ATI RN MENTAL HEALTH 2019 ACTUAL EXAM 160 QUESTIONS AND
CORRECT ANSWERS 2023-2024 UPDATE ALREADY A GRADED|NEW!!
1. A nurse is reviewing the medication administration record for a client who is
experiencing adverse effects of chlorpromazine. The nurse should administer
benztropine to relieve which of the following adverse effects?
A. Blurred vision
B. Orthostatic hypotension
C. Dry mouth
D. Acute dystonia
Answer: D. Acute dystonia
Rationale: The nurse should administer benztropine, an anticholinergic agent, to
relieve acute dystonia, which is an extrapyramidal adverse effect of
chlorpromazine.
2. A nurse is planning discharge teaching with a family member of a client who has
diagnosis of depression. Which of the following information about relapse should
the nurse include?
A. Additional acute episodes of depression are unlikely following inpatient care.
B. Early identification of changes, such as decreased social involvement, is
important.
C. Medication compliance will prevent further need for inpatient hospitalization.
D. It is helpful to regularly reinforce to the client that things will get better.
Answer: B. Early identification of changes, such as decreased social involvement,
is important.
Rationale: Decreased social involvement is a manifestation of depression, and
early identification of findings can lead to early intervention.
3. A nurse is assessing a client who is experiencing opioid withdrawal. Which of
the following manifestations should the nurse expect?
A. Sedation
B. Rhinorrhea
C. Bradycardia
D. Hypothermia
Answer: B. Rhinorrhea
Rationale: The nurse should expect the client who is experiencing opioid
withdrawal to have rhinorrhea and flu-like manifestations such as yawning,
sneezing, and abdominal pain.
4. A nurse is assessing a family's dynamics during a counseling session. The nurse
should recognize which of the following findings as an indication of a boundary
issue?
A. An adolescent family member who questions parental authority
B. A family with three generations in the same household
C. Older children who are responsible for their younger siblings
D. Two adults and their children from prior relationships in the same household
Answer: C. Older children who are responsible for their younger siblings
Rationale: This is an example of enmeshed boundaries in which there are no
distinctions between the roles of family members.
5. A nurse is assisting a client who has a terminal illness adjust to progressive loss
of independence. Which of the following statements by the client indicates
acceptance of her illness?
A. "I am going to order a wheelchair for when I'm unable to walk."
B. "I am going to stop paying my bills since I won't be around much longer."
C. "I wish you would go take care of somebody who actually needs you."
D. "I am sure I'm going to be able to continue to care for myself without help."
Answer: A. "I am going to order a wheelchair for when I'm unable to walk."
Rationale: The client is recognizing the reality of continued loss of independence
and is anticipating the need for assistive devices, which indicates the behavioral
response of acceptance.
6. A nurse is caring for a child who is taking methylphenidate. The nurse should
monitor the child for which of the following findings as an adverse effects of
methylphenidate?
A. Weight gain
B. Tinnitus
C. Tachycardia
D. Increased salvation
Answer: C. Tachycardia
Rationale: The nurse should monitor the child for tachycardia, which is an adverse
effect of methylphenidate.
7. A nurse is creating a plan of care for a client who has been placed in seclusion
after threatening to harm others or the unit. Which of the following interventions
should the nurse include in the plan?
A. Document the client's behavior every 8 hr.
B. Limit the client's fluid intake to 50 mL/hr.
C. Renew the prescription for the client every 4 hr.
D. Toilet the client every 4 hr.
Answer: C. Renew the prescription for the client every 4 hr.
Rationale: The nurse should assess the client's behavior frequently during
seclusion and should renew the prescription for seclusion for an adult client every
4 hr, for a maximum of 24 hr.
8. A nurse observes a client on a mental health unit pushing on the locked unit
door. Which of the following statements should the nurse make?
A. "It appears as though you would like to open the door."
B. "You will feel more comfortable after you've been here for a while."
C. "It is okay to not want to be here."
D. "You really shouldn't be pushing on the door."
Answer: A. "It appears as though you would like to open the door."
Rationale: This statement is an example of the therapeutic technique of making
observations. This technique encourages the client to notice the behavior so that
they can describe thoughts and feelings related to that behavior.
9. A nurse is education the parent of a child who has a new diagnosis of autism
spectrum disorder. Which of the following manifestations of this disorder should
the nurse include in the teaching?
A. Fear of abandonment
B. Motor and verbal tics
C. Hostile behavior
D. Language delay
Answer: D. Language delay
Rationale: The nurse should identify that language delays are a manifestation of
autism spectrum disorder.
10. A nurse is discussing a 12-step program with a client who has alcohol use
disorder and is in an acute care facility undergoing detoxification. Which of the
following information should the nurse include in the teaching?
A. The program will help the client accept responsibility for the disorder.
B. The client should obtain a sponsor before discharge for an increased chance of
recovery.
C. The client will need to identify individuals who have contributed to the disorder.
D. The program will need a prescription from the client's provider prior to
attendance.
Answer: B. The client should obtain a sponsor before discharge for an increased
chance of recovery.
Rationale: The nurse should teach the client that peer support has been shown to
increase program attendance and the chances of recovery. If the client does not
have a sponsor, they can be assigned one when they begin attending the program.
11. A charge nurse on a mental health unit is discussing client rights with a newly
licensed nurse. Which of the following statements should the charge nurse make?
A. "Clients can't refuse to take medications if they are admitted involuntarily."
B. "You can notify a client's family if they are admitted involuntarily."
C. "Clients who are admitted involuntarily maintain the right to give informed
consent for procedures."
D. "You can remove a client's privileges if they are admitted involuntarily and
refuse to attend therapy sessions."
Answer: C. "Clients who are admitted involuntarily maintain the right to give
informed consent for procedures."
Rationale: Clients who are admitted involuntarily maintain the right to give
informed consent for treatment. They also have the right to give informed consent
for procedures.
12. A nurse in the emergency department is caring for four clients. Which of the
following clients is the nurse required to report as a potential victim of abuse?
A. A school-age child who has bruises on the knees
B. An older adult client who is bedbound and has a stage IV pressure ulcer
C. An adolescent who has a vaginal candida infection
D. A young adult who is pregnant and has a sprained ankle
Answer: B. An older adult client who is bedbound and has a stage IV pressure
ulcer
Rationale: A stage IV pressure ulcer on an older adult client who is bedbound can
indicate
13. A nurse is admitting a client who has major depressive disorder and a new
prescription for tranylcypromine. Which of the following over-the-counter
medications that the client reports taking should alert the nurse to a potential
adverse reactions?
A. Lansoprazole
B. Naproxen - No adverse interaction w/ this drug.
C. Magnesium hydroxide
D. Phenylephrine
Answer: D. Phenylephrine
Rationale: Clients who are taking tranylcypromine, an MAOI antidepressant,
should not take phenylephrine and other over-the-counter medications for sinus
congestion, colds, or allergies due to their actions on the sympathetic nervous
system, which can result in severe hypertension.
14. A nurse is planning care for a client who has generalized anxiety disorder. At
which of the following levels of anxiety should the nurse plan to teach the client
relaxation techniques?
A. Panic
B. Moderate
C. Severe
D. Mild
Answer: D. Mild
Rationale: The nurse should plan to teach the client relaxation techniques during
the mild level of anxiety. This is when the client will be able to concentrate and
process information.
15. A nurse is planning care for a client who has bipolar disorder and is
experiencing mania. Which of the following interventions should the nurse include
in the plan of care?
A. Encourage the client to participate in group therapy
B. Instructing the client to avoid napping during the day
C. Offer the client high-calorie finger foods frequently
D. Decrease the client's daily fiber intake
Answer: C. Offer the client high-calorie finger foods frequently
Rationale: The nurse should frequently offer the client high-calorie foods that can
be eaten while the client is on the go. Clients experiencing mania might be unable
to sit down for meals and can experience weight loss and dehydration.
16. A nurse is counseling an adolescent who has anorexia nervosa and reports
excessive laxative use and fear of gaining weight. The client states, "I'm so fat I
can't even stand to look at myself." Which of the following therapeutic responses
demonstrates the nurse's use of summarizing?
A. "You've discussed several concerns about your weight. Let's go back and talk
about your belief that you are fat."
B. "You're saying that you think you are fat and are using laxatives because you are
afraid of gaining weight."
C. "You don't want to look at yourself because you think you are fat."
D. "You and I can work together to overcome your fears of gaining weight."
Answer: B. "You're saying that you think you are fat and are using laxatives
because you are afraid of gaining weight."
Rationale: The nurse is using the therapeutic technique of summarizing to review
the key points of the discussion.
17. A school nurse is assessing a school-age child who experienced the traumatic
loss of a parent 8 months ago. Which of the following findings should the nurse
identify as an indication that the child is experiencing post-traumatic stress
disorder (PTSD)?
A. Clinging behaviors directed toward a teacher
B. Increased time spent sleeping
C. Intense focus on school work
D. Lack of interest in an upcoming holiday
Answer: D. Lack of interest in an upcoming holiday
Rationale: The child who has PTSD will have negative moods and difficulty
remembering aspects of the traumatic event. The child can also have a loss of
interest or lack of participation in significant activities and events such as holidays.
18. A nurse is planning discharge teaching for a client who has severe
schizoaffective disorder. The nurse should identify that which of the following
treatment options can offer interdisciplinary services for the client at home?
A. Community mental health center
B. Mental health day program
C. Partial hospitalization program
D. Assertive community treatment
Answer: D. Assertive community treatment
Rationale: Assertive community treatment provides comprehensive, communitybased services to clients who have severe mental illness based upon individualized
needs. Services are available in any setting, including the client's home, 24 hr per
day and provide crisis intervention, medication services, and advocacy.
19. A nurse in an emergency department is caring for a female adolescent who has
a diagnosis of bulimia nervosa and has a fainting episode during a ballet
performance. Which of the following statements by the parent acknowledges the
client's diagnosis?
A. "She works so hard at ballet. Will she still be able to perform?"
B. "She won't let me take the trash from her room. I'm concerned about what she
has in there."
C. "She told me she was tired, so I did her chores for her today."
D. "She is happier with her appearance now that she's lost some weight."
Answer: B. "She won't let me take the trash from her room. I'm concerned about
what she has in there."
Rationale: The client might be binge eating and attempting to hide food
containers, which is a common behavior among clients who have bulimia nervosa.
The parent's statement indicates awareness of the client's behavior.
20. A nurse in a mental health facility is caring for a client who has schizophrenia.
Which of the following findings places the client at the greatest risk for selfdirected injury or injuring others?
A. Inability to communicate with others
B. Feelings of absence of self-worth
C. Lack of motivation to perform daily tasks
D. Command hallucinations
Answer: D. Command hallucinations
Rationale: A client who has schizophrenia and is experiencing command
hallucinations can hear voices telling them to hurt themselves or others. Therefore,
a client who is experiencing command hallucinations is at the greatest risk for selfdirected injury or injuring others.
21. A nurse is caring for a client who is experiencing a panic attack. Which of the
following actions should the nurse take?
A. Orient the client to person, place, and time
B. Assist the client with deep-breathing exercises
C. Calm the client by using therapeutic touch
D. Have the client sit alone in a quiet room
Answer: B. Assist the client with deep-breathing exercises
Rationale: Relaxation techniques, such as deep, abdominal breathing exercises,
help defuse manifestations of anxiety.
22. A nurse is assessing a client who has bulimia nervosa. The nurse should expect
which of the following findings?
A. Amenorrhea
B. Lanugo
C. Cold extremities
D. Tooth erosion
Answer: D. Tooth erosion
Rationale: A client who has bulimia nervosa is likely to have dental caries and
tooth erosion caused by frequent exposure to gastric acid from vomiting.
23. A nurse is providing teaching to the partner of a client who is in a rehabilitation
program for alcohol use disorder. The nurse should identify that which of the
following statements by the client's partner indicates an understanding of the
teaching?
A. "I will avoid social events until my partner has completed treatment."
B. "It is important for me to focus my attention on my partner's addiction."
C. "I will not take charge of my partner's work responsibilities."
D. "I want my partner to promise to change addictive behaviors."
Answer: C. "I will not take charge of my partner's work responsibilities."
Rationale: The nurse should identify that it is important for the individual who has
the substance use disorder to take charge of personal responsibilities.
24. A nurse is talking with a group of parents who have recently experienced the
death of a child. Which of the following actions should the nurse take?
A. Encourage the parents to avoid discussing the death with their other children to
protect their feelings.
B. Recommend each parent grieve in private to avoid hindering each other's
healing.
C. Suggest forming a weekly support group for parents who have experienced the
death of a child.
D. Advise the parents to begin counseling if they are still grieving in a few months.
Answer: C. Suggest forming a weekly support group for parents who have
experienced the death of a child.
Rationale: Support groups are a positive resource in the process of recovery for
parents following the death of a child.
25. A nurse is performing an admission assessment on a client and notices that the
client appears withdrawn and fearful. To establish a trusting nurse-client
relationship, which of the following actions should the nurse take first?
A. Inform the client that this administration is confidential
B. Introduce the client to other clients in the day room
C. Assist the client in facilitation behavior change
D. Determine coping strategies that the client has used in the past
Answer: A. Inform the client that this administration is confidential
Rationale: According to evidence-based practice, the nurse should first inform the
client about confidentiality during the orientation phase of the nurse-client
relationship.
26. A nurse is planning care for a client who is to undergo electroconvulsive
therapy (ECT). Which of the following actions should the nurse include in the
plan?
A. Administer phenytoin 30 min prior to the procedure.
B. Instruct the client to expect a headache following the procedure.
C. Place the client in four point restraints prior to the procedure.
D. Monitor the client's cardiac rhythm during the procedure.
Answer: D. Monitor the client's cardiac rhythm during the procedure.
Rationale: The seizure induced during ECT can stress the client's heart. Therefore,
the nurse should plan to monitor the client's cardiac rhythm during ECT via an
electrocardiogram.
27. A nurse at a providers office is interviewing an older adult client. Which of the
following actions should the nurse plan to take?
Nurse's Notes: The client reports a history of anxiety; diagnosed with Alzheimer's
disease 2 months ago. The client's partner died 6 months ago. Reports decreased
appetite, low energy levels, and insomnia for several weeks; some memory loss.
Graphic Results:
SaO2 96% on room air
Respiratory rate
20/min
Blood pressure 112/76 mm Hg (lying)
Blood pressure 104/68 mm Hg (standing)
Heart rate 68/min
Temperature 36° C (96.8°F) Medication
Administration Record:
Captopril 12.5 mg by mouth three times daily
Digoxin 0.125 mg by mouth each morning
Multivitamin with iron one by mouth daily
Docusate sodium 50 mg by mouth each evening
A. Use a screening tool to evaluate the client for depression
B. Ask the provider to decrease the dosage of the client's blood pressure
medication.
C. Instruct the client to decrease intake of vitamin B12.
D. Suggest the client go for a brisk walk 20 min just before bedtime.
Answer: A. Use a screening tool to evaluate the client for depression
Rationale: Depression can be underdiagnosed among older adult clients. The
nurse should identify several risk factors for depression from the client's data,
including having Alzheimer's disease, anxiety, and the loss of a loved one.
Manifestations of depression can also be nonspecific for older adult clients and can
include weight loss, decreased energy levels, and difficulty sleeping.
28. A nurse is preparing to participate in an interdisciplinary conference for a client
who has bipolar disorder. Which of the following behaviors is the priority for the
nurse to report to the treatment team?
A. Calling family members
B. Spending time alone
C. Giving away possessions
D. Excessive crying
Answer: C. Giving away possessions
Rationale: Giving away possessions indicates that this client is at greatest risk for
suicide. Therefore, this is the priority finding for the nurse to report to the
treatment team.
29. A nurse is updating the plan of care for a client who has bulimia nervosa and is
5% above their ideal body weight. Which of the following interventions should the
nurse include in the plan?
A. Include a liquid supplement with meals.
B. Identify the client's trigger foods.
C. Allow the client at least 1 hr for each meal.
D. Weigh the client at bedtime each day.
Answer: B. Identify the client's trigger foods.
Rationale: A. Include a liquid supplement with meals. - Include a liquid
supplement for someone who is below their ideal body weight and might not eat
solid foods or might need the additional nutrition to gain weight.
B. Identify the client's trigger foods. - The nurse should identify the trigger foods
that initiate the client's binge and assist the client to understand their thoughts and
behavior that relate to the food.
C. Allow the client at least 1 hr for each meal. - Limit meals to 30 mins to prevent
putting excessive focus on foods.
D. Weigh the client at bedtime each day. - Pt should be weighed in morning and
void prior to oral intake. RN should weigh pt daily for 1st week then 3 x per week
after that.
30. A nurse on an acute mental health facility is receiving change-of-shift report for
four clients. Which of the following client should the nurse assess first?
A. A client who does not recognize familiar people
B. A client who cannot verbalize their needs
C. A client who is awake and disoriented at night
D. A client who is experiencing delusions of persecution
Answer: D. A client who is experiencing delusions of persecution
Rationale: The presence of delusions of persecution indicates that this client is at
the greatest risk for injury due to the client's belief that a person in power is out to
harm them. Therefore, the nurse should assess this client first.
31. A nurse is teaching a newly licensed nurse about nursing care plans for clients
who have depressive disorders. Which of the following statements by the newly
licensed nurse indicates an understanding of the teaching?
A. "I will use the same plan of care and interventions for each client who has
depression."
B. "Each nurse will develop a separate plan of care for each client who has
depression."
C. "I will update the plan of care as a client's manifestations of depression change."
D. "An assistive personnel can use the plan of care for client teaching."
Answer: C. "I will update the plan of care as a client's manifestations of
depression change."
Rationale: The nurse should update the plan of care as a client's status and needs
change.
32. A nurse is assessing a client who has major depressive disorder and has been
receiving amitriptyline for 1 week. Which of the following outcomes should the
nurse expect?
A. Rapid improvement in affect within 30 to 60 min after taking the medication
B. Greater risk of attempting suicide as affect and energy improve
C. Onset of frequent, loose stools
D. Development of physiologic dependence on the medication
Answer: B. Greater risk of attempting suicide as affect and energy improve
Rationale: The nurse should identify that an initial response to amitriptyline can
develop in 1 week. For a client who has major depressive disorder with suicidal
ideation, the energy to carry out a plan is increased after 1 week of treatment.
33. A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the
following laboratory findings should the nurse expect?
A. Increased creatine phosphokinase (CPK)
B. Increase low-density lipoproteins (LDL)
C. Decreased fasting blood glucose
D. Decreased aspartate aminotransferase (AST)
Answer: A. Increased creatine phosphokinase (CPK)
Rationale: An increase in CPK, a muscle enzyme released when muscle tissue is
damaged, occurs with cardiomyopathy.
34. A nurse is caring for a client who is in an abusive relationship and is assisting
in the development of a safety plan. Which of the following actions is the first
component of a safety plan?
A. Develop a code word that means "time to go."
B. Identify signs of escalation of violence.
C. Have a predetermined place to go in the event of violence.
D. Keep a hidden packed bag of necessities.
Answer: B. Identify signs of escalation of violence.
Rationale: It is important for the client to be able to identify signs of escalation of
violence, which are the greatest risk to the client. Therefore, this is the first
component of the safety plan because it increases awareness of when danger is
imminent and it is time to leave.
35. A nurse is planning care for a client who has made repeated physical threats
toward others on the unit. Although the client does not want to leave the unit, the
nurse requests the provider to transfer the client to a unit that is equipped to
manage violent behavior. Which of the following ethical principles should the
nurse apply in this situation?
A. Nonmaleficence
B. Veracity
C. Justice
D. Autonomy
Answer: A. Nonmaleficence
Rationale: It is the responsibility of the nurse to do no harm to clients. The nurse
is applying the ethical principle of nonmaleficence by requesting to transfer this
client to a unit better able to manage their behavior and thereby prevent injury to
others on the unit.
36. A nurse on a mental health unit is caring for a group of clients. Which of the
following actions by the nurse is an example of the ethical principle of justice?
A. Allowing a client to choose which unit activities to attend
B. Attempting alternative therapies instead of restraints for a client who is
combative
C. Providing a client with accurate information about their prognosis
D. Spending adequate time with a client who is verbally abusive
Answer: D. Spending adequate time with a client who is verbally abusive
Rationale: By spending adequate time with a client who is verbally abusive, the
nurse is demonstrating the ethical principle of justice. When the nurse spends an
appropriate amount of time with each client regardless of their behavior and in
keeping with their individual needs, the nurse guarantees that all clients receive
equal care.
37. A nurse is teaching the partner of a client who has bipolar disorder how to
identify manifestations of acute mania. Which of the following findings should the
client's partner report to the provider?
A. Obsessive attention to detail
B. Inability to sleep
C. Reports of fatigue
D. Isolation from others
Answer: B. Inability to sleep
Rationale: During acute mania, the client is extremely active and does not sleep,
which can lead to exhaustion. Therefore, the nurse should instruct the partner to
report this finding.
38. A nurse on a medical-surgical unit is assessing a client who sustained injuries
12 hr ago following a motor-vehicle crash. The client's admission blood alcohol
level was 325 mg/dL. Which of the following findings should indicate to the nurse
that the client is experiencing alcohol withdrawal?
A. Somnolence
B. Blood pressure 154/96 mm Hg
C. Pinpoint pupils
D. Blood glucose 210 mg/dL
Answer: B. Blood pressure 154/96 mm Hg
Rationale: Physical manifestations of alcohol withdrawal occur in addition to
psychological effects. A client who is experiencing alcohol withdrawal is expected
to have hypertension, tachycardia, and fever greater than 38.3°C (101° F). It will
be important for the nurse to rule out infection in the client who has a fever.
39. A nurse is performing a cognitive assessment to distinguish delirium from
dementia in a client whose family reports episodes of confusion. Which of the
following assessment findings supports the nurse's suspicion of delirium?
A. Slow onset
B. Aphasia
C. Confabulation
D. Easily distracted
Answer: D. Easily distracted
Rationale: Extreme distractibility is a hallmark manifestation of delirium.
40. A nurse is caring for an older adult client who begins to cry and states, "I knew
God would punish men and I deserve this horrible sickness!" Which of the
following responses should the nurse make?
A. "Why do you think you deserve this punishment?"
B. "Don't worry about being punished by God."
C. "Let's talk about what is upsetting you."
D. "You shouldn't say things that will upset you so much."
Answer: C. "Let's talk about what is upsetting you."
Rationale: The nurse is acknowledging the client's concerns and is showing a
desire to understand what the client is thinking and feeling.
41. A nurse is caring for a child who has conduct disorder and is behaving in a
destructive manner, throwing objects, and kicking orders. Which of the following
therapeutic nursing interventions is the priority?
A. Encourage expression of feelings
B. Support the child's attendance at an assertiveness training group
C. Assist the child to perform relaxation breathing
D. Reduce environmental stimuli
Answer: D. Reduce environmental stimuli
Rationale: The greatest risk to the child and others is harm. Therefore, the nurse's
priority intervention is to reduce environmental stimuli in an attempt to de-escalate
the behavior and prevent injury.
42. A nurse is caring for a client who gave birth to a stillborn baby. Which of the
following statements should the nurse make?
A. "you probably want to hold your baby"
B. "I'll stay with you just in case you want to talk."
C. "I know how you must be feeling."
D. "It hurts now, but things will be better soon."
Answer: B. "I'll stay with you just in case you want to talk."
Rationale: This response demonstrates the therapeutic communication techniques
of offering self and indicates the nurse's interest in the client and a desire to
understand the client's feelings.
43. A nurse in a mental health clinic is caring for a client who has post-traumatic
stress disorder (PTSD) after returning from military deployment. Which of the
following is the priority action for the nurse to take?
A. Assist the client to identify personal areas of strength.
B. Encourage the client to talk about experiences during the deployment.
C. Stay with the client when flashbacks occur.
D. Teach the client stress-management techniques.
Answer: C. Stay with the client when flashbacks occur.
Rationale: The greatest risk to this client is injury that can occur during a
flashback; therefore, the priority intervention for the nurse is to remain with the
client and offer reassurance and support when flashbacks occur.
44. A nurse is caring for an older adult client who is experiencing delirium. Which
of the following interventions should the nurse include in the client's plan of care?
A. Offer the clients various choices for meal selection
B. Assign different nursing personnel for each shift
C. Permit the client to perform daily rituals to decrease anxiety
D. Maintain an environment that has low lightning
Answer: C. Permit the client to perform daily rituals to decrease anxiety
Rationale: A. Offer the clients various choices for meal selection - A RN should
provide a pt w/ delirium a plan of care that decreases agitation and anxiety by
limiting the choices a pt is asked to make.
B. Assign different nursing personnel for each shift - Plan of care should provide
consistent nursing personnel.
C. Permit the client to perform daily rituals to decrease anxiety - The nurse should
provide a client who has delirium with a plan of care that decreases agitation and
anxiety by permitting the client to perform daily rituals.
D. Maintain an environment that has low lightning - RN should provide well -lit
environment.
45. A nurse is teaching coping strategies to a client who is experiencing depression
related to partner violence. Which of the following statements by the client
indicates an understanding of the teaching?
A. "I will spend extra time at work to keep from feeling depressed."
B. "I will talk about my feelings with a close friend."
C. "I will be able to learn how to prevent my partner's attacks."
D. "I will use meditation instead of taking my antidepressant."
Answer: B. "I will talk about my feelings with a close friend."
Rationale: Discussing feelings, such as fear and depression, with a support person
is an effective coping strategy and can provide the client with emotional support
and other resources.
46. A nurse is teaching the guardians of a client about their adolescent child's
diagnosis of bulimia nervosa. Which of the following statements made by the
guardians indicates an understanding of their client's illness?
A. "This disease will increase our child's risk for high blood pressure."
B. "It is important for our child to have regular dental checkups."
C. "We need to weigh our child daily for several weeks, then once per week."
D. "Bleeding during our child's periods will increase because of this disease."
Answer: B. "It is important for our child to have regular dental checkups."
Rationale: For a client who has bulimia nervosa, repeated vomiting erodes tooth
enamel and predisposes the teeth to caries. Thus, the nurse should teach the
guardians that regular dental checkups are important for a client who has bulimia
nervosa
47. A nurse is teaching a group of newly licensed nurses about the use of
mechanical restraints. Which of the following information should the nurse include
in the teaching?
A. Complete documentation about the client's status every hour while they are in
restraints.
B. Maintain the client in restraints for a minimum of 4 hr.
C. Apply restraints when other means of managing the client's behavior have
failed.
D. Request that the provider assess the client within 8 hr of the application of
restraints.
Answer: C. Apply restraints when other means of managing the client's behavior
have failed.
Rationale: According to the Patient Self-Determination Act, clients have a right to
be free from restraints or seclusion unless the safety of the client or others is at
risk. De-escalation methods for controlling behavior should be attempted prior to
initiating restraints.
48. A nurse on a mental health unit observes a client who has acute mania hit
another client. Which of the following actions should the nurse take first?
A. Call the provider to obtain an immediate prescription for restraint.
B. Prepare to administer benzodiazepine IM.
C. Call for a team of staff members to help with the situation.
D. Check the client who has was hit for injuries.
Answer: C. Call for a team of staff members to help with the situation.
Rationale: The greatest risk is injury to the client and others. Therefore, the first
action the nurse should take is to call for assistance to prevent further injury to
themselves or others.
49. A nurse in a mental health clinic is planning care for four clients. Which of the
following tasks should the nurse delegate to assistive-personnel (AP)?
A. Discuss outpatient resources with a client who has post-traumatic stress
disorder.
B. Create a plan of care for a client who is experiencing alcohol withdrawal.
C. Explain sleep hygiene to a client who has insomnia.
D. Stay with a client who has anorexia nervosa for 1 hr after mealtimes.
Answer: D. Stay with a client who has anorexia nervosa for 1 hr after mealtimes.
Rationale: Staying with a client who has anorexia nervosa following mealtimes is
within the range of function of an AP. APs are allowed to attend to the safety of
clients who are stable, and this task does not require assessment or technical skill.
50. A nurse is receiving change-of-shift report for four clients. Which of the
following clients should the nurse plan to see first?
A. A client who has avoidant personality disorder and refuses to attend group
therapy
B. A client who has bipolar disorder and reports being kidnapped by aliens
overnight
C. A client who is taking bupropion and reports having insomnia the past 2 nights
D. A client who is taking clozapine and reports a sore throat and chills
Answer: D. A client who is taking clozapine and reports a sore throat and chills
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse
should determine to first see the client who is taking clozapine and reports a sore
throat and chills. Clozapine can cause agranulocytosis, a serious adverse effect that
causes neutropenia. The nurse should withhold the medication and notify the
provider of these findings.
51. A nurse is preparing to discharge to home an older adult client who attempted
suicide. The client lives alone and has difficulty performing ADLs. Which of the
following referrals should the nurse initiate? SATA
A. Occupational therapy
B. Meal delivery services
C. Speech-language pathologist
D. Physical therapy
E. Home health services
Answer: A. Occupational therapy
Rationale: A. Occupational therapy - Occupational therapy is correct. An
occupational therapist can assist the client to perform ADLs.
B. Meal delivery services - Meal delivery services is correct. Meal delivery
services are necessary due to the client's difficulty performing ADLs.
C. Speech-language pathologist - There is no indication that the client needs a
referral for a speech-language pathologist. Only if they had difficulty swallowing.
D. Physical therapy - Physical therapy is correct. A physical therapist can assess
the client's mobility needs and assist with ADLs.
E. Home health services - Home health services is correct. Home health services
provide a nursing assessment of the client's physical and mental status, as well as
assistance with ADLs.
52. A nurse is assessing a client for risk factors for the development of depression.
The nurse should identify that which of the following factors places the client at an
increased risk for depression?
A. The client is married - Not a risk.
B. The client recently received a promotion at work - Presence of a negative life
event rather than a positive life event is a risk factor for development of
depression.
C. The client has COPD
D. The client is a male - Female, not males, are at higher risk.
Answer: C. The client has COPD
Rationale: A. The client is married - Not a risk.
B. The client recently received a promotion at work - Presence of a negative life
event rather than a positive life event is a risk factor for development of
depression.
C. The client has COPD - The nurse should identify that clients who have a chronic
medical illness are at an increased risk for the development of depression.
D. The client is a male - Female, not males, are at higher risk.
53. A nurse is planning prevention strategies for partner violence in the community.
Which of the following strategies should the nurse include as a method of
secondary prevention?
A. Provide teaching about the use of positive coping mechanisms.
B. Establish screening programs to identify at-risk clients.
C. Refer survivors of intimate partner abuse to a legal advocacy program.
D. Organize rehabilitation therapy for clients who have experienced intimate
partner abuse.
Answer: B. Establish screening programs to identify at-risk clients.
Rationale: A. Provide teaching about the use of positive coping mechanisms. This is an ex of primary prevention. Positive coping mechanisms help pt’s and
their partners cope with stress and help to prevent the incidence of partner violence
in the community.
B. Establish screening programs to identify at-risk clients. - This is an example of
secondary prevention. By establishing screening programs, the nurse can identify
individuals who are at risk for partner violence in the community and can take the
necessary steps to address individual client needs.
C. Refer survivors of intimate partner abuse to a legal advocacy program. - This is
tertiary prevention. This takes place after the violence has occurred.
D. Organize rehabilitation therapy for clients who have experienced intimate
partner abuse. - This is an ex of tertiary prevention. This takes place after partner
violence has occurred & facilitates support and rehab for the pt.
54. A nurse is preparing to administer diazepam 7.5 mg IV bolus to a client for
alcohol withdrawal. Available is diazepam injection 5 mg/mL. How many mL
should the nurse administer? (Round the answer to the nearest tenth. Use a leading
zero if it applies. Do not use a trailing zero.)
Answer: x mL = 1.5
Follow these steps for the Desired Over Have method of calculation:
Step 1: What is the unit of measurement the nurse should calculate? mL
Step 2: What is the dose the nurse should administer? Dose to administer = Desired
7.5 mg
Step 3: What is the dose available? Dose available = Have 5 mg
Step 4: Should the nurse convert the units of measurement? No
Step 5: What is the quantity of the dose available? 1 mL
Step 6: Set up an equation and solve for X. X = (Desired × Quantity) / Have X =
(7.5 mg × 1 mL) / 5 mg X mL = 1.5
Step 7: Round if necessary.
Step 8: Determine whether the amount to administer makes sense. If there are 5
mg/mL and the prescription reads 7.5 mg, it makes sense to administer 1.5 mL.
The nurse should administer diazepam 1.5 mL IV bolus.
55. A nurse in a community health center is teaching families of clients who have
post-traumatic stress disorder (PTSD) about expected clinical manifestations.
Which of the following manifestations should the nurse include?
A. Repeatedly talks about the traumatic incident
B. sleeps excessively
C. experiences feelings of isolation
D. uses repetitive speech
Answer: C. experiences feelings of isolation.
Rationale: The nurse should expect clients who have PTSD to feel estranged and
detached from others.
56. A nurse is facilitating a community meeting for acute care clients. One client is
constantly talking and using the majority of the group's time. Which of the
following interventions should the nurse implement?
A. Tell the client to talk less or risk being removed from the meeting.
B. Ask group members to discuss their feelings about this client's monopolizing
behavior.
C. End the group meeting and take the client aside to discuss the disruptive
behavior.
D. Focus on other group members and ignore the client who is doing all the
talking.
Answer: B. Ask group members to discuss their feelings about this client's
monopolizing behavior.
Rationale: This intervention will validate other members' feelings toward the
client who is dominating the meeting. It also should encourage group problemsolving.
57. A nurse is caring for four clients in an emergency department. The nurse should
identify that which of the following clients can give informed consent?
A. A 17-year-old client who lives with friends
B. A 50-year-old client who has a blood alcohol level of 80 mg/dL
C. A 35-year-old client who has major depressive disorder
D. A 65-year-old client who just received a dose of morphine
Answer: C. A 35-year-old client who has major depressive disorder
Rationale: A client who has major depressive disorder is capable of making health
care decisions unless the client is determined to be legally incompetent.
58. A nurse in a community health center is working with a group of clients who
have post-traumatic stress disorder. Which of the following interventions should
the nurse include to reduce anxiety among the group members?
A. Response prevention
B. Guided imagery
C. Aversion therapy
D. Light therapy
Answer: B. Guided imagery
Rationale: Guided imagery involves assisting the client to imagine a restful and
safe place. This method is effective in reducing anxiety in clients who have posttraumatic stress disorder.
59. A client who has a recent diagnosis of bipolar disorder is placed in a room with
a client who has severe depression. The client who has depression reports to the
nurse, "My roommate never sleeps and keeps me up, too." Which of the following
actions should the nurse take?
A. Move the client who has bipolar disorder to a private room.
B. Administer sleep medication to the client who has bipolar disorder.
C. Move the client who has severe depression to a private room. This pt is at risk
for self-harm and feel isolated, moving this pt is not a good idea.
D. Administer sleep medication to the client who has severe depression.
Answer: A. Move the client who has bipolar disorder to a private room.
Rationale: Clients who have bipolar disorder can disrupt the therapeutic milieu for
other clients. Therefore, the nurse should move this client to a private room.
60. A nurse is reviewing laboratory results for a client who has schizophrenia and
is taking clozapine. Which of the following values should the nurse identify as a
contraindication for receiving clozapine
A. WBC count 2,500/mm
B. Hgb 11.5 mg/dL
C. Platelets 150,000/mm
D. RBC count 3.5 million/mm
Answer: A. WBC count 2,500/mm3
Rationale: A. WBC count 2,500/mm3 - Clozapine can cause agranulocytosis,
which can be fatal due to overwhelming infection. The nurse should identify a
WBC count of less than 3,000/mm3 as a possible manifestation of agranulocytosis
and should withhold the medication and notify the provider.
B. Hgb 11.5 mg/dL - This drug doesn’t affect Hgb levels.
C. Platelets 150,000/mm - This is WNL.
D. RBC count 3.5 million/mm - This drug does not affect RBC levels.
