suicidal ideation and experiencing auditory hallucinations,
which are serious concerns that require immediate attention. The nurse must prioritize
this patient's safety and address the risk of self-harm.
21. A community mental health nurse is planning care to address the issue of depression
among older adult patients in the community. Which of the following interventions
should the nurse plan as a method of tertiary prevention?
A. Educating patients on health promotion techniques to reduce the risk of depression
B. Performing screenings for depression at community health programs
C. Establishing rehabilitation programs to decrease the effects of depression
D. Providing support groups for patients at risk for depression
Answer: C. Establishing rehabilitation programs to decrease the effects of depression
Rationale:
Tertiary prevention focuses on managing and reducing the impact of an existing disease
or condition. Establishing rehabilitation programs for older adults with depression aims
to help them recover, regain function, and improve their quality of life, thereby
addressing the effects of the illness.

22. A nurse is working in a community mental health facility. Which of the following
services does this type of program provide? (Select all that apply)
A. Educational groups
B. Medication dispensing programs
C. Individual counseling programs
D. Detoxification programs
E. Family therapy
Answer: A. Educational groups
B. Medication dispensing programs
C. Individual counseling programs
E. Family therapy
Rationale:
Community mental health programs often provide educational sessions to help
individuals understand mental health issues and promote wellness. Many community
mental health facilities have programs to ensure that patients receive their medications
as prescribed, promoting adherence and monitoring for side effects. Individual
counseling is a key component of mental health services, offering patients personalized
support and therapy to address their specific needs.
23. A nurse in an acute mental health facility is assisting with discharge planning for a
patient who has a severe mental illness and requires supervision much of the time. The
patient's wife works all day but is home by late afternoon. Which of the following
strategies should the nurse suggest as appropriate follow-up care?
A. Receiving daily care from a home health aide
B. Having a weekly visit from a nurse case worker
C. Attending a partial hospitalization program
D. Visiting a community mental health center on a daily basis
Answer: C. Attending a partial hospitalization program
Rationale:

A partial hospitalization program (PHP) provides structured support and treatment
during the day while allowing patients to return home in the evenings. This option is
appropriate for individuals who require supervision and support but do not need 24-hour
inpatient care. It also allows the patient to engage in therapeutic activities while
receiving care.
24. A nurse is caring for a group of patients. Which of the following patients should a
nurse consider for referral to an assertive community treatment (ACT) group?
A. A patient in an cute care mental health facility who has fallen several times while
running down the hallway
B. A patient who lives at home and keeps "forgetting" to come in for his monthly
antipsychotic injection for schizophrenia
C. A patient in a day treatment program who says he is becoming more anxious during
group therapy
D. A patient in a weekly grief support group who says she still misses her deceased
husband who has been dead for 3 months
Answer: B. A patient who lives at home and keeps "forgetting" to come in for his
monthly antipsychotic injection for schizophrenia
Rationale:
Assertive Community Treatment (ACT) is designed for individuals with severe mental
illnesses who need comprehensive, individualized support to manage their conditions
and remain in the community. This patient’s difficulty with adhering to his treatment
regimen suggests he could benefit from the intensive support and outreach provided by
an ACT team.
25. A nurse is teaching a patient who has an anxiety disorder and is scheduled to begin
classical psychoanalysis. Which of the following patient statements indicates an
understanding of this form of therapy?
A. "Even if my anxiety improves, I will need to continue this therapy for 6 weeks."
B. "The therapist will focus on my past relationships during our sessions ."
C. "Psychoanalysis will help me reduce my anxiety by changing my behaviors."

D. "This therapy will address my conscious feelings about stressful experiences."
Answer: B. "The therapist will focus on my past relationships during our sessions ."
Rationale:
Classical psychoanalysis emphasizes exploring unconscious thoughts and past
experiences, particularly those related to early relationships and conflicts. This
understanding reflects the goal of psychoanalysis to uncover how past relationships
affect current behavior and emotions.
26. A nurse is discussing free association as a therapeutic tool with a patient who has
major depressive disorder. Which of the following patient statements indicates
understanding of this technique?
A. "I will write down my dreams as soon as I wake up."
B. "I may begin to associate my therapist with important people in my life."
C. "I can learn to express myself in a nonaggressive manner."
D. "I should say the first thing that comes to my mind."
Answer: D. "I should say the first thing that comes to my mind."
Rationale:
Free association is a technique used in psychoanalysis where the patient is encouraged to
verbalize thoughts as they occur, without censorship or filtering. This statement
accurately reflects the core principle of free association, allowing unconscious thoughts
and feelings to surface.
27. A nurse is preparing to implement cognitive reframing techniques for a patient who
has an anxiety disorder. Which of the following techniques should the nurse include in
the plan of care? (Select all that apply)
A. Priority restructuring
B. Monitoring thoughts
C. Diaphragmatic breathing
D. Journal keeping
E. Meditation
Answer: A. Priority restructuring

B. Monitoring thoughts
D. Journal keeping
Rationale:
This technique involves helping the patient identify and prioritize their thoughts and
concerns, allowing them to focus on what is most important and manage anxiety more
effectively. This technique encourages patients to become aware of their negative
thoughts and cognitive distortions, which is essential for cognitive reframing. Keeping a
journal allows patients to track their thoughts and feelings, facilitating reflection and the
identification of patterns that can be reframed.
28. A nurse is caring for a patient who has a new prescription for disulfiram for
treatment of alcohol use disorder. The nurse informs the patient that this medication can
cause nausea and vomiting if he drinks alcohol. Which of the following types of
treatment is this method an example?
A. Aversion therapy
B. Flooding
C. Biofeedback
D. Dialectical behavior therapy
Answer: A. Aversion therapy
Rationale:
Aversion therapy is a behavioral treatment method that aims to discourage undesirable
behaviors by associating them with unpleasant consequences. In the case of disulfiram
(commonly known by the brand name Antabuse), the medication causes nausea and
vomiting when alcohol is consumed, creating an aversive reaction to drinking alcohol.
This approach is intended to help individuals with alcohol use disorder avoid drinking.
29. A nurse is assisting with systematic desensitization for a patient who has an extreme
fear of elevators. Which of the following actions should the nurse implement with this
form of therapy?
A. Demonstrate riding in an elevator, and then ask the patient to imitate the behavior.

B. Advise the patient to say "stop" out loud every time he begins to feel an anxiety
response related to an elevator.
C. Gradually expose the patient to an elevator while practicing relaxation techniques.
D. Stay with the patient in an elevator until his anxiety response diminishes.
Answer: C. Gradually expose the patient to an elevator while practicing relaxation
techniques.
Rationale:
Systematic desensitization is a behavioral therapy technique used to help individuals
overcome phobias by gradually exposing them to the feared object or situation while
teaching them relaxation techniques to manage anxiety. In this case, gradually exposing
the patient to an elevator, starting with less anxiety-provoking scenarios (like thinking
about elevators or looking at pictures), and practicing relaxation techniques will help
reduce their fear response over time.
30. A nurse wants to use democratic leadership with a group whose purpose is to learn
appropriate conflict resolution techniques. The nurse is correct in implementing this
form of group leadership when she demonstrates which of the following actions?
A. Observes group techniques without interfering with the group process
B. Discusses a technique and then directs members to practice the technique
C. Asks for group suggestions of techniques and then support discussion
D. Suggests techniques and asks group members to reflect on their use
E. Democratic leadership supports group interaction and decision making to solve
problems.
Answer: A. Observes group techniques without interfering with the group process
Rationale:
Democratic leadership encourages participation and collaboration among group
members. By asking for suggestions and facilitating discussion, the nurse promotes a
sense of ownership and empowerment within the group, which is essential for effective
learning and conflict resolution.

31. A nurse is planning group therapy for patients dealing with bereavement. Which of
the following activities should the nurse include in the initial phase? (Select all that
apply)
A. Encourage the group to work toward goals
B. Define the purpose of the group
C. Discuss termination of the group
D. Identify informal roles of members within the group
E. Establish an expectation of confidentiality within the group
Answer: B. Define the purpose of the group
E. Establish an expectation of confidentiality within the group
Rationale:
In the initial phase of group therapy, it’s essential to clarify the group’s goals and
purpose to ensure that all members understand what they can expect and what they are
working towards. Establishing confidentiality is crucial in the initial phase to create a
safe environment where members feel secure sharing their feelings and experiences
related to bereavement.
32. A nurse working on an acute mental health unit forms a group to focus on selfmanagement of medications. At each of meetings, two of the members use the
opportunity to discuss their common interest in gambling on sports. This is an example
of which of the following concepts?
A. Triangulation
B. Group process
C. Subgroup
D. Hidden agenda
Answer: D. Hidden agenda
Rationale:
A subgroup is formed when a smaller group of members within a larger group begins to
connect over a specific interest, which can divert attention from the main focus of the
group. In this case, the two members discussing their common interest in gambling on

sports represent a subgroup that is not aligned with the primary goal of self-management
of medications.
33. A nurse is conducting a family therapy session. The adolescent son tells the nurse
that he plans ways to make his sister look bad so his parents will think he's the better
sibling, which he believes will give him more privileges. The nurse should identify this
dysfunctional behavior as which of the following?
A. Placation
B. Manipulation
C. Blaming
D. Distraction
Answer: B. Manipulation
Rationale:
Manipulation involves influencing or controlling a person or situation to achieve a
desired outcome, often in a deceptive or unethical way. In this case, the adolescent is
intentionally planning to make his sister look bad to gain favor with his parents, which
clearly reflects manipulative behavior aimed at achieving more privileges.
34. A nurse is working with an established group and identifies various member roles.
Which of the following should the nurse identify as an individual role?
A. A member who praises input from other members
B. A member who follows the direction of other members
C. A member who brags about accomplishments
D. A member who evaluates the group's performance toward a standard
Answer: C. A member who brags about accomplishments
Rationale:
This behavior reflects an individual role, as it focuses on self-promotion and personal
achievement rather than contributing to the group's dynamics or goals. Individuals who
brag about their accomplishments may seek recognition and validation from others,
often at the expense of group cohesion.

35. A nurse is preparing to provide an educational seminar on stress to other nursing
staff. Which of the following information should the nurse include in the discussion?
A. Excessive stressors cause the patient to experience distress.
B. The body's initial adaptive response to stress is denial.
C. Absence of stressors results in homeostasis.
D. Negative, rather than positive, stressors produce a biological response.
Answer: A. Excessive stressors cause the patient to experience distress.
Rationale:
Excessive stressors can overwhelm an individual’s ability to cope, leading to distress,
which can manifest as physical, emotional, or psychological symptoms. This statement
accurately reflects the relationship between stressors and their impact on patient wellbeing.
36. A nurse is discussing acute vs prolonged stress with a patient. Which of the following
effects should the nurse identify as an acute stress response? (Select all that apply)
A. Chronic pain
B. Depressed immune system
C. Increased blood pressure
D. Panic attacks
E. Unhappiness
Answer: B. Depressed immune system
C. Increased blood pressure
E. Unhappiness
Rationale:
Acute stress responses typically involve immediate physiological and psychological
reactions. Here’s a breakdown of the options This is a common acute stress response as
the body prepares for a "fight or flight" reaction. These can occur as an acute response to
stress, marked by intense fear and physical symptoms.
37. A nurse is teaching a patient about stress-reduction techniques. Which of the
following patient statements indicates understanding of the teaching?

A. "Cognitive reframing will help me change my irrational thoughts to something
positive."
B. "Progressive muscle relaxation uses a mechanical device to help me gain control over
my pulse rate."
C. "Biofeedback causes my body to release endorphins so that I feel less stress and
anxiety."
D. "Mindfulness allows me to prioritize the stressors that I have in my life so that I have
less anxiety."
Answer: A. "Cognitive reframing will help me change my irrational thoughts to
something positive."
Rationale:
Cognitive reframing is a therapeutic technique that helps individuals identify and
challenge negative or irrational thoughts, enabling them to replace these thoughts with
more positive, realistic ones. This understanding reflects a grasp of how cognitive
reframing works as a stress-reduction technique.
38. A patient says she is experiencing increased stress because her significant other is
"pressuring me and my kids to go live with him. I love him, but I'm not ready to do
that." Which of the following recommendations should the nurse make to promote a
change in the patient's situation?
A. Learn to practice mindfulness
B. Use assertiveness techniques
C. Exercise regularly
D. Rely on the support of a close friend
Answer: B. Use assertiveness techniques
Rationale:
Using assertiveness techniques can help the patient communicate her feelings and
boundaries regarding the pressure from her significant other. Assertiveness allows her to
express her needs and concerns clearly and respectfully, which is essential in situations
where she feels pressured to make a decision she is not ready for.

39. A nurse is caring for a patient who states, "I'm so stressed at work because of my
coworker. He expects me to finish his work because he's too lazy!" When discussing
effective communication, which of the following statements by the patient to his
coworker indicates patient understanding?
A. "You really should complete your own work. I don't think it's right to expect me to
complete your responsibilities."
B. "Why do you expect me to finish your work? You must realize that I have my own
responsibilities."
C. "It is not fair to expect me to complete your work. If you continue, then I will report
your behavior to our supervisor."
D. "When I have to pick up extra work, I feel very overwhelmed. I need to focus on my
own responsibilities."
Answer: D. "When I have to pick up extra work, I feel very overwhelmed. I need to
focus on my own responsibilities."
Rationale:
This statement demonstrates effective communication by expressing the patient’s
feelings and needs without blaming the coworker. It uses "I" statements, which focus on
the speaker's feelings and experiences, promoting understanding and reducing
defensiveness in the conversation.
40. A nurse is providing teaching for a patient who is scheduled to receive ECT for the
treatment of major depressive disorder. Which of the following patient statements
indicates understanding of the teaching?
A. "It is common to treat depression with ECT before trying medications."
B. "I can have my depression cured if I receive a series of ECT treatments."
C. "I should receive ECT once a week for 6 weeks."
D. "I will receive a muscle relaxant to protect me from injury during ECT."
Answer: D. "I will receive a muscle relaxant to protect me from injury during ECT."
Rationale:

This statement reflects an understanding of the procedure, as muscle relaxants are
typically administered to prevent muscle contractions and protect the patient during the
seizure induced by ECT.
41. A charge nurse is discussing TMS with a newly licensed nurse. Which of the
following statements by the newly licensed nurse indicates an understanding of the
teaching?
A. "TMS is indicated for patients who have schizophrenia spectrum disorders."
B. "I will provide post anesthesia care following TMS."
C. "TMS treatments usually last 5-10 minutes."
D. "I will schedule the patient for daily TMS treatments for the first several weeks."
Answer: D. "I will schedule the patient for daily TMS treatments for the first several
weeks."
Rationale:
Transcranial Magnetic Stimulation (TMS) typically involves a series of treatments
scheduled daily, often for several weeks, to effectively target depression or other mood
disorders.
42. A nurse is assessing a patient immediately following an ECT procedure. Which of
the following findings should the nurse expect? (Select all that apply)
A. Hypotension
B. Paralytic ileus C.
C. Memory loss
D. Nausea
E. Confusion
Answer: C. Memory loss
D. Nausea
E. Confusion
Rationale:
Short-term memory loss is a common side effect following ECT. Patients may have
difficulty recalling events that occurred around the time of the treatment. Nausea can

occur after ECT due to the effects of anesthesia and the procedure itself. Confusion or
disorientation can also be expected immediately after ECT as the patient wakes from
anesthesia.
43. A nurse is leading a peer group discussion about the indications for ECT. Which of
the following indications should the nurse include in the discussion?
A. Borderline personality disorder
B. Acute withdrawal related to a substance use disorder
C. Bipolar disorder with rapid cycling
D. Dysphoric disorder
Answer: C. Bipolar disorder with rapid cycling
Rationale:
ECT is often indicated for severe episodes of depression or mania in bipolar disorder,
especially when rapid cycling occurs, as it can be difficult to treat with medications
alone.
44. A nurse is planning care for a patient following surgical implantation of a VNS
device. The nurse should plan to monitor for which of the following adverse effects?
(Select all that apply)
A. Voice changes
B. Seizure activity
C. Disorientation
D. Dysphagia
E. Neck pain
Answer: A. Voice changes
D. Dysphagia
E. Neck pain
Rationale:
This can occur due to the proximity of the VNS device to the vagus nerve, which can
affect vocal cord function. Difficulty swallowing is a potential side effect because the
vagus nerve is involved in swallowing processes. Discomfort or pain in the neck area

can result from the surgical implantation of the VNS device and irritation of surrounding
tissues.
45. A nurse observes a patient who has OCD repeatedly applying, removing, and then
reapplying makeup. The nurse identifies that repetitive behavior in a patient who has
OCD is due to which of the following underlying reasons?
A. Narcissistic behavior
B. Fear of rejection from staff
C. Attempt to reduce anxiety
D. Adverse effect of antidepressant medication
Answer: C. Attempt to reduce anxiety
Rationale:
Patients with Obsessive-Compulsive Disorder (OCD) often engage in repetitive
behaviors (compulsions) as a way to alleviate the anxiety caused by their intrusive
thoughts (obsessions). In this case, the patient’s repetitive application of makeup is a
compulsion aimed at reducing anxiety related to their fears about appearance or
judgment.
46. A nurse is caring for a patient who is experiencing a panic attack. Which of the
following actions should the nurse take?
A. Discuss new relaxation techniques
B. Show the patient how to change his behavior
C. Distract the patient with a television show
D. Stay with the patient and remain quiet
Answer: D. Stay with the patient and remain quiet
Rationale:
During a panic attack, it is crucial for the nurse to provide support and reassurance
without overwhelming the patient. Staying with the patient conveys safety and stability,
while remaining quiet allows the patient to process their feelings without added pressure.

47. A nurse is assessing a patient who has generalized anxiety disorder. Which of the
following findings should the nurse expect? (Select all that apply)
A. Excessive worry for 6 months
B. Impulsive decision making
C. Delayed reflexes
D. Restlessness
E. Need for reassurance
Answer: A. Excessive worry for 6 months
Rationale:
This is a hallmark symptom of generalized anxiety disorder (GAD). Patients often
experience persistent and excessive worry about various aspects of life. Individuals with
GAD commonly report feelings of restlessness or being on edge. Many patients with
GAD often seek reassurance from others about their worries and concerns.
48. A nurse is caring for a patient who has body dysmorphic disorder. Which of the
following actions should the nurse plan to take first?
A. Assessing the patient's risk for self-harm
B. Instilling hope for positive outcomes
C. Encouraging the patient to participate in group therapy sessions
D. Encouraging the patient to participate in treatment decisions
Answer: A. Assessing the patient's risk for self-harm
Rationale:
This is the priority action because individuals with body dysmorphic disorder (BDD)
often experience significant distress and may have suicidal ideation or engage in selfharm. Ensuring the patient's safety is crucial. While this is important in the therapeutic
process, it should follow the assessment of safety.
49. A nurse is caring for a patient who has acute stress disorder and is experiencing
severe anxiety. Which of the following statements should the nurse make?
A. "Tell me about how you are feeling right now."
B. "You should focus on the positive things in your life to decrease your anxiety."

C. "Why do you believe you are experiencing this anxiety?"
D. "Let's discuss the medications your provider is prescribing to decrease your anxiety."
Answer: A. "Tell me about how you are feeling right now."
Rationale:
This statement invites the patient to express their feelings and provides an opportunity
for the nurse to assess the patient’s emotional state and build rapport. It is essential in
managing anxiety and facilitating communication. While this suggestion may be helpful,
it can dismiss the patient's current feelings and may not be effective in the moment of
severe anxiety.
50. A nurse working on an acute mental health unit is caring for a patient who has PTSD.
Which of the following findings should the nurse expect? (Select all that apply)
A. Difficulty concentrating on tasks
B. Obsessive need to talk about the traumatic event
C. Negative self-image
D. Recurring nightmares
E. Diminished reflexes
Answer: A. Difficulty concentrating on tasks
C. Negative self-image
D. Recurring nightmares
Rationale:
Patients with PTSD often experience cognitive impairments, including difficulty
focusing and concentrating due to intrusive thoughts and hyperarousal. PTSD can lead to
feelings of worthlessness or guilt, resulting in a negative self-perception. Nightmares are
a common symptom of PTSD, as patients often relive the traumatic event during sleep.
While some patients may want to discuss their trauma, others may avoid talking about it
altogether. This is not a typical finding associated with PTSD. This is not characteristic
of PTSD. Patients typically experience hyperarousal and heightened startle responses
rather than diminished reflexes.

51. A nurse is involved in a serious and prolonged mass casualty incident in the
emergency department. Which of the following strategies should the nurse use to help
prevent developing a trauma-related disorder? (Select all that apply)
A. Avoid thinking about the incident when it is over
B. Take breaks during the incident for food and water
C. Debrief with others following the incident
D. Hold emotions in check in the days following the incident
E. Take advantage of offered counseling
Answer: B. Take breaks during the incident for food and water
C. Debrief with others following the incident
E. Take advantage of offered counseling
Rationale:
Ensuring physical well-being through breaks helps maintain mental resilience and
reduces the risk of stress-related disorders. Debriefing allows for emotional processing
and sharing of experiences, which can help mitigate the effects of trauma. Professional
counseling provides support and coping strategies to address the emotional aftermath of
traumatic events. This strategy is counterproductive; avoidance can exacerbate stress and
lead to trauma-related disorders.
52. A nurse is collecting an admission history for a patient who has acute stress disorder
(ASD). Which of the following information should the nurse expect to collect?
A. The patient remembers many details about the traumatic incident
B. The patient expresses heightened elation about what is happening
C. The patient states he first noticed manifestations of the disorder 6 weeks after the
traumatic incident occurred.
D. The patient expresses a sense of unreality about the traumatic event
Answer: D. The patient expresses a sense of unreality about the traumatic event
Rationale:
In acute stress disorder (ASD), individuals often experience dissociative symptoms, such
as feelings of unreality or detachment from the traumatic event. This response is part of
their way of coping with the intense stress and emotional impact of the trauma. In

contrast, option A is incorrect because patients with ASD may have fragmented or
unclear memories of the trauma. Option B is also incorrect, as heightened elation is not
typical of ASD. Lastly, option C is incorrect since symptoms of ASD usually develop
within three days to four weeks following the trauma, not after six weeks.
53. A nurse is caring for a patient who has derealization disorder. Which of the following
findings should the nurse identify as an indication of derealization?
A. The patient explains that her body seems to be floating above the ground
B. The patient has the idea that someone is trying to kill her and steal her money
C. The patient states that the furniture in the room seems to be small and far away
D. The patient cannot recall anything that happened during the past 2 weeks
Answer: C. The patient states that the furniture in the room seems to be small and far
away
Rationale:
This statement reflects the characteristic experience of derealization, where the
individual perceives their surroundings as distorted or unreal, making objects appear
smaller or further away. Option A describes a sensation of depersonalization, where the
individual feels detached from their body. Option B indicates a delusion, which is not
typical of derealization. Option D describes amnesia, which is not a primary feature of
derealization disorder.
54. A nurse in an acute mental health facility is planning care for a patient who has
dissociative fugue. Which of the following interventions should the nurse add to the plan
of care?
A. Teach the patient to recognize how stress brings on a personality change in the patient
B. Repeatedly present the patient with information about past events
C. Make decisions for the patient regarding routine daily activities
D. Work with the patient on grounding techniques
Answer: D. Work with the patient on grounding techniques
Rationale:

Grounding techniques are effective for patients with dissociative fugue, as they help
reconnect the individual with the present moment and their surroundings. This can
reduce feelings of disorientation and enhance awareness. Option A may not be
appropriate, as the patient may not recognize stress as a trigger due to their dissociative
state. Option B could be overwhelming and may not aid in recovery. Option C
undermines the patient's autonomy and can increase feelings of helplessness, which is
not conducive to healing.
55. A nurse working in an acute mental health facility is caring for a 35-year-old female
patient who has manifestations of depression. The patient lives at home with her partner
and two young children. She currently smokes and has a history of chronic asthma.
Which of the following factors put the patient at risk for depression? (Select all that
apply)
A. Age
B. Gender
C. History of chronic asthma
D. Smoking
E. Being Married
Answer: A. Age
B. Gender
C. History of chronic asthma
E. Being Married
Rationale:
A. Age and B. Gender are significant risk factors, as women and younger adults are
more prone to depression. C. Chronic asthma contributes to stress and emotional
challenges, increasing the risk. D. Smoking is linked to a higher incidence of depression.
E. Being married generally offers protective factors rather than increasing risk.
56. A nurse working on an acute mental health unit is admitting a patient who has major
depressive disorder and comorbid anxiety disorder. Which of the following actions is the
nurse's priority?

A. Placing the patient on one-to-one observation
B. Assisting the patient to perform ADLs
C. Encouraging the patient to participate in counseling
D. Teaching the patient about medication adverse effects
Answer: A. Placing the patient on one-to-one observation
Rationale:
This is crucial for ensuring the safety of a patient with major depressive disorder and
comorbid anxiety, as they may be at risk for self-harm or suicidal ideation. Close
monitoring helps to prevent any potential harm while establishing a therapeutic
relationship. Once safety is ensured, the nurse can then focus on assisting with ADLs,
encouraging counseling, and providing education about medications.
57. A nurse working in an outpatient clinic is providing teaching to a patient who has a
new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following
statements by the patient indicates understanding of the teaching?
A. "I can expect my problems with PMDD to be worst when I'm menstruating."
B. "I will use light therapy 30 min a day to prevent further recurrences of PMDD."
C. "I am aware that my PMDD causes me to have rapid mood swings."
D. "I should increase my caloric intake with a nutritional supplement when my PMDD is
active."
Answer: C. "I am aware that my PMDD causes me to have rapid mood swings."
Rationale:
This reflects an awareness of one of the key symptoms of premenstrual dysphoric
disorder, which includes significant mood changes, irritability, and emotional instability.
The other options misrepresent the timing of symptoms, suggest ineffective treatments,
or do not directly relate to PMDD management.
58. A charge nurse is discussing the care of a patient who has MDD with a newly
licensed nurse. Which of the following statements by the newly licensed nurse indicates
an understanding of the teaching?

A. "Care during the continuation phase focuses on treating continued manifestations of
MDD."
B. "The treatment of MDD during the maintenance phase lasts for 6-12 weeks."
C. "The patient is at greatest risk for suicide during the first weeks of an MDD episode."
D. "Medication and psychotherapy are most effective during the acute phase of MDD."
Answer: C. "The patient is at greatest risk for suicide during the first weeks of an MDD
episode."
Rationale:
This reflects the critical awareness that individuals with major depressive disorder
(MDD) are particularly vulnerable to suicidal thoughts and behaviors in the early stages
of an episode. The other statements contain inaccuracies about treatment phases and
timelines related to MDD management.
59. A nurse is interviewing a 25-year-old patient who has a new diagnosis of dysthymic
disorder. Which of the following findings should the nurse expect?
A. Wide fluctuations of mood
B. Report of a minimum of 5 clinical findings of Depression
C. Presence of manifestations for at least 2 years
D. Inflated sense of self-esteem
Answer: C. Presence of manifestations for at least 2 years
Rationale:
Dysthymic disorder, now referred to as persistent depressive disorder, is characterized by
a chronic form of depression that lasts for at least two years in adults. Unlike major
depressive disorder, it typically involves less severe symptoms but can still significantly
impact functioning. The other options do not align with the characteristics of dysthymic
disorder.
60. A nurse is planning care for a patient who has bipolar disorder and is experiencing a
manic episode. Which of the following interventions should the nurse include in the plan
of care? (Select all that apply)
A. Provide flexible patient behavior expectations

B. Offer concise explanations
C. Establish consistent limits
D. Disregard patient complaints
E. Use a firm approach with communication
Answer: B. Offer concise explanations
C. Establish consistent limits
E. Use a firm approach with communication
Rationale:
These strategies help create a structured environment that can reduce anxiety and
promote safety during a manic episode. Providing concise explanations aids in
comprehension, establishing limits helps manage behavior, and a firm approach offers
clear boundaries while maintaining respect for the patient.
61. A nurse is teaching a newly licensed nurse about the use of ECT for the treatment of
bipolar disorder. Which of the following statements by the newly licensed nurse
indicates understanding?
A. "ECT is the recommended initial treatment for bipolar disorder."
B. "ECT is contraindicated for patients who have suicidal ideation."
C. "ECT is effective for patients who are experiencing severe mania."
D. "ECT is prescribed to prevent relapse of bipolar behavior."
Answer: C. "ECT is effective for patients who are experiencing severe mania."
Rationale:
Electroconvulsive therapy (ECT) is often used as a treatment for severe mood episodes,
including acute mania in bipolar disorder, especially when rapid response is needed or
when other treatments have not been effective. Option A is incorrect because ECT is not
the first-line treatment; medications are typically tried first. Option B is also incorrect as
ECT can actually be considered for patients with suicidal ideation when other treatments
are ineffective. Option D is misleading, as ECT is not primarily prescribed for relapse
prevention; rather, it is used to treat acute episodes.

62. A nurse is caring for a patient who has bipolar disorder. The patient states, "I am very
rich, and I feel I must give my money to you." Which of the following responses should
the nurse make?
A. "Why do you think you feel the need to give money away?"
B. "I am here to provide care and cannot accept this from you."
C. "I can request that your case manager discuss appropriate charity options with you."
D. "You should know that giving away your money is inappropriate."
Answer: B. "I am here to provide care and cannot accept this from you."
Rationale:
This response maintains professional boundaries and emphasizes the nurse's role in
providing care, which is important in managing a patient with bipolar disorder,
particularly during a manic episode where they may exhibit impulsive or grandiose
behavior. Option A invites further discussion but does not address the boundary issue.
Option C could be helpful but does not directly address the immediate concern of the
patient's offer. Option D is dismissive and may not effectively guide the patient toward
understanding appropriate behavior.
63. A nurse in an acute mental health facility is caring for a patient who has bipolar
disorder. Which of the following is the priority nursing action?
A. Set consistent limits for expected patient behavior
B. Administer prescribed medications as scheduled
C. Provide the patient with step by step instructions during hygiene activities
D. Monitor the patient for escalating behavior
Answer: D. Monitor the patient for escalating behavior
Rationale:
In a patient with bipolar disorder, especially during a manic episode, monitoring for
escalating behavior is crucial to prevent potential harm to the patient or others. Early
identification of escalating behavior allows for timely interventions to ensure safety.
While administering medications, setting limits, and providing instructions are
important, they come after ensuring the immediate safety of the patient.

64. A nurse is discussing relapse prevention with a patient who has bipolar disorder.
Which of the following information should the nurse include in the teaching? (Select all
that apply)
A. Use caffeine in moderation to prevent relapse
B. Difficulty sleeping can indicate a relapse
C. Begin taking your medications as soon as a relapse begins
D. Participating in psychotherapy can help prevent a relapse
E. Anhedonia is a clinical manifestation of a depressive relapse
Answer: B. Difficulty sleeping can indicate a relapse
D. Participating in psychotherapy can help prevent a relapse
E. Anhedonia is a clinical manifestation of a depressive relapse
Rationale:
Sleep disturbances are often early warning signs of a potential relapse in bipolar
disorder. Engaging in psychotherapy can provide coping strategies and support, which
are essential for preventing relapses. Anhedonia, or the loss of interest or pleasure in
activities, is a common symptom of depression and can signal a depressive relapse.
65. A nurse is caring for a patient who has substance-induced psychotic disorder and is
experiencing auditory hallucinations. The patient states, "The voices won't leave me
alone!" Which of the following statements should the nurse make? (Select all that apply)
A. "When did you start hearing the voices?"
B. "The voices are not real, or else we would both hear them."
C. "It must be scary to hear voices."
D. "Are the voices telling you to hurt yourself?"
E. "Why are the voices talking to only you?"
Answer: A. "When did you start hearing the voices?"
C. "It must be scary to hear voices."
D. "Are the voices telling you to hurt yourself?"
Rationale:
Asking when the patient started hearing the voices can help assess the duration and
context of the hallucinations. Acknowledging the patient's feelings normalizes their

experience and builds rapport, which can help in the therapeutic relationship. It’s crucial
to assess for any potential risk of harm, making sure the patient is safe.
66. A nurse is completing an admission assessment for a patient who has schizophrenia.
Which of the following findings should the nurse document as positive symptoms?
(Select all that apply)
A. Auditory hallucination
B. Lack of motivation
C. Use of clang association
D. Delusion of persecution
E. Constantly waving arms
F. Flat affect
Answer: A. Auditory hallucination
C. Use of clang association
D. Delusion of persecution
E. Constantly waving arms
Rationale:
Auditory hallucination involves hearing voices that aren’t present. Clang association is
disorganized speech using rhymes or sounds. Delusion of persecution reflects false
beliefs of being targeted. Constantly waving arms indicates abnormal motor behavior.
In contrast, Lack of motivation and Flat affect are negative symptoms, representing
deficits in function.
67. A nurse is caring for a patient who has schizoaffective disorder. Which of the
following statements indicates the patient is experiencing depersonalization?
A. "I am a superhero and am immortal."
B. "I am no one, and everyone is me."
C. "I feel monsters pinching me all over."
D. "I know that you are stealing my thoughts."
Answer: B. "I am no one, and everyone is me."
Rationale:

The statement B, "I am no one, and everyone is me," reflects depersonalization by
indicating a loss of personal identity and a sense of merging with others. In contrast, A
demonstrates grandiose delusions, C describes tactile hallucinations, and D indicates a
delusion of thought interference. These other statements represent different aspects of
psychosis rather than depersonalization. Thus, B specifically captures the essence of
experiencing a distorted sense of self, which is characteristic of depersonalization in
schizoaffective disorder.
68. A nurse is caring for a patient on an acute mental health unit The patient reports
hearing voices that are telling her to "kill your doctor." Which of the following actions
should the nurse take first?
A. Use therapeutic communication to discuss the hallucination with the patient
B. Initiate one-to-one observation of the patient
C. Focus the patient on reality
D. Notify the provider of the patient's statement
Answer: B. Initiate one-to-one observation of the patient
Rationale:
Use therapeutic communication is important but should follow immediate safety
measures. Focus the patient on reality is a therapeutic approach but is less critical than
ensuring safety. Notify the provider is necessary but should occur after addressing
immediate safety concerns.
69. A nurse is speaking with a patient who has schizophrenia when he suddenly seems to
stop focusing on the nurse's questions and begins looking at the ceiling and talking to
himself. Which of the following actions should the nurse take?
A. Stop the interview at this point, and resume later when the patient is better able to
concentrate.
B. Ask the patient, "Are you seeing something on the ceiling?"
C. Tell the patient, "You seem to be looking at something on the ceiling. I see something
there, too."
D. Continue the interview without comment on the patient's behavior.

Answer: B. Ask the patient, "Are you seeing something on the ceiling?"
Rationale:
Stop the interview is not ideal, as it may leave the patient feeling unheard. Tell the
patient, "I see something there, too," could reinforce a possible hallucination and is not
appropriate. Continue the interview without comment may overlook the patient's current
state and needs.
70. A nurse manager is discussing the care of a patient who has a personality disorder
with a newly licensed nurse. Which of the following statements by the newly licensed
nurse indicates an understanding of the teaching?
A. "I can promote my patient's sense of control by establishing a schedule."
B. "I should encourage patients who have a schizoid personality disorder to increase
socialization."
C. "I should practice limit-setting to help prevent patient manipulation."
D. "I should implement assertiveness training with patients who have antisocial
personality disorder."
Answer: C. "I should practice limit-setting to help prevent patient manipulation."
Rationale:
"I can promote my patient's sense of control by establishing a schedule" is beneficial but
may not be the primary focus for all personality disorders. "I should encourage patients
who have a schizoid personality disorder to increase socialization" is not appropriate, as
these patients typically prefer isolation. "I should implement assertiveness training with
patients who have antisocial personality disorder" is not typically effective, as these
patients often lack regard for others' rights.
71. A nurse is caring for a patient who has avoidant personality disorder. Which of the
following statements is expected from a patient who has this type of personality
disorder?
A. "I'm scared that you're going to leave me."
B. "I'll go to group therapy if you'll let me smoke."
C. "I need to feel that everyone admires me."

D. "I sometimes feel better if I cut myself."
Answer: A. "I'm scared that you're going to leave me."
Rationale:
"I'll go to group therapy if you'll let me smoke" suggests a more manipulative or
conditional behavior, which is not typical of avoidant personality disorder. "I need to
feel that everyone admires me" indicates a need for admiration, more characteristic of
narcissistic personality disorder. "I sometimes feel better if I cut myself" suggests selfharm behavior, which is not specific to avoidant personality disorder.
72. A nurse is caring for a patient who has borderline personality disorder. The patient
says, "The nurse on the evening shift is always nice! You are the meanest nurse ever!"
The nurse should recognize the patient's statement as an example of which of the
following defense mechanisms?
A. Regression
B. Splitting
C. Undoing
D. Identification
Answer: B. Splitting
Rationale:
Regression and Undoing do not apply here, as they involve different behaviors.
Identification is also unrelated, as it involves mimicking others rather than extreme
evaluations.
73. A nurse is assisting with a court-ordered evaluation of a patient who has antisocial
personality disorder. Which of the following findings should the nurse expect? (Select
all that apply)
A. Demonstrates extreme anxiety when placed in a social situation
B. Has difficulty making even simple decisions
C. Attempts to convince other patients to give him their belongings
D. Becomes agitated if his personal area is not neat and orderly
E. Blames others for his past and current problems

Answer: C. Attempts to convince other patients to give him their belongings
E. Blames others for his past and current problems
Rationale:
Demonstrates extreme anxiety is more characteristic of anxiety disorders rather than
antisocial personality disorder. Has difficulty making decisions is not typical for this
disorder, as individuals often display a degree of confidence or impulsivity. Becomes
agitated if his personal area is not neat suggests obsessive traits, which are not
characteristic of antisocial personality disorder.
74. A charge nurse is preparing a staff education session on personality disorders. Which
of the following personality characteristics associated with all of the personality
disorders should the charge nurse include in the teaching? (Select all that apply)
A. Difficulty in getting along with other members of a group
B. Belief in the ability to become invisible during times of stress
C. Display of defense mechanisms when routines are changed
D. Claiming to be more important than other persons
E. Difficulty understanding why it is inappropriate to have a personal relationship with
staff
Answer: A. Difficulty in getting along with other members of a group
C. Display of defense mechanisms when routines are changed
E. Difficulty understanding why it is inappropriate to have a personal relationship with
staff
Rationale:
Reflects a common challenge across personality disorders, as interpersonal difficulties
are a hallmark of these conditions. Highlights that individuals with personality disorders
often use defense mechanisms to cope with changes, demonstrating their struggles with
emotional regulation. Indicates a lack of awareness of boundaries, which is prevalent in
many personality disorders. Belief in the ability to become invisible during times of
stress is not a general characteristic associated with personality disorders. Claiming to be
more important than other persons may apply to specific disorders, such as narcissistic
personality disorder, but not universally to all personality disorders.

75. A nurse is caring for a patient who has early stage Alzheimer's disease and a new
prescription for donepezil. The nurse should include which of the following statements
when teaching the patient about the medication?
A. "You should avoid taking over-the-counter acetaminophen while on donepezil."
B. "You can expect the progression of cognitive decline to slow with donepezil."
C. "You will be screened for underlying kidney disease prior to starting donepezil."
D. "You should stop taking donepezil if you experience nausea or diarrhoea."
Answer: B. "You can expect the progression of cognitive decline to slow with
donepezil."
Rationale:
"You should avoid taking over-the-counter acetaminophen while on donepezil" is
incorrect; acetaminophen does not have known interactions with donepezil. "You will be
screened for underlying kidney disease prior to starting donepezil" is not a standard
requirement for donepezil use. "You should stop taking donepezil if you experience
nausea or diarrhoea" is misleading; while these can be side effects, the patient should
consult their healthcare provider before stopping the medication.
76. A nurse in a long-term care facility is caring for a patient who has major
neurocognitive disorder and attempts to wander out of the building. The patient states, "I
have to get home." Which of the following statements should the nurse make?
A. "You have forgotten that this is your home."
B. "You cannot go outside without a staff member."
C. "Why would you want to leave? Aren't you happy with your care?"
D. "I am your nurse. Let's walk together to your room."
Answer: D. "I am your nurse. Let's walk together to your room."
Rationale:
"You have forgotten that this is your home" is dismissive and may cause confusion or
frustration. "You cannot go outside without a staff member" sounds restrictive and may
increase the patient's anxiety. "Why would you want to leave? Aren't you happy with

your care?" can be perceived as confrontational and may not address the patient's
feelings or needs.
77. A home health nurse is making a visit to a patient who has Alzheimer's disease to
assess the home for safety. Which of the following suggestions should the nurse make to
decrease the patient's risk for injury? (Select all that apply)
A. Install childproof door locks.
B. Place rugs over electrical cords.
C. Mark cleaning supplies with colored tape.
D. Place the patient's mattress on the floor.
E. Install light fixtures above stairs.
Answer: A. Install childproof door locks.
D. Place the patient's mattress on the floor.
E. Install light fixtures above stairs.
Rationale:
Install childproof door locks can help prevent the patient from wandering outside and
ensure safety. Place the patient's mattress on the floor minimizes the risk of injury from
falls, as it reduces the distance to the ground. Install light fixtures above stairs enhances
visibility and safety when navigating stairs, reducing the risk of falls.
78. A nurse is making a home visit to a patient who is in the late stage of Alzheimer's
disease. The patient's partner, who is the primary caregiver, wishes to discuss concerns
about the patient's nutrition and the stress of providing care. Which of the following
actions should the nurse take?
A. Verify that a current power of attorney document is on file.
B. Instruct the patient's partner to offer finger foods to increase oral intake.
C. Provide information on resources for respite care.
D. Schedules the patient for placement of an enteral feeding tube.
Answer: C. Provide information on resources for respite care.
Rationale:

Verify that a current power of attorney document is on file may be important but does
not directly address the caregiver's immediate concerns about nutrition and stress.
Instruct the patient's partner to offer finger foods to increase oral intake is a practical
suggestion but may not address the broader stressors the caregiver is facing. Schedules
the patient for placement of an enteral feeding tube is an invasive intervention that
should only be considered after thorough discussion with the healthcare team and the
caregiver, focusing on the patient’s comfort and quality of life.
79. A nurse is performing an admission assessment for a patient who has delirium related
to an acute UTI. Which of the following findings should the nurse expect? (Select all
that apply)
A. History of gradual memory loss
B. Family report of personality changes
C. Hallucinations
D. Unaltered level of consciousness
E. Restlessness
Answer: B. Family report of personality changes
C. Hallucinations
E. Restlessness
Rationale:
Family report of personality changes is a common observation in delirium, as the
patient's behavior can fluctuate significantly. Hallucinations are a possible symptom of
delirium, particularly in acute situations such as an infection. Restlessness is often seen
in delirium, as patients may exhibit agitation or increased activity levels.
80. A nurse is planning a staff education program on substance use in older adults.
Which of the following is appropriate for the nurse to include in the presentation?
A. Older adults require higher doses of a substance to achieve a desired effect.
B. Older adults commonly use rationalization to cope with a substance use disorder.
C. Older adults are at an increased risk for substance use following retirement.
D. Older adults develop substance use to mask manifestations of dementia.

Answer: C. Older adults are at an increased risk for substance use following retirement.
Rationale:
Older adults require higher doses of a substance to achieve a desired effect is inaccurate;
they often have increased sensitivity and may require lower doses due to changes in
metabolism. Older adults commonly use rationalization to cope with a substance use
disorder is too general and does not specifically address common coping mechanisms in
this population. Older adults develop substance use to mask manifestations of dementia
is misleading; while some may misuse substances, this statement does not accurately
represent the complexities of substance use in older adults.
81. A nurse is assessing a patient who has alcohol use disorder and is experiencing
withdrawal. Which of the following findings should the nurse expect? (Select all that
apply)
A. Bradycardia
B. Fine tremors of both hands
C. Hypotension
D. Vomiting
E. Restlessness
Answer: B. Fine tremors of both hands
D. Vomiting
E. Restlessness
Rationale:
Fine tremors of both hands are a common symptom of alcohol withdrawal, often
observed as the body reacts to the absence of alcohol. Vomiting can occur during
withdrawal due to gastrointestinal upset and is a typical withdrawal symptom.
Restlessness is also expected, as anxiety and agitation are common during withdrawal.
82. A nurse is planning care for a patient who is experiencing benzodiazepine
withdrawal. Which of the following interventions should the nurse identify as the
priority?
A. Orient the patient frequently to time, place, and person.

B. Offer fluids and nourishing diet as tolerated.
C. Implement seizure precautions.
D. Encourage participation in group therapy sessions.
Answer: C. Implement seizure precautions.
Rationale:
Orient the patient frequently to time, place, and person is important for cognitive support
but is not the priority in this situation. Offer fluids and nourishing diet as tolerated is
beneficial for overall health but does not address immediate safety concerns. Encourage
participation in group therapy sessions is valuable for long-term recovery but is not
urgent in the context of withdrawal.
83. A nurse is caring for a patient who has alcohol use disorder. The patient is no longer
experiencing withdrawal manifestations. Which of the following medications should the
nurse anticipate administering to assist the patient with maintaining abstinence from
alcohol?
A. Chlordiazepoxide
B. Bupropion.
C. Disulfiram
D. Carbamazepine
Answer: C. Disulfiram
Rationale:
Chlordiazepoxide is used for managing alcohol withdrawal symptoms, not for long-term
abstinence. Bupropion is primarily used for depression and smoking cessation, not
specifically for alcohol use disorder. Carbamazepine may be used in some cases for
withdrawal management but is not a first-line treatment for maintaining abstinence.
84. A nurse is providing teaching to the family of a patient who has a substance use
disorder. Which of the following statements by a family member indicate an
understanding of the teaching? (Select all that apply)
A. "We need to understand that she is responsible for her disorder."
B. "Eliminating any codependent behavior will promote her recovery."

C. "She should participate in an Al-Anon group to help her recover."
D. "The primary goal of her treatment is abstinence from substance use."
E. "She needs to discuss her feelings about substance use to help her recover."
Answer: B. "Eliminating any codependent behavior will promote her recovery."
D. "The primary goal of her treatment is abstinence from substance use."
E. "She needs to discuss her feelings about substance use to help her recover."
Rationale:
Highlights the importance of recognizing and addressing codependent behaviors, which
can hinder recovery. Accurately reflects that the primary goal of treatment for substance
use disorder is achieving and maintaining abstinence. Emphasizes the need for the
patient to explore and express feelings about substance use, which is important for
recovery.
85. A nurse is preparing to obtain a nursing history from a patient who has a new
diagnosis of anorexia nervosa. Which of the following questions should the nurse
include in the assessment? (Select all that apply)
A. "What is your relationship like with your family."
B. "Why do you want to lose weight?"
C. "Would you describe your current eating habits?"
D. "At what weight do you believe you will look better?"
E. "Can you discuss your feelings about your appearance?"
Answer: A. "What is your relationship like with your family."
C. "Would you describe your current eating habits?"
E. "Can you discuss your feelings about your appearance?"
Rationale:
"What is your relationship like with your family?" is important for understanding
potential psychological and social factors that may contribute to the disorder. "Would
you describe your current eating habits?" helps assess the patient’s specific behaviors
and patterns related to food intake. "Can you discuss your feelings about your
appearance?" allows the nurse to explore the patient’s body image concerns, which are
central to anorexia nervosa.

86. A nurse is caring for an adolescent patient who has anorexia nervosa with rapid
weight loss and a current weight of 90 lb. Which of the following statements indicates
the patient is experiencing the cognitive distortion catastrophizing?
A. "Life isn't worth living if I gain weight."
B. "Don't pretend like you don't know how fat I am."
C. "If I could be skinny, I know I'd be popular."
D. "When I look in the mirror, I see myself as obese."
Answer: A. "Life isn't worth living if I gain weight."
Rationale:
"Don't pretend like you don't know how fat I am." indicates a distorted perception of
body image but is more about denial and projection than catastrophizing. "If I could be
skinny, I know I'd be popular." suggests a belief in a positive outcome associated with
being thin, which doesn’t reflect catastrophizing. "When I look in the mirror, I see
myself as obese." illustrates a distorted body image but is not an example of
catastrophizing.
87. A nurse is performing an admission assessment of a patient who has bulimia nervosa
with purging behavior. Which of the following is an expected finding? (Select all that
apply)
A. Amenorrhea
B. Hypokalaemia
C. Mottling of the skin
D. Slightly elevated body weight
E. Presence of lanugo on the face
Answer: B. Hypokalaemia
D. Slightly elevated body weight
Rationale:
Hypokalaemia is a common finding in patients with bulimia nervosa due to the loss of
potassium from vomiting and laxative use, which can lead to serious complications.

Slightly elevated body weight is also typical, as individuals with bulimia often maintain
a body weight that is within or above the normal range despite their eating disorder.
88. A nurse on an acute care unit is planning care for a patient who has anorexia nervosa
with binge- eating and purging behavior. Which of the following nursing actions should
the nurse include in the patient's plan of care?
A. Allow the patient to select preferred meal times.
B. Establish consequences for purging behavior.
C. Provide the patient with a high-fat diet at the start of treatment.
D. Implement one-to-one observation during meal times.
Answer: D. Implement one-to-one observation during meal times.
Rationale:
Allow the patient to select preferred meal times may not be appropriate, as structure and
routine are important in treatment for eating disorders. Establish consequences for
purging behavior is not therapeutic; a focus on positive reinforcement and support is
more effective than punitive measures. Provide the patient with a high-fat diet at the start
of treatment is not typically recommended; a balanced diet that gradually increases
caloric intake is preferred.
89. A nurse is caring for a patient who has bulimia nervosa and has stopped purging
behavior. The patient tells the nurse that she is afraid she is going to gain weight. Which
of the following responses should the nurse make?
A. "Many patients are concerned about their weight. However the dietitian will ensure
that you don't get too many calories in your diet."
B. "Instead of worrying about your weight, try to focus on other problems at this time."
C. "I understand you have concerns about your weight, but first, let's talk about your
recent accomplishments."
D. "You are not overweight, and the staff will ensure that you do not gain weight while
you are in the hospital. We know that is important to you."
Answer: C. "I understand you have concerns about your weight, but first, let's talk about
your recent accomplishments."

Rationale:
"Many patients are concerned about their weight. However, the dietitian will ensure that
you don't get too many calories in your diet." is dismissive and does not address the
patient's feelings directly. "Instead of worrying about your weight, try to focus on other
problems at this time." minimizes the patient's concerns and can come off as
invalidating. "You are not overweight, and the staff will ensure that you do not gain
weight while you are in the hospital. We know that is important to you." may reinforce
the patient's weight-focused mindset and does not encourage a broader view of health.
90. A nurse is discussing the risk factors for somatic symptom disorder with a newly
licensed nurse. Which of the following risk factors should the nurse include? (Select all
that apply)
A. Age older than 65 years
B. Anxiety disorder
C. Female gender
D. Coronary artery disease
E. Obesity
Answer: B. Anxiety disorder
C. Female gender
Rationale:
Anxiety disorder is a significant risk factor for somatic symptom disorder, as individuals
with anxiety may be more likely to focus on physical symptoms. Female gender is also a
well-documented risk factor, as somatic symptom disorder is more prevalent in women
than in men.
91. A nurse is reviewing the medical record of a patient who has conversion disorder.
Which of the following findings should the nurse identify as placing the patient as risk
for conversion disorder?
A. Death of a child 2 months ago
B. Recent weight loss of 30 lb
C. Retirement 1 year ago

D. History of migraine headaches
Answer: A. Death of a child 2 months ago
Rationale:
Recent weight loss of 30 lb could indicate an underlying medical condition or significant
stress but is not specifically a risk factor for conversion disorder. Retirement 1 year ago
might lead to some stress but is less acute than the recent loss of a child and is not a
strong risk factor. History of migraine headaches does not directly correlate with the risk
for conversion disorder.
92. A nurse is assessing a patient who has illness anxiety disorder. Which of the
following findings should the nurse expect? (Select all that apply)
A. Obsessive thoughts about disease
B. History of childhood abuse
C. Avoidance of health care providers
D. Depressive disorder
E. Narcissistic personality
Answer: A. Obsessive thoughts about disease
B. History of childhood abuse
C. Avoidance of health care providers
D. Depressive disorder
Rationale:
Obsessive thoughts about disease are characteristic of illness anxiety disorder, where the
patient is preoccupied with fears of having a serious illness. History of childhood abuse
can contribute to the development of various mental health disorders, including illness
anxiety disorder, as it may lead to increased anxiety and coping mechanisms. Avoidance
of health care providers can occur as the patient may fear receiving bad news or being
diagnosed with a serious illness, leading to avoidance behavior. Depressive disorder is
often comorbid with anxiety disorders, including illness anxiety disorder, as patients
may experience feelings of hopelessness and low mood related to their health concerns.

93. A nurse is developing a plan of care for a patient who has conversion disorder.
Which of the following actions should the nurse include?
A. Encourage the patient to spend time alone in his room
B. Monitor the patient for self-harm once per day
C. Allow the patient unlimited time to discuss physical Manifestations
D. Discuss alternative coping strategies with the patient
Answer: D. Discuss alternative coping strategies with the patient
Rationale:
Encourage the patient to spend time alone in his room is not supportive and may
increase feelings of isolation or anxiety. Monitor the patient for self-harm once per day
is insufficient; ongoing monitoring for self-harm may be necessary, especially if there
are concerns. Allow the patient unlimited time to discuss physical manifestations can
reinforce maladaptive behavior and may not promote progress in treatment.
94. A nurse is counseling a patient who has factitious disorder imposed on another.
Which of the following patient statements should the nurse expect?
A. "I had to pretend I was injured in order to get disability benefits."
B. "I know that my abdominal pain is caused by a malignant tumor."
C. "I needed to make my son sick so that someone else would take care of him for a
while."
D. "I became deaf when I heard that my husband was having an affair with my best
friend."
Answer: C. "I needed to make my son sick so that someone else would take care of him
for a while."
Rationale:
"I had to pretend I was injured in order to get disability benefits." suggests a different
motivation (financial gain) that aligns more with malingering rather than factitious
disorder. "I know that my abdominal pain is caused by a malignant tumor." indicates
insight into a real or fabricated condition but does not fit the context of factitious
disorder imposed on another. "I became deaf when I heard that my husband was having

an affair with my best friend." suggests a conversion disorder rather than factitious
behavior.
95. A nurse working in a mental health clinic is providing teaching to a patient who has a
new prescription for diazepam for generalized anxiety disorder. Which of the following
information should the nurse provide?
A. Three to six weeks of treatment is required to achieve therapeutic benefit
B. Combining alcohol with diazepam will produce a paradoxical response
C. Diazepam has a lower risk for dependence than other antianxiety medications
D. Report confusion as a potential indication of toxicity
Answer: D. Report confusion as a potential indication of toxicity
Rationale:
Three to six weeks of treatment is required to achieve therapeutic benefit is inaccurate
for diazepam; it typically provides immediate relief of anxiety symptoms. Combining
alcohol with diazepam will produce a paradoxical response is misleading; rather, it can
cause severe sedation and respiratory depression, rather than a paradoxical effect.
Diazepam has a lower risk for dependence than other antianxiety medications is
incorrect; benzodiazepines like diazepam do carry a risk of dependence, especially with
long-term use.
96. A nurse working in an emergency department is caring for a patient who has
benzodiazepine toxicity due to an overdose. Which of the following actions is the nurse's
priority?
A. Administer flumazenil
B. Identify the patient's level of orientation
C. Infuse IV fluids
D. Prepare the patient for gastric lavage
Answer: B. Identify the patient's level of orientation
Rationale:
Administer flumazenil is a possible treatment for benzodiazepine toxicity but should be
approached cautiously due to the risk of seizures, especially if the patient has a history

of dependence. Infuse IV fluids may be necessary for hydration and support, but it is not
the immediate priority without first assessing the patient's condition. Prepare the patient
for gastric lavage is typically not recommended in cases of benzodiazepine overdose,
especially if the patient is drowsy or has reduced consciousness due to the risk of
aspiration.
97. A nurse is caring for a patient who is to begin taking fluoxetine for treatment of
generalized anxiety disorder. Which of the following statements indicates the patient
understands the use of this medication?
A. "I will take the medication at bedtime."
B. "I will follow a low-sodium diet while taking this medication."
C. "I will need to discontinue this medication slowly."
D. "I will be at risk for weight loss with long term use of this medication."
Answer: C. "I will need to discontinue this medication slowly."
Rationale:
"I will take the medication at bedtime." is not necessarily accurate for fluoxetine, as it is
often taken in the morning to avoid insomnia due to its stimulating effects. "I will follow
a low-sodium diet while taking this medication." is not relevant, as fluoxetine does not
require dietary sodium restrictions. "I will be at risk for weight loss with long-term use
of this medication." is misleading; while some patients may experience weight loss
initially, many often experience weight gain with long-term use.
98. A nurse is assessing a patient 4 hr after receiving an initial dose of fluoxetine. Which
of the following findings should the nurse report to the provider as indications of
serotonin syndrome? (Select all that apply)
A. Hypothermia
B. Hallucinations
C. Muscular flaccidity
D. Diaphoresis
E. Agitation
Answer: B. Hallucinations

D. Diaphoresis
E. Agitation
Rationale:
Hallucinations are a significant indication of serotonin syndrome, suggesting altered
mental status due to excess serotonin activity. Diaphoresis (excessive sweating) is
another common symptom of serotonin syndrome, often accompanying other symptoms.
Agitation is also indicative of serotonin syndrome, as increased serotonin can lead to
heightened levels of anxiety and agitation.
99. A nurse is caring for a patient who takes paroxetine to treat PTSD. The patient states
that he grinds his teeth during the night, which causes pain in his mouth. The nurse
should identify which of the following interventions as possible measures to manage the
patient's bruxism? (Select all that apply)
A. Concurrent administration of buspirone
B. Administration of a different SSRI
C. Use of a mouth guard
D. Changing to a different class of antianxiety medication
E. Increasing the dose of paroxetine
Answer: A. Concurrent administration of buspirone
C. Use of a mouth guard
D. Changing to a different class of antianxiety medication
Rationale:
A, C, & D. Concurrent administration of buspirone, using a mouth guard, and changing
to a different class are effective measures
Concurrent administration of buspirone can help manage anxiety symptoms and may
reduce bruxism as a side effect of SSRIs like paroxetine. Use of a mouth guard is a
common measure to protect the teeth and alleviate pain caused by grinding during sleep.
Changing to a different class of antianxiety medication may be effective if bruxism is a
significant side effect; medications such as benzodiazepines or non-SSRI options could
be considered.

100. Other SSRIs will have the same effect. Increasing the dose will worsen the bruxism.
nurse is providing teaching to a patient who has a new prescription for amitriptyline.
Which of the following statements by the patient indicates an understanding of the
teaching?
A. "While taking this medication, I'll need to stay out of the sun to avoid a skin rash."
B. "I may feel drowsy for a few weeks after starting this medication."
C. "I cannot eat my favorite pizza with pepperoni while taking this medication."
D. "This medication will help me lose the weight that I have gained over the last year."
Answer: B. "I may feel drowsy for a few weeks after starting this medication."
Rationale:
Amitriptyline is a tricyclic antidepressant that often causes sedation as a side effect,
especially when treatment is initiated. Patients may experience drowsiness or fatigue as
their bodies adjust to the medication, and this effect can persist for a few weeks.
101. A nurse is caring for a patient who is taking phenelzine. For which of the following
adverse effects should the nurse monitor? (Select all that apply)
A. Elevated blood glucose level
B. Orthostatic hypotension
C. Priapism
D. Headache
E. Bruxism
Answer: B. Orthostatic hypotension
D. Headache
Rationale:
Orthostatic hypotension is a known adverse effect of phenelzine, which is a monoamine
oxidase inhibitor (MAOI). It can cause dizziness and falls when moving from sitting to
standing due to blood pressure changes. Headache can also occur as a side effect of
phenelzine due to dietary interactions or changes in blood pressure. Elevated blood
glucose level is not typically associated with phenelzine. Priapism is not a common side
effect of phenelzine; it is more associated with certain antidepressants like trazodone.
Bruxism is primarily linked to SSRIs and other medications, not MAOIs like phenelzine.

102. A nurse is review the medical record of a patient who has a new prescription for
bupropion for depression. Which of the following findings is the priority for the nurse to
report to the provider?
A. The patient has a family history of SAD.
B. The patient currently smokes 1.5 packs of cigarettes per day.
C. The patient had a motor vehicle crash last year and sustained a head injury.
D. The patient has a BMI of 25 and has gained 10 lb over the last year.
Answer: C. The patient had a motor vehicle crash last year and sustained a head injury.
Rationale:
The patient has a family history of SAD (Seasonal Affective Disorder) is relevant but
does not present an immediate risk related to the medication. The patient currently
smokes 1.5 packs of cigarettes per day is important, as bupropion is sometimes used to
help with smoking cessation, but it is not as critical as the head injury. The patient has a
BMI of 25 and has gained 10 lb over the last year may indicate a weight concern, but it
does not pose an immediate risk with bupropion.
103. A nurse is teaching a patient who has a new prescription for imipramine how to
minimize anticholinergic effects. Which of the following instructions should the nurse
include in the teaching? (Select all that apply)
A. Void just before taking the medication
B. Increase the dietary intake of potassium
C. Wear sun glassed when outside
D. Change positions slowly when getting up
E. Chew sugarless gum
Answer: A. Void just before taking the medication
C. Wear sun glassed when outside
E. Chew sugarless gum
Rationale:
Void just before taking the medication can help manage urinary retention, a common
anticholinergic effect of imipramine. Wear sunglasses when outside is important because

anticholinergic medications can cause sensitivity to light, making sunglasses necessary
to protect the eyes. Chew sugarless gum can help alleviate dry mouth, another common
side effect of anticholinergic medications. Increase the dietary intake of potassium is not
relevant to managing anticholinergic effects; it’s more related to other concerns such as
diuretic use. Change positions slowly when getting up is good advice for managing
orthostatic hypotension, which is not directly related to anticholinergic effects.
104. A charge nurse is discussing mirtazapine with a newly licensed nurse. Which of the
following statements by the newly licensed nurse indicates understanding?
A. "This medication increases the release of serotonin and norepinephrine."
B. "I will need to monitor the patient for hyponatremia while taking this medication."
C. "This medication is contraindicated for patients who have an eating disorder."
D. "Sexual dysfunction is a common adverse effect of this medication."
Answer: A. "This medication increases the release of serotonin and norepinephrine."
Rationale:
"I will need to monitor the patient for hyponatremia while taking this medication." is not
typically associated with mirtazapine; this is more relevant to certain diuretics or SSRIs.
"This medication is contraindicated for patients who have an eating disorder." is
misleading; while caution is advised, it is not outright contraindicated. "Sexual
dysfunction is a common adverse effect of this medication." is incorrect; mirtazapine is
less likely to cause sexual side effects compared to other antidepressants.
105. A nurse is caring for a patient who is prescribed lithium therapy. The patient states
that he wants to take ibuprofen for osteoarthritis pain relief. Which of the following
statements should the nurse make?
A. "That is a good choice. Ibuprofen does not interact with lithium."
B. "Regular aspirin would be a better choice than ibuprofen."
C. "Lithium decreases the effectiveness of ibuprofen."
D. "The ibuprofen will make your lithium level fall too low."
Answer: B. "Regular aspirin would be a better choice than ibuprofen."
Rationale:

"That is a good choice. Ibuprofen does not interact with lithium." is incorrect, as
ibuprofen can indeed interact with lithium. "Lithium decreases the effectiveness of
ibuprofen." is misleading; the interaction is the other way around—ibuprofen can affect
lithium levels. "The ibuprofen will make your lithium level fall too low." is incorrect; it
can actually raise lithium levels.
106. A nurse is discussing early indications of toxicity with a patient who has a new
prescription for lithium carbonate for bipolar disorder. The nurse should include which
of the following manifestations in the teaching? (Select all that apply)
A. Constipation
B. Polyuria
C. Rash
D. Muscle weakness
E. Tinnitus
Answer: B. Polyuria
Rationale:
Constipation is not a common early sign of lithium toxicity. Rash can occur but is not
specifically indicative of early lithium toxicity. Muscle weakness can be a sign of
toxicity but is usually seen at higher levels. Tinnitus is not commonly associated with
lithium toxicity.
107. A nurse is discussing routine follow-up needs with a patient who has a new
prescription for valproate. The nurse should inform the patient of the need for routine
monitoring of which of the following?
A. AST/ALT and LDH
B. Creatinine and BUN
C. WBC and granulocyte counts
D. Serum sodium and potassium
Answer: A. AST/ALT and LDH
Rationale:

Creatinine and BUN are typically monitored for renal function but are not the primary
focus for valproate therapy. WBC and granulocyte counts are monitored for patients
taking other medications that can cause bone marrow suppression, but they are not
routinely monitored for valproate unless there's a specific concern. Serum sodium and
potassium are not routinely monitored with valproate use.
108. A nurse is caring for a patient who is experiencing extreme mania due to bipolar
disorder. Prior to administration of lithium carbonate, the patient's lithium blood level
1.2 mEq/L. Which of the following actions should the nurse take?
A. Administer the next dose of lithium carbonate as scheduled.
B. Prepare for administration of aminophylline.
C. Notify the provider for a possible increase in the dosage of lithium carbonate.
D. Request a stat repeat of the patient's lithium blood level.
Answer: A. Administer the next dose of lithium carbonate as scheduled.
Rationale:
Prepare for administration of aminophylline is not relevant here, as aminophylline is not
used for lithium toxicity or management. Notify the provider for a possible increase in
the dosage of lithium carbonate is premature since the level is within the therapeutic
range. Request a stat repeat of the patient's lithium blood level is unnecessary because
the current level is already acceptable.
109. A nurse is admitting a patient who has a new diagnosis of bipolar disorder and is
scheduled to begin lithium therapy. When collecting a medical history from the patient's
adult daughter, which of the following statements is the priority to report to the
provider?
A. "My mother has diabetes that is controlled by her diet."
B. "My mother recently completed a course of prednisone for acute bronchitis."
C. "My mother received her flu vaccine last month."
D. "My mother is currently on furosemide for her congestive heart failure."
Answer: D. "My mother is currently on furosemide for her congestive heart failure."
Rationale:

"My mother has diabetes that is controlled by her diet." is important but less critical than
the effects of furosemide on lithium therapy. "My mother recently completed a course of
prednisone for acute bronchitis." is relevant but does not have the same immediate
implications for lithium therapy as furosemide. "My mother received her flu vaccine last
month." is not a significant concern related to lithium therapy.
110. A nurse is caring for a patient who has schizophrenia and exhibits a lack of
grooming and a flat affect. The nurse should anticipate a prescription of which of the
following medications?
A. Chlorpromazine
B. Thiothixene
C. Risperidone
D. Haloperidol
Answer: C. Risperidone
Rationale:
Chlorpromazine is a typical antipsychotic, but atypical antipsychotics like risperidone
are often preferred for their broader efficacy on both positive and negative symptoms.
Thiothixene is also a typical antipsychotic with limited efficacy on negative symptoms.
Haloperidol is another typical antipsychotic that primarily addresses positive symptoms
and may not be as effective for negative symptoms.
111. A nurse is caring for a patient who takes ziprasidone. The patient reports difficulty
swallowing the oral medication and becomes extremely agitated with injectable
administration. The nurse should contact the provider to discuss a change in which of the
following medications? (Select all that apply)
A. Olanzapine
B. Quetiapine
C. Aripiprazole
D .Clozapine
E. Asenapine
Answer: C. Aripiprazole

D .Clozapine
Rationale:
Aripiprazole is available in an orally disintegrating tablet form, which might be
beneficial for the patient. Clozapine can also be given as an orally disintegrating tablet,
making it a viable option for those with swallowing difficulties.
112. A charge nurse is discussing manifestations of schizophrenia with a newly licensed
nurse. Which of the following manifestations should the charge nurse identify as being
effectively treated by first generation antipsychotics? (Select all that apply)
A. Auditory hallucinations
B. Withdrawal from social situations
C. Delusions of grandeur
D. Severe agitation
E. Anhedonia
Answer: A. Auditory hallucinations
C. Delusions of grandeur
Rationale:
These are considered positive symptoms and are effectively treated by first-generation
antipsychotics. This is another positive symptom that responds well to treatment with
first-generation antipsychotics.
113. A nurse is assessing a patient who is currently taking perphenazine. Which of the
following findings should the nurse identify as an extrapyramidal symptom (EPS)?
(Select all that apply)
A. Decreased LOC
B. Drooling
C. Involuntary arm movements
D. Urinary retention
E. Continual pacing
Answer: B. Drooling
C. Involuntary arm movements

E. Continual pacing
Rationale:
This can be a result of muscle rigidity or impaired swallowing associated with EPS.
Involuntary arm movements: This is characteristic of dyskinesia, a type of EPS.
Continual pacing: This can indicate akathisia, which is a feeling of inner restlessness and
an uncontrollable need to be in motion.
114. A nurse is providing discharge teaching for a patient who has schizophrenia and a
new prescription for iloperidone. Which of the following patient statements indicates
understanding of the teaching?
A. "I will be able to stop taking this medication as soon as I feel better."
B. "If I feel drowsy during the day, I will stop taking this medication and call my
provider."
C. "I will be careful not to gain too much weight while taking this medication."
D. "This medication is highly addictive and must be withdrawn slowly."
Answer: C. "I will be careful not to gain too much weight while taking this medication."
Rationale:
This is incorrect; antipsychotic medications should be taken as prescribed, often longterm, even if symptoms improve. Stopping medication without consulting the provider
can be harmful; it's essential to discuss any side effects. Iloperidone is not considered
addictive in the same way as substances like opioids or benzodiazepines, and while any
medication should generally be tapered if discontinued, this is not specific to
iloperidone.
115. A nurse is teaching the parents of a child who has autism spectrum disorder and a
new prescription for imipramine about indications of toxicity. Which of the following
should the nurse include in the teaching? (Select all that apply)
A. Seizures
B. Agitation
C. Photophobia
D. Dry mouth

E. Irregular pulse
Answer: A. Seizures
B. Agitation
E. Irregular pulse
Rationale:
This is a serious potential side effect of imipramine, indicating toxicity. Increased
agitation can occur as a sign of toxicity and should be monitored. Cardiovascular effects,
including irregular heart rhythms, are a concern with tricyclic antidepressants like
imipramine.
116. A nurse is providing teaching to an adolescent patient who has a new prescription
for clomipramine for OCD. Which of the following information should the nurse
provide?
A. Eat a diet high in fiber
B. Check temperature daily
C. Take medication first thing in the morning before eating
D. Add extra calories to the diet as between-meal snacks
Answer: A. Eat a diet high in fiber
Rationale:
Clomipramine, a tricyclic antidepressant, can cause constipation as a side effect, so a
high-fiber diet can help mitigate this issue. This is not typically necessary for
clomipramine unless there's a specific concern, such as fever due to an adverse reaction.
Clomipramine is often taken at bedtime due to its sedative effects, not necessarily in the
morning. While this may be relevant for some patients, it is not a general
recommendation for clomipramine users.
117. A nurse is providing teaching to an adolescent patient who is to begin taking
atomoxetine for ADHD. The nurse should instruct the patient to monitor for which of the
following adverse effects? (Select all that apply)
A. Somnolence
B. Yellowing skin

C. Increased appetite
D. Fever
E. Malaise
Answer: B. Yellowing skin
D. Fever
E. Malaise
Rationale:
Yellowing skin: This can indicate liver problems, which is a serious side effect of
atomoxetine, so monitoring for jaundice is important. Fever can be a sign of an adverse
reaction or an underlying infection, so it should be monitored. General feelings of
discomfort or illness can also indicate potential side effects or complications that need to
be addressed. While somnolence (drowsiness) can occur, it is less common with
atomoxetine compared to stimulants used for ADHD. Atomoxetine is more commonly
associated with decreased appetite, not increased appetite.
118. A nurse is caring for a school age child who has conduct disorder and a new
prescription for methylphenidate transdermal patches. Which of the following
information should the nurse provide about the medication?
A. Apply the patch once daily at bedtime
B. Place the patch carefully in a trash can after removal
C. Apply the transdermal patch to the anterior waist area
D. Remove the patch each day after 9 hr
Answer: D. Remove the patch each day after 9 hr
Rationale:
Methylphenidate transdermal patches are typically designed to be worn for up to 9
hours, after which they should be removed to minimize the risk of side effects and to
adhere to the dosing schedule.
119. A nurse is teaching a patient who has intermittent explosive disorder about a new
prescription for fluoxetine. Which of the following information should the nurse
provide? (Select all that apply)

A. An adverse effect of this medication is CNS depression
B. Administer the medication in the morning
C. Monitor for weight loss while taking this medication
D. Therapeutic effects of this medication will take 1-3 weeks to fully develop
E. This medication blocks the synaptic reuptake of serotonin in the brain.
Answer: B. Administer the medication in the morning
C. Monitor for weight loss while taking this medication
E. This medication blocks the synaptic reuptake of serotonin in the brain.
Rationale:
Fluoxetine is often taken in the morning to minimize the risk of insomnia, which can be
a side effect. Fluoxetine can affect appetite and weight, so it’s important to monitor for
potential weight loss, especially in patients with certain eating concerns. Fluoxetine is a
selective serotonin reuptake inhibitor (SSRI), and it works by increasing serotonin levels
in the brain, which can help improve mood and reduce impulsive behaviors.
120. A nurse is providing teaching to a patient who has alcohol use disorder and a new
prescription for carbamazepine. Which of the following information should the nurse
include in the teaching?
A. "This medication will help prevent seizures during alcohol withdrawal."
B. "Taking this medication will decrease your cravings for alcohol."
C. "This medication maintains your blood pressure at a normal level during alcohol
withdrawal."
D. "Taking this medication will improve your ability to maintain abstinence from
alcohol."
Answer: A. "This medication will help prevent seizures during alcohol withdrawal."
Rationale:
Carbamazepine is commonly used to prevent seizures associated with alcohol
withdrawal. It helps stabilize the neuronal membrane and reduce seizure activity.

121. A nurse is assisting in the discharge planning for a patient following alcohol
detoxification. The nurse should anticipate prescriptions for which of the following
medications to promote long- term abstinence from alcohol? (Select all that apply)
A. Lorazepam
B. Diazepam
C. Disulfiram
D. Naltrexone
E. Acamprosate
Answer: C. Disulfiram
D. Naltrexone
E. Acamprosate
Rationale:
This medication works by causing unpleasant reactions when alcohol is consumed,
thereby discouraging drinking. It's used for long-term maintenance in abstinent
individuals. Naltrexone helps reduce cravings for alcohol and blocks the euphoric effects
of alcohol. It is effective in promoting long-term abstinence. This medication is used to
help individuals maintain abstinence from alcohol by reducing withdrawal symptoms
and cravings.
122. A nurse is evaluating a patient's understanding of a new prescription for clonidine
for the treatment or opioid use disorder. Which of the following statements by the patient
indicates an understanding of the teaching?
A. "Taking this medication will help reduce my craving for heroin."
B. "While taking this medication, I should keep a pack of sugarless gum."
C. "I can expect some diarrhea from taking this medicine."
D. "Each dose of this medication should be placed under my tongue to dissolve."
Answer: B. "While taking this medication, I should keep a pack of sugarless gum."
Rationale:
This indicates an understanding that clonidine can cause dry mouth, a common side
effect, and that chewing gum can help alleviate this symptom.

123. A nurse is discussing the use of methadone with a newly licensed nurse. Which of
the following statements by the newly licensed nurse indicates an understanding of the
teaching? (Select all that apply)
A. "Methadone is a replacement for physical dependence to opioids."
B. "Methadone reduces the unpleasant effects associated with abstinence syndrome."
C. "Methadone can be used during opioid withdrawal and to maintain abstinence."
D. "Methadone increases the risk for acetaldehyde syndrome."
E. "Methadone must be prescribed and dispensed by an approved treatment center."
Answer: A. "Methadone is a replacement for physical dependence to opioids."
B. "Methadone reduces the unpleasant effects associated with abstinence syndrome."
C. "Methadone can be used during opioid withdrawal and to maintain abstinence."
E. "Methadone must be prescribed and dispensed by an approved treatment center."
Rationale:
This is accurate; methadone is used as a replacement therapy to manage opioid
dependence. Methadone helps alleviate withdrawal symptoms and cravings. It can help
during withdrawal and is used in maintenance therapy for recovery. Methadone is
regulated and must be administered through certified programs.
124. A nurse is teaching a patient who has tobacco use disorder about the use of nicotine
gum. Which of the following information should the nurse include in the teaching?
A. Chew the gm for no more than 10 min.
B. Rinse out the mouth immediately before chewing the gum.
C. Avoid eating 15 min prior to chewing the gum.
D. Use of the gum is limited to 90 days.
Answer: C. Avoid eating 15 min prior to chewing the gum.
Rationale:
This is important because eating or drinking can affect the absorption of nicotine from
the gum.
125. A nurse is caring for a patient following the loss of her partner due to a terminal
illness. Identify the sequence of Engel's five stages of grief that the nurse should expect

the patient to experience. (Select the stages of grief in the order of occurrence. All steps
must be used.)
A. Developing awareness
B. Restitution
C. Shock and disbelief
D. Recovery
E. Resolution of the loss
Answer: The correct order is
C. Shock and disbelief
A. Developing awareness
E. Resolution of the loss
B. Restitution
D. Recovery
Rationale:
D. Recovery
Step 1: C. Shock and disbelief
Step 2: A. Developing awareness
Step 3: B. Restitution
Step 4: E. Resolution Step 5:
This is the initial reaction to a loss, where the individual may have difficulty accepting
the reality of the situation. It often involves feelings of numbness or denial. After the
initial shock, the person begins to confront the reality of the loss. This stage involves
acknowledging feelings associated with the loss and understanding its implications. In
this stage, individuals start to come to terms with their grief. They may reflect on the
loss and begin to integrate it into their lives, leading to a more stable emotional state.
126. A charge nurse is reviewing Kugler-Ross: Five Stages of Grief with a group of
newly licensed nurses. Which of the following stages should the charge nurse include in
the teaching? (Select all that apply)
A. Disequilibrium
B. Denial

C. Bargaining
D. Anger
E. Depression
Answer: B. Denial
C. Bargaining
D. Anger
E. Depression
Rationale:
This initial stage involves disbelief or shock regarding the loss. The person may have
difficulty accepting the reality of the situation. In this stage, individuals may seek to
negotiate or make deals in hopes of reversing or lessening the loss, often expressing a
desire to change the circumstances. This stage involves feelings of frustration and
helplessness. Individuals may direct their anger toward themselves, others, or even the
deceased. This stage reflects the deep sadness that can accompany the acknowledgment
of the loss. Individuals may feel a profound sense of emptiness and grief. Disequilibrium
is not one of the five stages defined by Kübler-Ross; it is a term used in other contexts to
describe the emotional turmoil that can occur during grief but does not specifically
represent a stage in her model.
127. A nurse is working with a patient who has recently lost his mother. The nurse
recognizes that which of the following factors influence a patient's grief and coping
ability? (Select all that apply)
A. Interpersonal relationships
B. Culture
C. Birth order
D. Religious beliefs
E. Prior experience with loss
Answer: A. Interpersonal relationships
B. Culture
D. Religious beliefs
E. Prior experience with loss

Rationale:
The support and connection a person has with family, friends, and community can
significantly impact their ability to cope with grief. Cultural beliefs and practices
surrounding death and mourning can shape how individuals experience and express their
grief. Spirituality and religious beliefs can provide comfort and a framework for
understanding loss, influencing how a person copes with grief. Previous experiences
with loss can affect a person's resilience and coping strategies in the face of new grief.
Birth order is not typically recognized as a significant factor influencing grief and
coping. While it can affect family dynamics, it does not have the same direct impact as
the other factors listed.
128. A nurse is discussing normal grief with a patient who recently lost a child. Which of
the following statements made by the patient indicates understanding? (Select all that
apply)
A. "I may experience feelings of resentment."
B. "I will probably withdraw from others."
C. "I can expect to experience changes in sleep."
D. "It is possible that I will experience suicidal thoughts."
E. "It is expected that I will have a loss of self-esteem."
Answer: A. "I may experience feelings of resentment."
B. "I will probably withdraw from others."
C. "I can expect to experience changes in sleep."
Rationale:
It's common for individuals in grief to feel complex emotions, including resentment,
particularly if they feel that others do not understand their pain. Withdrawal is a typical
response to grief, as individuals may need time alone to process their feelings. Grief can
significantly affect sleep patterns, leading to insomnia or increased fatigue. While some
may experience thoughts of self-harm during intense grief, this is not considered a
typical or expected part of normal grief and may indicate a need for professional
support. While grief can impact self-esteem, it is not universally expected. The focus is

more on emotional pain and coping rather than a loss of self-esteem as a standard
reaction.
129. A nurse is caring for a patient who lost his mother to cancer last month. The patient
states, "I'd still have my mother if the doctor would have diagnosed her sooner." Which
of the following responses should the nurse make?
A. "You sound angry. Anger is a normal feeling associated with loss."
B. "I think you would feel better if you talked about your feelings with a support group."
C. "I understand just how you feel. I felt the same when my mother died."
D. "Do other members of your family also feel this way?"
Answer: A. "You sound angry. Anger is a normal feeling associated with loss."
Rationale:
This response acknowledges the patient's feelings and normalizes the emotion of anger
in the grieving process. It provides an opportunity for the patient to express their feelings
further and reflects understanding of the complexities of grief.
130. A nurse is assisting the parents of a school-age child who has oppositional defiant
disorder in identifying strategies to promote positive behavior. Which of the following is
an appropriate strategy for the nurse to recommend? (Select all that apply)
A. Allow the child to choose consequences for negative behavior
B. Use role-playing to act out unacceptable behavior
C. Develop a reward system for acceptable behavior
D. Encourage the child to participate in school sports
E. Be consistent when addressing unacceptable behavior
Answer: C. Develop a reward system for acceptable behavior
D. Encourage the child to participate in school sports
E. Be consistent when addressing unacceptable behavior
Rationale:
Positive reinforcement can help encourage desired behaviors in children with
oppositional defiant disorder. Participation in sports can provide structure, promote
teamwork, and help improve self-esteem, which can positively influence behavior.

Consistency is key in setting clear expectations and consequences, helping the child
understand boundaries.
131. A nurse is performing an admission assessment on an adolescent patient who has
depression. Which of the following manifestations should the nurse expect (Select all
that apply)
A. Fear of being alone
B. Substance use
C. Weight gain
D. Irritability
E. Aggressiveness
Answer: B. Substance use
D. Irritability
E. Aggressiveness
Rationale:
Adolescents with depression may turn to substances as a coping mechanism to alleviate
their emotional pain. Depression in adolescents often presents as irritability rather than
classic sadness, and this can manifest as frustration or anger. Some adolescents may
exhibit aggressive behavior as a result of their underlying depression, especially if
they're feeling misunderstood or overwhelmed. Fear of being alone could also be present
in some adolescents with depression, but it is less commonly highlighted than the
selected options. Weight gain can occur, but depression is often more associated with
weight loss due to decreased appetite, so it may not be as typical.
132. A nurse is obtaining a health history from the parents of a 12 year old patient who
has conduct disorder. Which of the following findings should the nurse expect? (Select
all that apply)
A. Bullying of others
B. Threats of suicide
C. Law-breaking activities
D. Narcissistic behavior

E. Flat affect
Answer: A. Bullying of others
B. Threats of suicide
C. Law-breaking activities
Rationale:
Children with conduct disorder often engage in aggressive behavior towards others,
including bullying. While not all children with conduct disorder will exhibit suicidal
thoughts, some may have a higher risk of self-harm due to underlying issues like
frustration or emotional distress. Conduct disorder is characterized by behaviors that
violate societal norms or rules, including engaging in illegal activities. Narcissistic
behavior may not be a primary characteristic of conduct disorder, although some
children may exhibit self-centeredness. Flat affect is more commonly associated with
other disorders, such as depression or schizophrenia, rather than conduct disorder
specifically.
133. A nurse in a pediatric clinic is caring for a preschool-age child who has a new
diagnosis of ADHD. When teaching the parent about this disorder, which of the
following statements should the nurse include in the teaching?
A. "Behaviors associated with ADHD are present prior to age 3."
B. "This disorder is characterized by argumentativeness."
C. "Below-average intellectual functioning is associated with ADHD."
D. "Because of this disorder, your child is at increased risk for injury."
Answer: D. "Because of this disorder, your child is at increased risk for injury."
Rationale:
ADHD symptoms typically manifest before age 7, but they are often not formally
recognized until later, so stating they are present before age 3 may not always be
accurate. While children with ADHD may struggle with behavior regulation,
argumentativeness is more characteristic of Oppositional Defiant Disorder (ODD),
which can co-occur but is not a defining feature of ADHD itself. ADHD can occur in
children of all intellectual levels. While some children with ADHD may have learning

difficulties, it is not accurate to say that below-average intellectual functioning is a
defining characteristic of ADHD.
134. A nurse is assessing a 4-year-old child for indications of autism spectrum disorder.
For which of the following manifestations should the nurse assess?
A. Impulsive behavior
B. Repetitive counting
C. Destructiveness
D. Somatic problems
Answer: B. Repetitive counting
Rationale:
While children with ASD can exhibit impulsive behaviors, this is not a hallmark feature
of the disorder. Impulsivity is more commonly associated with AttentionDeficit/Hyperactivity Disorder (ADHD). Destructive behavior is not specifically
indicative of autism. Children with ASD may exhibit challenging behaviors, but
destructiveness is not a defining symptom. Somatic complaints are not characteristic of
autism spectrum disorder. Instead, children with ASD often have distinct communication
and social interaction challenges.
135. A nurse is conducting chart reviews of multiple patients at a community mental
health facility. Which of the following events is an example of patient experiencing a
maturational crisis?
A. Rape
B. Marriage
C. Severe physical illness
D. Job loss
Answer: B. Marriage
Rationale:
This is an example of an adventitious crisis, which arises from unexpected and often
traumatic events. This also falls under adventitious crises, as it involves unforeseen
circumstances that significantly impact a person's life. Job loss is typically considered an

external or situational crisis rather than a maturational one, as it is usually not a planned
or predictable event.
136. A nurse is caring for a patient who is experiencing a crisis. Which of the following
medications might the provider prescribe? (Select all that apply)
A. Lithium carbonate
B. Paroxetine
C. Risperidone
D. Haloperidol
E. Lorazepam
Answer: B. Paroxetine
Rationale:
Paroxetine is an SSRI typically used for depression and anxiety disorders but is not the
first line for acute crises. Risperidone is an atypical antipsychotic that can be used to
manage agitation and psychotic symptoms in crisis situations. Haloperidol is a firstgeneration antipsychotic often used in acute settings to manage severe agitation and
psychosis. Lorazepam is a benzodiazepine that can help manage acute anxiety and
agitation.
137. A nurse is assessing a patient who has major depressive disorder. The nurse should
identify which of the following patient statements as an overt comment about suicide?
(Select all that apply)
A. "My family will be better off if I'm dead."
B. "The stress in my life is too much to handle."
C. "I wish my life was over."
D. "I don't feel like I can ever be happy again."
E. "If I kill myself then my problems will go away."
Answer: A. "My family will be better off if I'm dead."
C. "I wish my life was over."
E. "If I kill myself then my problems will go away."
Rationale:

The statements A, C, and E are overt comments about suicide because they explicitly
express suicidal ideation or intent. Statement A suggests that the patient believes their
death would benefit their family, indicating a wish to end their life. Statement C
expresses a desire for life to end, which is a clear indication of suicidal thoughts.
Statement E directly connects the act of suicide with the resolution of problems,
revealing a plan and motivation for self-harm. These comments highlight the urgency for
further assessment and intervention.
138. A nurse is caring for a patient who states, "I plan to commit suicide." Which of the
following assessments should the nurse identify as the priority?
A. patient's educational and economic background
B. Lethality of the method and availability of means
C. Quality of the patient's social support
D. patient's insight into the reasons for the decision
E. The greatest risk to the patient is self-harm as a result of carrying out a suicide plan.
Answer: B. Lethality of the method and availability of means
Rationale:
The priority assessment is B. Lethality of the method and availability of means because
it directly addresses the immediate risk to the patient’s safety. Understanding how lethal
the chosen method is and whether the patient has access to the means allows the nurse to
evaluate the urgency of intervention. While other factors, such as social support and
insight, are important for ongoing care, ensuring the patient is safe from self-harm is the
foremost concern in this situation.
139. A nurse is assisting with the development of protocols to address the increasing
number of suicide attempts in the community. Which of the following interventions
should the nurse include as a primary intervention? (Select all that apply)
A. Conducting a suicide risk screening on all new patients
B. Creating a support group for family members of patients who completed suicide
C. Educating high school teens about suicide prevention
D. Initiating one-on-one observation for a patient who has suicidal ideation

E. Teaching middle-school educators about warning indicators of suicide
Answer: A. Conducting a suicide risk screening on all new patients
C. Educating high school teens about suicide prevention
Rationale:
Conducting a suicide risk screening on all new patients helps identify individuals at risk
early on, enabling timely intervention and support. Educating high school teens about
suicide prevention raises awareness and equips young people with the knowledge to
recognize warning signs and seek help, which can prevent potential suicide attempts.
140. A nurse is caring for a patient who is on suicide precautions. Which of the
following interventions should the nurse include in the plan of care?
A. Assign the patient to a private room
B. Document the patient's behavior every hour
C. Allow the patient to keep perfume in her room
D. Ensure that the patient swallows medication
Answer: D. Ensure that the patient swallows medication
Rationale:
Assigning the patient to a private room (A) can increase isolation and risk, while
documenting behavior every hour (B) may not be sufficient for constant monitoring.
Allowing the patient to keep perfume (C) poses a safety risk, as it could potentially be
used for self-harm. Therefore, ensuring medication compliance is the priority
intervention in this context.
141. A nurse is conducting a class for a group of newly licensed nurses on caring for
patients who at risk for suicide. Which of the following information should the nurse
include in the teaching?
A. A patient's verbal threat of suicide is attention-seeking behavior
B. Interventions are ineffective for patients who really want to commit suicide
C. Using the term suicide increases the patient's risk for a suicide attempt
D. A no-suicide contract decreases the patient's risk for a suicide attempt
Answer: D. A no-suicide contract decreases the patient's risk for a suicide attempt

Rationale:
The other options are misleading or incorrect. A minimizes the seriousness of suicidal
thoughts by labeling them as attention-seeking, which can be harmful. B implies
hopelessness regarding interventions, which can discourage effective care. C suggests
that discussing suicide increases risk, while open communication is essential for
assessment and intervention. Thus, focusing on safety contracts is a key teaching point.
142. A nurse is conducting group therapy with a group of patients. Which of the
following statements made by a patient is an example of aggressive communication?
A. "I wish you could not make me angry."
B. "I feel angry when you leave me."
C. "It makes me angry when you interrupt me."
D. "You'd better listen to me."
Answer: D. "You'd better listen to me."
Rationale:
Aggressive communication often involves threats, demands, or a tone that can be
perceived as hostile or confrontational. In this case, the statement uses a commanding
phrase ("You'd better") that implies an ultimatum and lacks consideration for the feelings
or autonomy of others.
143. A nurse is caring for a patient who is speaking in a loud voice with clenched fists.
Which of the following actions should the nurse take?
A. Insist that the patient stop yelling
B. Request that other staff members remain close by
C. Move as close to the patient as possible
D. Walk away from the patient
Answer: B. Request that other staff members remain close by
Rationale:
When a patient exhibits signs of agitation, such as speaking loudly and having clenched
fists, it indicates potential emotional distress or escalating aggression. Ensuring the
presence of additional staff can help maintain safety for both the patient and the nurse. It

allows for support if the situation escalates while ensuring there are resources available
to manage the situation effectively.
144. A nurse is assessing a patient in an inpatient mental health unit. Which of the
following findings should the nurse expect if the patient is in the pre-assaultive stage of
violence? (Select all that apply)
A. Lethargy
B. Defensive responses to questions
C. Disorientation
D. Facial grimacing
E. Agitation
Answer: B. Defensive responses to questions
D. Facial grimacing
E. Agitation
Rationale:
Defensive responses to questions indicate heightened sensitivity and potential
frustration, which can precede aggressive behavior. Facial grimacing may reflect
discomfort or distress, suggesting the individual is experiencing escalating emotions.
Agitation is a common sign of increased anxiety and restlessness that can lead to
violence.
145. A nurse is caring for a patient in an inpatient mental health facility who gets up
from a chair and throws it across the day room. Which of the following is the priority
nursing action?
A. Encourage the patient to express her feelings
B. Maintain eye contact with the patient
C. Move the patient away from others
D. Tell the patient that the behavior is not acceptable
Answer: C. Move the patient away from others
Rationale:

The priority nursing action is C. Move the patient away from others. This intervention is
crucial for ensuring the safety of the patient, other patients, and staff in the facility. By
removing the patient from the situation, the nurse can help prevent further escalation of
aggressive behavior. While maintaining eye contact (B) and discussing feelings (A) may
be important later, they are not the immediate priorities in this situation. Telling the
patient that the behavior is not acceptable (D) is also less effective when immediate
safety is at risk. Therefore, ensuring a safe environment is the most critical action.
146. A nurse is caring for a patient who is screaming at staff members and other patients.
Which of the following is a therapeutic response by the nurse to the patient?
A. "Stop screaming, and walk with me outside."
B. "Why are you so angry and screaming at everyone?"
C. "You will not get your way by screaming."
D. "What was going through your mind when you started screaming?"
Answer: A. "Stop screaming, and walk with me outside."
Rationale:
The therapeutic response is A. "Stop screaming, and walk with me outside." This
approach addresses the behavior while providing a constructive solution to redirect the
patient’s energy and emotions. By inviting the patient to walk outside, the nurse
promotes a calmer environment and shows a willingness to engage. The other options
are less effective: B and D may come across as confrontational or probing when the
patient is already agitated. C focuses on consequences rather than addressing the
patient's emotional state or providing support. Therefore, redirecting the patient in a
calm manner is the most therapeutic response.
147. A charge nurse is leading a peer group discussion about family and community
violence. Which of the following statements by a member of the group indicates an
understanding of the teaching?
A. "Children older than 3 are at greater risk for abuse."
B. "Substance use disorder does not increase the risk for violence."
C. "Entering an intimate relationship increases the risk for violence."

D. "Pregnancy increases the risk for violence toward the intimate partner."
Answer: D. "Pregnancy increases the risk for violence toward the intimate partner."
Rationale:
The statement that indicates an understanding of the teaching is D. "Pregnancy increases
the risk for violence toward the intimate partner." This acknowledges that during
pregnancy, there can be heightened tensions and stress, which may lead to an increased
risk of violence in intimate relationships. The other statements are incorrect: A is
misleading as younger children are generally at higher risk for abuse, particularly those
under 3. B is false; substance use disorder is a known risk factor for violence. C is also
inaccurate, as entering an intimate relationship can potentially increase the risk of
violence, especially if there are underlying issues. Thus, option D correctly reflects an
understanding of the dynamics involved in violence.
148. A nurse is preparing to assess an infant who has shaken baby syndrome. Which of
the following is an expected finding? (Select all that apply)
A. Sunken fontanels
B. Respiratory distress
C. Retinal haemorrhage
D. Altered LOC
E. Increase in head circumference
Answer: B. Respiratory distress
C. Retinal haemorrhage
D. Altered LOC
E. Increase in head circumference
Rationale:
Respiratory distress can occur due to brain injury affecting respiratory function. Retinal
haemorrhage is a classic finding in cases of shaken baby syndrome, resulting from the
violent shaking motion. Altered level of consciousness (LOC) may be present due to
brain injury or swelling. Increase in head circumference can indicate swelling or
bleeding within the brain.

149. A nurse working in an emergency department is assessing a preschool-age child
who reports abdominal pain. When conducting a head-to-toe assessment, which of the
following findings should alert the nurse to possible abuse?
A. Abrasions on knees
B. Round burn marks on forearms
C. Mismatched clothing
D. Abdominal rebound tenderness
E. Areas of ecchymosis on torso
Answer: B. Round burn marks on forearms
E. Areas of ecchymosis on torso
Rationale:
Round burn marks on forearms are concerning as they may indicate intentional harm or
punishment. Areas of ecchymosis on the torso can also be a sign of abuse, especially if
the bruising is in locations that are not typical for accidental injuries in children.
Abrasions on knees could result from normal play activities. Mismatched clothing may
not necessarily indicate abuse, as it can result from various factors. Abdominal rebound
tenderness is a sign of potential internal injury but does not specifically indicate abuse.
Therefore, options B and E are the most indicative of possible abuse.
150. A nurse is preparing a community education seminar about family violence. When
discussing types of violence, the nurse should include which of the following?
A. Refusing to pay bills for a dependent, even when funds are available, is neglect.
B. Intentionally causing an older adult to fall is an example of physical violence.
C. Striking an intimate partner is an example of sexual violence.
D. Failure to provide a stimulating environment for normal development is emotional
abuse.
Answer: B. Intentionally causing an older adult to fall is an example of physical
violence.
Rationale:
Refusing to pay bills for a dependent, even when funds are available, is neglect. This is
true, but it doesn't encompass all aspects of neglect. Striking an intimate partner is an

example of sexual violence. This is incorrect; striking is considered physical violence,
not sexual violence. Failure to provide a stimulating environment for normal
development is emotional abuse. This is also true but doesn't capture the full definition
of emotional abuse, which typically involves actions that directly harm a person's
emotional well-being.
151. A nurse is caring for an adult patient who has injuries resulting from intimate
partner abuse. The patient does not wish to report the violence to law enforcement
authorities. Which of the following nursing actions is the highest priority?
A. Advise the patient about the location of women's shelters
B. Encourage the patient to participate in a support group for survivors of abuse
C. Implement case management to coordinate community and social services
D. Educate the patient about the use of stress management techniques
Answer: A. Advise the patient about the location of women's shelters
Rationale:
While the other options are valuable, they focus more on long-term support rather than
addressing the immediate need for safety. B (support groups), C (case management), and
D (stress management techniques) can be important later, but ensuring the patient has a
safe place to go is the most urgent concern in the context of intimate partner abuse.
152. A nurse is discussing silent rape reaction with a newly licensed nurse. The nurse
should identify which of the following characteristics as expected for this type of
reaction? (Select all that apply)
A. Sudden development of phobias
B. Development of substance use disorder
C. Increased level of anxiety during interview
D. Reactivation of a prior physical disorder
E. Unwillingness to discuss the sexual assault
Answer: A. Sudden development of phobias
C. Increased level of anxiety during interview
E. Unwillingness to discuss the sexual assault

Rationale:
Sudden development of phobias can occur as a response to trauma, indicating
heightened anxiety and fear. Increased level of anxiety during the interview is common
as the patient may feel vulnerable discussing the assault. Unwillingness to discuss the
sexual assault reflects the emotional pain and trauma associated with the experience,
leading individuals to avoid talking about it. Development of substance use disorder and
D. Reactivation of a prior physical disorder may occur in some cases but are not
characteristic features of the silent rape reaction specifically. Therefore, options A, C,
and E are the correct answers.
153. A nurse is assessing a patient who experienced sexual assault. Which of the
following findings indicate the patient is experiencing an emotional reaction of rapetrauma syndrome? (Select all that apply)
A. Genitourinary soreness
B. Difficulties with low self-esteem
C. Sleep disturbances
D. Emotional outburst
E. Difficulty making decisions
Answer: D. Emotional outburst
E. Difficulty making decisions
Rationale:
Emotional outburst can be a sign of the intense emotional distress and trauma following
a sexual assault. Difficulty making decisions often reflects the impact of trauma on
cognitive functioning and emotional stability.
154. A nurse is discussing the care of a patient following a sexual assault with a newly
licensed nurse. Which of the following statements by the newly licensed nurse indicates
an understanding of the teaching?
A. "I will administer prophylactic treatment for sexually transmitted infections."
B. "I am not required to obtain informed consent before the sexual assault nurse
examiner collects forensic evidence."

C. "I can expect manifestations of rape-trauma syndrome to be similar to bipolar
disorder."
D. "I should use narrative documentation when documenting subjective data."
Answer: C. "I can expect manifestations of rape-trauma syndrome to be similar to
bipolar disorder."
Rationale:
"I am not required to obtain informed consent before the sexual assault nurse examiner
collects forensic evidence." This is incorrect; informed consent is essential. "I can expect
manifestations of rape-trauma syndrome to be similar to bipolar disorder." This is
misleading, as the manifestations of rape-trauma syndrome are distinct and should not be
conflated with bipolar disorder symptoms. "I should use narrative documentation when
documenting subjective data." While narrative documentation can be used, it’s important
to follow specific protocols for documenting such sensitive cases, which may include
more structured approaches.
155. A nurse is caring for a patient who was recently raped. The patient states, "I never
should have been out on the street alone at night." Which of the following responses
should the nurse make?
A. "Your actions had nothing to do with what happened."
B. "You should focus on recovery rather than blaming yourself for what happened."
C. "You believe this wouldn't have happened if you hadn't been out alone?"
D. "Why do you feel that you should not have been alone on the street at night?"
Answer: C. "You believe this wouldn't have happened if you hadn't been out alone?"
Rationale:
"Your actions had nothing to do with what happened." This may come off as dismissive
of the patient's feelings. "You should focus on recovery rather than blaming yourself for
what happened." While supportive, it doesn't invite discussion about the patient's
emotions. "Why do you feel that you should not have been alone on the street at night?"
This might sound confrontational and could make the patient feel defensive.

156. A community health nurse is leading a discussion about rape with a neighborhood
task force. Which of the following statements by a neighborhood citizen indicates an
understanding of the teaching?
A. "Rape is a crime of passion."
B. "Acquaintance rape often involves alcohol."
C. "Young adults are the typical victims of sexual assault."
D. "The majority of rapists are unknown to the victims."
Answer: D. "The majority of rapists are unknown to the victims."
Rationale:
"Rape is a crime of passion." This is misleading; while some rapes may involve
emotional factors, rape is primarily about power and control, not passion. "Acquaintance
rape often involves alcohol." While alcohol can be a factor, this statement may
oversimplify the complexities of acquaintance rape. "Young adults are the typical
victims of sexual assault." While young adults can be victims, sexual assault can affect
individuals of all ages, making this statement not entirely accurate.
157. A nurse is caring for a patient who is receiving cefotaxime (Claforan) 1 g by
intermittent IV bolus. The amount available is cefotaxime 1 g in dextrose 5% in water
(D5W) 100 mL to infuse over 45 min. The drop factor shown on the package of IV
tubing is 10 gtt/mL. The nurse should make sure the manual IV infusion delivers how
many gtt/min? (Round the answer to the nearest whole number.) 22 gtt/min A nurse is
observing a patient’s IV site. Which of the following findings indicate phlebitis? (Select
all that apply.)
A. Tingling sensation below insertion site
B. Tachycardia
C. Palpable, hard mass above insertion site
D. Cool, pale skin
E. Pain at site
Answer: E. Pain at site
Rationale:

Incorrect: A tingling sensation below the insertion site is a clinical manifestation of
nerve damage.
Incorrect: Tachycardia is a clinical manifestation of fluid volume overload.
Correct: A palpable, hard mass above the insertion site is a clinical manifestation of
thrombophlebitis.
Incorrect: Cool, pale skin is a clinical manifestation of infiltration.
Correct: Pain at the IV site is a clinical manifestation of thrombophlebitis
158. A nurse manager is reviewing facility policies for IV therapy management with the
members of his team. The nurse manager should inform the team members that which of
the following techniques will minimize the risk of catheter embolism?
A. Perform hand hygiene before and after IV insertion.
B. Rotate the IV sites at least every 72 hr.
C. Minimize tourniquet time.
D. Avoid reinserting the needle into an IV catheter.
Answer: D. Avoid reinserting the needle into an IV catheter.
Rationale:
Incorrect: The nurse manager should remind the members of the team to perform hand
hygiene to prevent infection, but this technique does not reduce the risk of catheter
embolism.
Incorrect: The nurse manager should remind the members of the team to rotate IV sites
at least every 72 hr to prevent phlebitis, but this technique does not minimize the risk of
catheter embolism.
Incorrect: The nurse manager should remind the members of the team to minimize
tourniquet time, but this technique does not minimize the risk of catheter embolism.
Correct: The nurse manager should remind the members of the team to avoid reinserting
a needle into an IV catheter. This action can result in severing the end of the catheter and
consequently cause a catheter embolism.
159. A nurse is preparing to initiate IV therapy for an older adult patient. Which of the
following actions should the nurse plan to take?

A. Use a disposable razor to remove excess hair on the extremity.
B. Select the back of the patient’s hand to insert the IV catheter.
C. Distend the veins by using a blood pressure cuff.
D. Direct the patient to raise his arm above his heart.
Answer: C. Distend the veins by using a blood pressure cuff.
Rationale:
Incorrect: The nurse should remove excess hair by clipping it with scissors. Shaving
with a disposable razor can cause skin damage that can lead to infection.
Incorrect: In most instances, the nurse inserts the IV catheter into a distal site, such as
the back of the patient’s hand. However, when inserting an IV catheter for an older adult,
the nurse should select a site on the arm because older adults typically have fragile veins
in the backs of their hands.
Correct: The nurse should distend the veins using a blood pressure cuff to reduce
overfilling of the vein, which can result in a hematoma.
Incorrect: The nurse should direct the patient to hold his arm below the level of his heart
to distend the vein.
160. A nurse is caring for a patient receiving dextrose 5% in water IV at 250 mL/hr.
Which of the following findings indicate fluid overload? (Select all that apply.)
A. Hypotension
B. Bradycardia
C. Shortness of breath
D. Crackles heard in lungs
E. Distended neck veins
Answer: C. Shortness of breath
D. Crackles heard in lungs
E. Distended neck veins
Rationale:
Incorrect: Due to an excess of fluid in the cardiovascular system, hypertension is a
clinical manifestation of fluid volume overload.

Incorrect: Due to an increase in fluid in the cardiovascular system, tachycardia is a
clinical manifestation of fluid volume overload.
Correct: Due to an excess of fluid in the cardiovascular system, shortness of breath is a
manifestation of fluid volume overload.
Correct: Due to an excess of fluid in the cardiovascular system, crackles in the lungs is a
manifestation of fluid volume overload.
Correct: Due to an excess of fluid in the cardiovascular system, distended neck veins is a
manifestation of fluid volume overload.
161. A nurse on a medical-surgical unit is providing care for a group of patients who are
receiving IV therapy. The nurse is monitoring the patients for related complications. Use
ATI Active Learning Template: Nursing Skill to complete this item to include the
following:
• Indications: Identify three indications for IV therapy.
• Complications: Identify four potential complications of IV therapy.
Using the ATI Active Learning Template: Nursing
Skill
A. Indications for IV therapy
B. Complications of IV therapy
C. Catheter embolus
D. Additional Complication
Answer: A. Indications for IV therapy
B. Complications of IV therapy
C. Catheter embolus
D. Additional Complication
Rationale:
• To administer medications
• To supplement fluid intake
• To replace electrolytes and nutrients
• Infiltration
• Extravasation

• Cellulitis
• Fluid overload
• Hematoma
• Phlebitis/thrombophlebitis
162. A nurse is reinforcing teaching for a patient who has a new prescription for a
tetracycline antibiotic to treat Lyme disease. The nurse should remind the patient to
eliminate which of the following from her diet for the duration of treatment?
A. Milk products
B. Green, leafy vegetables
C. Grapefruit juice
D. Processed meats
Answer: A. Milk products
Rationale:
Correct: Tetracycline can interact with a chelating agent, such as milk, and form an
insoluble, unabsorbable compound. patients should not take tetracycline within 2 hr of
consuming dairy products.
Incorrect: Green, leafy vegetables are a good source of vitamin K, which can decrease
the therapeutic effects of anticoagulants but does not affect tetracycline use.
Incorrect: Grapefruit juice seems to act by inhibiting medication metabolism and raising
blood levels of some drugs, but it does not affect tetracycline use.
Incorrect: Consuming foods that contain tyramine, such as processed meats, can cause a
hypertensive crisis in patients who take monoamine oxidase inhibitors. Tyramine does
not affect tetracycline use.
163. A nurse is preparing to administer an IM dose of penicillin to a patient who has a
new prescription. The patient states she took penicillin 3 years ago and developed a rash.
Which of the following is an appropriate nursing action?
A. Administer the prescribed dose.
B. Withhold the medication.
C. Ask the provider to change the prescription to an oral form.

D. Administer an oral antihistamine at the same time.
Answer: B. Withhold the medication.
Rationale:
Incorrect: Administering the IM penicillin in the prescribed dosage could cause a severe
reaction and is not the appropriate action.
Correct: The nurse should withhold the medication and notify the provider of the
patient’s previous reaction to penicillin so that an alternative antibiotic can be
prescribed. Allergic reactions to penicillin can range from mild to severe anaphylaxis,
and prior sensitization should be reported to the provider.
Incorrect: Administering the penicillin orally rather than intramuscularly would not
prevent a reaction and is not the appropriate nursing action.
Incorrect: Giving the penicillin along with an oral antihistamine would not prevent a
reaction from occurring and is not the appropriate nursing action.