Preview Extract
{NGN} MENTAL HEALTH |ATI RN MENTAL HEALTH
ACTUAL EXAM WITH NGN QUESTIONS AND CORRECT
ANSWERS WITH RATIONALES 2023-2024 UPDATE
ALREADY A GRADED
1. A nurse is admitting a patient with schizophrenia to an acute care setting. When the nurse
questions the patient regarding their admission, the client states, "I'm red, in the head, and I'm
going to bed!" The nurse should document the client's speech pattern as which of the following?
a. Clang association
b. Word salad
c. Neologism
d. Echolalia
a. Clang association
Answer: a. Clang association
Rationale:
a. The nurse should document that the patients speech uses clang associations which often rhyme
or contain a string of words that can have a similar sound
b. In word salad, words are completely meaningless and disorganized.
c. Neologism consists of words that are made up by the patient
d. In echolalia, the patient repeats the words of another person
2. A nurse is assessing a patient who has schizophrenia. Which of the following findings should
the nurse document as a negative symptom of this disorder?
a. Delusions
b. Neologisms
c. Anhedonia
d. Echopraxia
Answer: c. Anhedonia
Rationale:
Positive symptoms of schizophrenia usually appear suddenly and are alteration in behavior,
perception, speech, and thought. Delusions, inability to think abstractly, neologisms (made up
words), echolalia (repeating of someone else's words, motor agitation, and echopraxia
(mimicking someone else's movements) are all positive symptoms of schizophrenia.
Negative symptoms of schizophrenia affect a person's ability to interact with others and are less
dominant than positive symptoms. Negative symptoms develop over time.
Examples of negative symptoms include flat affect, anergia (lack of energy), anhedonia (inability
to enjoy otherwise pleasurable activities), and thought blocking (inability to think, speak, or
move in response to outside stimuli)
3. A nurse is delegating patient care tasks to a licensed practical nurse (LPN) and an assistive
personnel. Which of the following tasks should the nurse assign to the LPN?
a. Administering oral medications
b. Performing range-of-motion exercises
c. Assisting a patient with bathing
d. Collecting a urine specimen
e. Change the dressing of a client who has borderline personality disorder and superficial selfinflicted wounds
Answer: c. Change the dressing of a client who has borderline personality disorder and
superficial self-inflicted wounds
Rationale:
A patient who has borderline personality disorder is at risk for self-mutilation such as cutting,
self-inflicted wounds, scratching or picking at wounds. It is within the LPNs scope of practice to
change the dressing, cleanse the wound, and collect data regarding the healing of the wound.
4. A nurse is assessing a school-age child who has conduct disorder. Which of the following
characteristics should the nurse expect the child to demonstrate?
a. Feelings of remorse
b. Extended periods of depression
c. Deficits in intellectual functioning
d. Aggression towards animals
Answer: d. Aggression toward animals
Rationale:
d. The nurse should identify that aggression toward people and animals is an expected
characteristic of a child who has conduct disorder
a. The nurse should identify that lack of remorse is an expected characteristic of a child who has
conduct disorder
b. The nurse should identify that a child who has bipolar disorder is likely to have extended
periods of depression. This is not an expected characteristic of a child who has conduct disorder
c. The nurse should identify that a child who has intellectual deficit disorder exhibits deficits in
intellectual functioning, such as reasoning, abstract thinking, and academic ability. A deficit in
intellectual functioning is not an expected characteristic of a child who has conduct disorder
5. A nurse in a mental health clinic is planning care for a client who has a new prescription for
Olanzapine. Which of the following interventions should the nurse identify as the priority?
Answer: Instruct the client to avoid driving during initial therapy
Rationale:
The greatest risk to the patient is injury resulting from drowsiness or dizziness. Therefore, the
nurse's priority intervention is to instruct the patient to avoid activities that require mental
alertness during initial medication therapy
6. A nurse is caring for a patient who has a history of substance use disorder and was
involuntarily admitted to a mental health facility. When the nurse attempts to administer oral
Lorazepam, the patient refuses to take the medication and becomes physically aggressive. Which
of the following actions should the nurse take?
a. Do not administer the Lorazepam
b. Request a prescription for IV lorazepam
c. Request that another nurse attempt to administer the lorazepam
d. Place the lorazepam in the patient's food
Answer: a. Do not administer the Lorazepam
Rationale:
a. Patients who are in a facility due to an involuntary admission retain the right to refuse
treatment. Therefore, the nurse should hold the medication and document the patient's refusal
b. Requesting a prescription for and administering IV lorazepam violates the patient's right to
refuse treatment
c. Requesting that another nurse administer the lorazepam violates the patient's right to refuse
treatment
d. Placing the lorazepam in the patient's food violates the patient's right to refuse treatment
7. A nurse is caring for a patient who has schizophrenia and is experiencing psychosis. The nurse
should identify that which of the following findings indicates a potential psychiatric emergency?
a. The patient is exhibiting echolalia
b. The patient reports command hallucinations
c. The patient reports loss of motivation
d. The patient is exhibiting blunted affect
Answer: b. The patient reports command hallucinations
Rationale:
b. The nurse should identify that command hallucinations can indicate a potential psychiatric
emergency for a patient who has schizophrenia. Command hallucinations can direct the patient
to harm themselves or others.
a. The nurse should identify that echolalia, or the repeating of another's words, is an expected
manifestation of schizophrenia
c. The nurse should identify that a loss of motivation, or avolition, is an expected manifestation
of schizophrenia
8. A nurse is assessing a patient who has borderline personality disorder. Which of the following
findings should the nurse expect?
a. Emotional lability
b. Self-sacrificing
c. Suspicious of others
d. Grandiosity
Answer: a. Emotional lability
Rationale:
It is the rapid transition from one emotion to another and is a primary feature of borderline
personality disorder. Patients who have BPD react to situations with emotional responses that are
out of proportion to the circumstances.
9. While observing group therapy, a nurse recognizes that a patient is behaving in a way
suggestive of dependent personality disorder. Which of the following behaviors is consistent
with this condition?
Answer: The patient needs excessive external input to make everyday decisions
Rationale:
patients who have dependent personality disorder need excessive input from others to make
everyday decisions
10. A home health nurse is assessing an older adult patient whose sibling is the primary
caregiver. Which of the following findings should the nurse identify as a possible indicator of
neglect?
a. Increased confusion
b. Sleep disturbances
c. Cluttered environment
d. Inappropriate dress
Answer: d. Inappropriate dress
Rationale:
d. Clothing that is soiled or not appropriate for weather conditions is a possible indicator of
neglect
a. Increased confusion is an indicator of psychological abuse
b. Sleep disturbances are an indicator of psychological abuse
c. A cluttered environment is not an indicator of neglect
11. A nurse is establishing a therapeutic relationship with a patient who has antisocial personality
disorder. Which of the following strategies should the nurse use when communicating with this
client?
Answer: Set realistic limits on the clients behavior
Rationale:
Patients who have antisocial personality disorder can seem to be in control of their behavior, but
are manipulative and impulsive and can suddenly become aggressive and assaultive. The nurse
should establish clear limits on specific aggressive and demanding behaviors.
12. A nurse in the emergency department is caring for a patient who has alcohol toxicity and is
unresponsive. Which of the following interventions should the nurse take?
Answer: Gather supplies for endotracheal intubation
Rationale:
The nurse should gather supplies for endotracheal intubation because an expected finding of an
unresponsive patient who has alcohol toxicity is respiratory depression
13. A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who
weighs 110 lb. Available is chlorpromazine syrup 10 mg/ 5 mL. How many mL should the nurse
administer? ___ mL
Answer: 14mL
Rationale:
110lb/2.2kg 0.55mg/kg 5ml/10mg = 14
14. A nurse is planning care for a patient experiencing acute mania. Which of the following
interventions should the nurse include in the plan to promote sleep?
Answer: Encourage frequent rest periods throughout the day
Rationale:
a patient experiencing acute mania is at risk for sleep disturbances and might go for extended
periods of time without sleep. Encouraging periods of rest throughout the day can limit the risk
of exhaustion.
15. A nurse is reviewing routine laboratory values for several patients who are taking lithium
carbonate. Which of the following patients should the nurse assess further for findings indicating
lithium toxicity?
Answer: A client who has a sodium level of 128 mEq/L
Rationale:
A sodium level of 128 mEq/L should alert the nurse that the patient is at risk for lithium toxicity
because renal excretion of lithium is decreased in the presence of low sodium levels
16. A nurse is admitting a female patient who has anorexia nervosa. Which of the following
manifestations should the nurse expect during the admission assessment?
a. Diarrhea
b. Heavy Menstrual bleeding
c. Tachycardia
d. Orthostatic hypotension
Answer: d. Orthostatic hypotension
Rationale:
d. Low weight, electrolyte imbalances, starvation, and dehydration can cause orthostatic
hypotension
a. Constipation is a manifestation of anorexia nervosa. Decreased food and fluid intake cause
constipation
b. Amenorrhea is a manifestation of anorexia nervosa. Low weight, decreased body fat, and poor
nutrition cause amenorrhea
c. Bradycardia is a manifestation of anorexia nervosa. Starvation and dehydration cause
cardiovascular abnormalities, including bradycardia
17. A nurse in a community health center is counseling a family of two parents and two children.
Which of the following statements by a family member indicates manipulative behavior?
Answer: "If you do my homework for me, I won't bother you for the rest of the day."
Rationale:
This is an example of manipulative behavior. It is an example of this when the family member
uses a behavior to get what they desire rather than directly asking for what they want.
18. A charge nurse is preparing an educational session for a group of newly licensed nurses to
review patient rights under the law. Which of the following statements should the nurse make?
Answer: "In the event a patient threatens to harm others, medications can be administered
without consent"
Rationale:
The charge nurse should inform the participants that their primary commitment is to the patient
and their priority is always to advocate for and protect their health and safety. During an
emergency situation, if the patient is threatening harm themselves or others, medications can be
administered without the patients consent or court order.
19. A patient who has paranoid schizophrenia is attending a treatment planning conference with a
family member. During the discussion of the medication adherence portion of the plan, a nurse
notices that the family member seems distracted. Which of the following actions should the
nurse take?
Answer: Ask the family member is they have any thoughts or questions about the treatment plan
Rationale:
This action involves the family member and allows them a venue to communicate about the
patients medication treatment plan
20. A nurse is caring for a group of patients. For which of the following situations should the
nurse complete an incident report?
Answer: A client was administered one-half of the prescribed dose of medication
Rationale:
An incident report is a recording of any occurrence that does not meet the standard of care. The
nurse should report medication errors using the facility's incident or occurrence form.
21. A nurse is caring for a group of patients. Which of the following findings is the nurse
required to report?
Answer: A client who has borderline personality disorder threatened to harm their roommate
Rationale:
Signs and symptoms of BPD include interpersonal relationships accompanied by threats and
other-directed violence. While it is important for the nurse to maintain the patients
confidentiality, when another individual might be in danger, the nurse is required by law to
report it to authorities.
22. A nurse is caring for a patient who has borderline personality disorder. Which of the
following goals is the priority when planning care for this patient?
a. The patient will take the prescribed medications as scheduled
b. The patient will express feelings of frustration
c. The patient will refrain from self-mutilation
d. The patient will participate in group therapy
Answer: c. The client will refrain from self-mutilation
Rationale:
c. The greatest risk to the patient is injury to self and others. Therefore, the priority goal is for the
patient to refrain from self-mutilation
a. Taking prescribed medications as scheduled to maintain therapeutic blood levels is an
important goal. However, this is not the priority goal
b. Expressing feelings of frustration to acknowledge these feelings is an important goal.
However, this is not the priority goal
d. Participating in group therapy as part of the treatment plan is an important goal. However, this
is not the priority goal
23. A nurse is discussing the home care of a patient who has advanced Alzheimer's disease. The
patient's caregiver is planning to go out of town for several days. Which of the following
resources should the nurse recommended to the caregiver?
a. Respite care
b. Partial hospitalization
c. Adult day care program
d. Geropsychiatric unit
Answer: a. Respite care
Rationale:
a. Respite care programs allow the patient to stay in a nursing facility for a set number of days,
allowing the caregivers to go on vacation or have some time to themselves
b. Partial hospitalization provides services for several hours during the day, but they are not
designed to offer 24-hr care. A patient with advanced Alzheimer's disease is unable to safely
remain at home unattended
c. Adult day care programs can provide services throughout the day to patient's with Alzheimer's
disease, allowing the caregiver the ability to work or have a break. The patient's return home in
the evening. A patient who has advanced Alzheimer's disease is unable to safely remain at home
unattended.
d. A geropsychiatric unit provides care for patients requiring acute psychiatric services due to
sudden mental status changes, psychosis, or other mental health services. These services are
ideal for patients who are at risk of harming themselves or others
24. A nurse is caring for an older adult patient who has dementia and has wandered into the day
room looking for their deceased partner. Which of the following actions should the nurse take?
a. Move the patient to a room near the nurses' station
b. Limit visitors until the patient is oriented to the environment
c. Tell the patient their partner is deceased
d. Talk with the patient about activities they enjoyed with their partner
Answer: d. Talk with the patient about activities they enjoyed with their partner
Rationale:
d. Talking about positive experiences can help distract the patient from their disorientation
a. When caring for a patient with dementia, avoid placing them in unfamiliar settings when
possible.
b. Family members should be encouraged to interact with the patient regardless of the patient's
state of dementia
c. Confrontation should not be used for a disoriented patient
25. A nurse is planning care for a newly admitted patient who has bipolar disorder and is
experiencing mania. Which of the following is the priority action by the nurse?
Answer: Provide frequent high-calorie snacks
Rationale:
The priority action the nurse should take when using Maslow's Hierarchy of Needs, is to meet
the patients need for adequate nutrition. Therefore, providing high-calorie snacks is the priority
action for the nurse to take
26. A nurse is caring for a patient who is experiencing alcohol withdrawal. Which of the
following medications should the nurse administer fist?
Answer: Diazepam 5 mg IV bolus
Rationale:
The greatest risk to the patient who is experiencing alcohol withdrawal are seizures, elevated
HR, and elevated BP. IV diazepam acts rapidly to prevent seizures, stabilize vital signs, and
decrease the intensity or withdrawal manifestations
27. A nurse in a clinic is assessing a patient whose partner died 4 months ago. Which of the
following statements indicates that the client is at risk or complicated grief?
Answer: "I feel so empty without my wife that it's hard to get up every morning."
Rationale:
The nurse should identify that when a patient has difficulty carrying on normal activities
following a loss, this is an indication that there is a risk for complicated grief
28. A nurse in a mental health clinic is caring for a client who has bipolar disorder and reports
that they stopped taking lithium 2 weeks ago. The nurse should recognize which of the following
as an expected adverse effect that might have caused the client to stop taking the medication?
a. Sore throat
b. Photophobia
c. Hand tremors
d. Constipation
Answer: c. Hand tremors
Rationale:
c. Fine hand tremors are an expected adverse effect of lithium and can interfere with
performance of ADLs causing the patient to stop taking the medication
a. A sore throat is not an expected adverse effect of lithium.
b. Photophobia is not an expected adverse effect of lithium.
d. Diarrhea is an early manifestation of lithium toxicity.
29. A nurse is teaching a patient who has a depressive disorder about fluoxetine. Which of the
following information should the nurse include in the teaching?
a. "You might notice an increase in saliva while taking this medication"
b. "You might experience difficulties with sexual functioning while taking this medication"
c. "You should expect an improvement of symptoms of depression in 3 to 4 days"
d. "You may notice a temporary ringing in the ears when starting this medication"
Answer: b. "You might experience difficulties with sexual functioning while taking this
medication."
Rationale:
b. Fluoxetine is an SSRI that can cause sexual dysfunction such as anorgasmia and impotence.
The nurse should instruct the patient to notify MD if sexual dysfunction occurs
a. Fluoxetine does not cause in increase in saliva productions. The nurse should instruct the
patient that they might experience dry mouth while taking fluoxetine
c. The nurse should instruct the patient that improvements in mood takes 1 to 3 weeks or longer
following the initiation of therapy with fluoxetine
d. Fluoxetine does not cause tinnitus. The nurse should instruct the patient that they might
experience visual disturbances, but this medication does not affect the ears
30. A nurse on a mental health unit is admitting a patient who is anxious and tells the nurse, "I
hear voices telling me what to do." Which of the following actions should the nurse take?
a. Tell the patient that the voices do not really exist
b. Touch the patient to help reduce feelings of anxiety
c. Instruct the patient to go to a quiet room when the voices start talking
d. Ask the patient what the voices are saying
Answer: d. Ask the client what the voices are saying
Rationale:
d. It is important for the nurse to ask the patient directly about the hallucinations to determine if
the patient or others are at risk for injury
a. The nurse should avoid negating the patient's hallucination
b. The nurse should avoid touching the patient without first asking for the patient's permission.
Touching the Patient violates one's personal space and can increase, rather than decrease,
feelings of anxiety.
c. The nurse should instruct the patient to listen to music or use other auditory distractions when
the voices are talking
31. A nurse is admitting a patient who has anorexia nervosa and is at 60% of ideal body weight.
Which of the following interventions should the nurse include in the plan of care?
Answer: Encourage the client to drink 125 mL of fluid each hour while awake
Rationale:
The nurse should encourage this to maintain hydration
32. During morning rounds, a nurse finds a patient who has schizophrenia trembling and tearful
in their bed. The patient reports that a bomb was placed in their room by a family member during
visiting hours. Which of the following actions should the nurse take?
Answer: Assess the client for evidence of a perceptual disturbance
Rationale:
The nurse should do this to determine if the patient is hallucinating or misperceiving external
stimuli, also known as experiencing illusions
33. A nurse is caring for a patient who has schizophrenia and began taking a conventional
antipsychotic medication yesterday. Which of the following findings indicates the nurse should
administer benzotropine 2 mg IM?
Answer: Shuffling gait
Rationale:
Benztropine is used to treat Parkinsonism manifestation such as shuffling gait
34. During a patient's initial interview in a mental health inpatient setting, a nurse identifies that
the patient is maintaining eye contact and leaning forward. Which of the following assumptions
should the nurse make based on the patient's nonverbal behaviors?
Answer: The client is interested in what the nurse is saying
Rationale:
The patient's posture and eye contact demonstrates an interest in the interview and what the nurse
is saying
35. A nurse is reviewing the electronic medical record of a patient who has schizophrenia and is
taking clozapine. Which of the following findings is the priority for the nurse to notify the
provider?
Answer: The patient reports an inability to breathe easily
Rationale:
Serious adverse effects, such as HF, myocarditis, and PE are associated with clozapine. When
using the greatest first framework, the nurse should identify that the greatest risk to the patient, is
dyspnea, which is a manifestation of respiratory or cardiac alterations, and should be reported to
the provider.
36. A nurse is reviewing the medical record of a patient who has anorexia nervosa. Which of the
following findings should the nurse identify as an indication the patient requires hospitalization?
Answer: Total body fat 8.7%
Rationale:
The nurse should recognize that criteria for hospitalization includes having a weight less than
75% of ideal body weight, or less than 10% body fat. The nurse should report this finding to the
provider.
37. A nurse is caring for a patient in a mental health facility. The nurse overhears another staff
member make derogatory comments to the patient. Which of the following actions should the
nurse take?
a. Confront the staff member
b. Encourage the patient to report the incident
c. Document the incident in the patient's health record
d. Report the occurrence to the charge nurse
Answer: d. Report the occurrence to the charge nurse
Rationale:
d. It is the charge and nurse manager's responsibility to confront the staff member about the
derogatory comments made to the patient
a. It is not the responsibility of the nurse to discipline other staff members
b. This action takes the responsibility away from the nurse who has overheard the comments
c. The incident should not be documented in the patient's health record
38. A nurse is planning care for a patient who has depression and has made frequent suicide
attempts. Which of the following statements indicates the patient has a decreased risk for
suicide?
a. "I'm relieved now that my financial affairs are in order"
b. "It is easier to talk about my feelings now."
c. "Suddenly, I have enough energy to do anything I want"
d. "Thank you for always taking such good care of me"
Answer: b. "It is easier to talk about my feelings now."
Rationale:
b. When patient express their feelings, this indicates a positive treatment outcome
a. When patients who have depression verbalize getting their affairs in order, they are at an
increased risk for suicide
c. When patients who have depression suddenly have more energy, they are at an increased risk
for suicide
d. Patients who have depression often show an appreciation for loved ones when they are
contemplating suicide
39. A nurse in a mental health facility is planning discharge for a patient who has a history of
alcohol use disorder. Which of the following post discharge activities should the nurse plan to
include?
Answer: Attending a relapse prevention group several times each week
Rationale:
The nurse should identify that the most effective strategy for relapse prevention is a 12 step
program such as AA
40. A nurse in an emergency department is admitting a patient who reports experiencing
headache and heart palpitations after having a glass of wine 1 hr ago. The client has a history of
depression, a current blood pressure of 210/105 mm Hg, and a temperature of 39.9 C (103.8 F).
Which of the following actions should the nurse take first?
Answer: Determine the patient's prescribed medication regimen
Rationale:
The first action of the nurse should be, using the nursing process, is to assess the patient. By
determining the patient's prescribed meds, the nurse can determine the cause of HTN such as the
patient taking an MAOI to treat depression. These meds can precipitate a HTN crisis if
consumed with tyramine containing foods, including wine.
41. A community health nurse is planning an education program about depressive disorders.
Which of the following factors should the nurse include as increasing the risk for depression?
a. Male gender
b. Hyperthyroidism
c. Substance use disorder
d. Being married
Answer: c. Substance use disorder
Rationale:
c. The nurse should identify that patients who have substance use disorder are at an increased
risk for the development of depressive disorders
a. The nurse should identify that female patients are at an increased risk for the development of
depressive disorders
b. The nurse should identify that patients who have hypothyroidism are at an increased risk for
the development of depressive disorders
d. The nurse should identify that patients who are single are at an increased risk for the
development of depressive disorders
42. A nurse is planning discharge for a patient who has bipolar disorder and has a prescription for
lithium. Which of the following patient statements indicates understanding of the teaching about
the medication?
Answer: "I should eat a regular diet with normal amounts of salt and fluids."
Rationale:
The nurse should identify that this statement indicates that the patient understands the teaching
because normal levels of sodium and fluid need to be maintained to ensure adequate excretions
of lithium. If sodium levels are low, the body compensates by decreasing lithium excretion,
which can lead to toxicity
43. A nurse is providing teaching to a patient who is to begin undergoing light therapy at home.
Which of the following information should the nurse include in the teaching?
a. Ensure a family member can be present during treatment
b. Increase fluid intake 24 hr before the treatment starts
c. Change position slowly when the treatment is complete
d. Avoid looking directly at the light during treatment
Answer: d. Avoid looking directly at the light during treatment.
Rationale:
d. Light therapy, or phototherapy can cause sensitivity to light. To minimize this effect, the
patient should avoid looking directly at the light
a. This precaution is not necessary for light treatment therapy
b. Light therapy does not increase the risk of dehydration
c. Light therapy is unlikely to cause otthostatic hypotension or dizziness
44. A nurse is planning care for a 7-year-old child who has ADHD. Which of the following
interventions should the nurse identify as the priority?
Answer: Remove unnecessary equipment from the child's surroundings
Rationale:
The greatest risk to the child who has ADHD is injury from impulsive behavior and the
decreased ability to perceive self-harm. Therefore the priority intervention is to remove
unnecessary equipment from the child's surrounding
45. A nurse is planning care for an adolescent who is being admitted to an acute care unit
following a suicide attempt. Which of the following interventions should the nurse identify as
the priority?
a. Arrange one-to-one observation of the patient
b. Encourage interaction with the patient's peers
c. Administer medication for depressive disorder
d. Encourage the patient to attend group support
Answer: a. Arrange one-to-one observation of the patient
Rationale:
a. The greatest risk to the patient is self-injury. Therefore, the priority nursing intervention is 1:1
observation to promote patient safety
b. Encouraging patient to interact with peers is important to facilitate socialization. However,
another intervention is the priority
c. Administering medication for depressive disorder is important to increase the patient's mood
over time. However, another intervention is the priority
d. Encouraging the patient to attend a support group is important. However, another intervention
is the priority
46. A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) and will
receive succinylcholine. The patient asks the nurse about this medication. Which of the
following responses should the nurse make?
a. "Succinylcholine will enhance the therapeutic effects of this treatment"
b. "Succinylcholine is given to reduce muscle movement during therapy."
c. "Succinylcholine will decrease the anxiety level that you might experience with this treatment"
d. "Succinylcholine is used as a general anesthetic to make sure you are sleeping during the
procedure"
Answer: b. "Succinylcholine is given to reduce muscle movement during therapy."
Rationale:
b. It is a muscle-paralyzing agent that will decrease muscle movement during the procedure so
the patient is less likely to be injured
a. The purpose of succinylcholine is not to increase the therapeutic effects of ECT.
c. Succinylcholine is not an antianxiety agent.
d. Succinylcholine is not a general anesthetic.
47. A nurse is planning care for a patient who has schizophrenia and reports auditory
hallucination. Which of the following interventions should the nurse include in the plan?
Answer: Promote the use of music to compete with the patient's auditory hallucinations
Rationale:
Competing reality-based stimulation such as the use of music or televisions during auditory
hallucinations can assist in limiting the effect the hallucination on the patient's stress level
48. A nurse is obtaining a mental health history from an older adult patient. Which of the
following actions should the nurse plan to take?
a. Raise the pitch of voice when speaking to the patient
b. Begin the interview by explaining the plan of care
c. Interview the patient in a private setting
d. Ask the patient to complete a detailed questionnaire
Answer: c. Interview the patient in a private setting
Rationale:
c. The nurse should interview patient in a private place when asking questions regarding patient
health
a. The nurse should use a lower pitch of voice when speaking because older adult patients are
typically able to hear words that are spoken with a lower pitch
b. The nurse should begin the interview by asking the patient to identify their needs and
concerns. The data is then used to create a personalized plan of care.
d. The nurse should limit the number of items on a questionnaire when getting data from an older
adult client
49. A nurse is caring for a patient who is experiencing a situational crisis. Which of the following
findings should the nurse expect?
Answer: The patient recently lost a grandparent in a motor vehicle crash
Rationale:
the patient experiences a situational crisis when an unexpected event occurs
50. A nurse in a n outpatient mental health setting is collecting a health history from a patient
who is taking paroxetine for depression. the patient reports to the nurse that he also takes herbal
supplements. The nurse should advise the patient that which of the following supplements
interacts adversely with paroxetine?
a. St. John's wort
b. Saw palmetto
c. Echinacea
d. Ginkgo
Answer: a. St. John's wort
Rationale:
a. This is an herbal preparation that decreases the reuptake of serotonin. the nurse should advise
the patient that taking st. john wort with another med that also inhibits the reuptake of serotonin,
such as paroxetine places the patient at risk for serotonin syndrome
b. Saw palmetto is used to treat benign prostatic hyperplasia. This does not interact adversely
with paroxetine
c. Echinacea is used to enhance immune function. It does not interact adversely with paroxetine
d. Ginkgo is used to relieve pain from peripheral arterial disease. It does not interact adversely
with paroxetine
51. A nurse is admitting a patient who has alcohol use disorder. Which of the following
statements by the patient indicates that the patient is using denial as a defense mechanism'?
a. "I put in extra hours at work so I won't think about drinking"
b. "I know that wine is good for my heart, so that's why I drink some each evening"
c. "I make up for my drinking by taking my partner on nice vacations"
d. "I am able to go to work every day, so I don't have a problem"
Answer: d. "I am able to go to work every day, so I don't have a problem."
Rationale:
d. by insisting that their drinking is not a problem by they can go to work every day, the patient
is using the defense mechanism of denial. this allows the patient to ignore the existence of their
substance use disorder
a. A patient who who consciously avoids thinking about uncomfortable feelings or thoughts is
using the defense mechanism of suppression
b. By relating their drinking ever evening to their heart health, the patient is using the defense
mechanism of rationalization
c. A patient who attempts to make up for an undesirable act by doing something positive is using
the defense mechanism of undoing
52. A nurse is assessing a patient who recently used cocaine. Which of the following findings
should the nurse expect?
Answer: Hypertension
Rationale:
cocaine is a stimulant that increases BP. it also increases HR, body temp, energy levels, and
metabolism
53. A nurse is communicating with a patient in an inpatient mental health facility. Which of the
following actions by the nurse demonstrates the use of active listening?
a. Offering self
b. Use of silence
c. Attention to body language
d. Reflection of feelings
Answer: c. Attention to body language
Rationale:
c. use of active listening involves identifying verbal and nonverbal communication by the
patient, which includes attention to body language
a. The nurse uses this therapeutic technique to demonstrate genuine interest in the patient
b. The nurse uses this therapeutic technique to demonstrate willingness to wait for the patient's
response
d. The nurse uses this therapeutic technique to encourage the patient to acknowledge their
feelings
54. A patient who has a diagnosis of depression is attending group therapy. During the group
meeting, the nurse asks each member to identify one goal for the day. When it is the patient's
turn they do not respond. Which of the following actions should the nurse take before repeating
the request to the client?
a. Allow for the patient time to formulate an answer
b. Prompt the patient to have a response
c. Move on to the next patient
d. Offer the patient a suggestion for a goal
Answer: a. Allow the client time to formulate an answer
Rationale:
a. Slowed response time is common in patients who have depression. The nurse should allow the
patient time to comprehend and formulate an answer to the question
b. A patient who has depression might have a slow response rate. Prompting can place pressure
on the patient
c. Skipping the patient might minimize the patient's involvement in the group process and cause
additional difficulty when answering the question
d. A patient who has depression is able to make decisions as necessary. Therefore, the nurse
should not deny the patient this ability to participate in the group therapy
55. A nurse is documenting admission assessment findings for a patient who has major
depressive disorder. The nurse should identify which of the following findings as clinical
manifestations? (Select all that apply.)
a. Feelings of hopelessness
b. Anhedonia
c. Flat facial expression
Answer: a. Feelings of hopelessness
b. Anhedonia
c. Flat facial expression
Rationale:
the nurse should document feelings of hopelessness as a clinical manifestation of MDD. the
nurse should document the inability to experience pleasure as a S/s of MDD. the nurse should
document a flat facial expression as a clinical S/S of MDD.
56. A nurse in a provider's office is collecting a health history from the guardian of a school-age
child who has been taking atomoxetine. Which of the following adverse effects reported by the
guardian is the priority for the nurse to report to the provider?
a. Reduced appetite
b. Fatigue
c. Dark urine
d. Sweating
Answer: c. Dark urine
Rationale:
c. The greatest risk for the child is liver damage from atomoxetine, which can progress to liver
failure and death. Therefore, this is the nurse's priority finding.
a. Although reduced appetite is an adverse effect of this medication and the child should be
weighed regularly to monitor this adverse effect, another finding is the nurse's priority
b. Although fatigue is an adverse effect of this medication, another finding is the nurse's priority
d. Although sweating is an adverse effect of this medication, another finding is the nurse's
priority
57. A nurse is caring for a patient who has antisocial personality disorder and is receiving
behavioral therapy through operant conditioning. Which of the following patient behaviors
indicates effectiveness of the therapy?
a. Controls anger outbursts to avoid being placed in seclusion
b. No longer exhibits a fear of social or public situations
c. Refrains from manipulating other to earn their dining room privileges
d. Imitates the therapist's use of relaxation technique
Answer: c. Refrains from manipulating others to earn dining room privileges
Rationale:
c. The goal of operant conditioning is to provide positive reinforcement in return for a desired
behavior. Refraining from manipulative behavior is a desired response
a. Changing behavior to avoid punishment us not an optimal goal of operant conditioning
therapy
b. There is no evidence that this patient has social phobia. Phobias are usually treated with
desensitization therapy
d. Imitating behavior is modeling and does not demonstrate the desired outcome of operant
conditioning
58. A nurse is caring for a patient who has a recent diagnosis of mild Alzheimer's disease. The
patient's partner asks the nurse about expected manifestations. The nurse should teach the partner
to expect which of the following manifestations to occur first?
a. Inability to recognize family members
b. Chooses clothing that is inappropriate for the weather
c. Exhibits a change in personality
d. Frequently misplaces objects
Answer: d. Frequently misplaces objects
Rationale:
d. according to EBP the nurse should identify that mild cognitive impairment, such as frequently
misplacing objects is one of the first manifestations expected to occur for a patient who has
Alzheimer's disease. As the disease progresses, other manifestations of moderate and severe
cognitive impairment will occur.
a. The inability to recognize family members manifests as Alzheimer's disease progresses.
However, EBP indicates that another manifestation is expected to occur first.
b. Difficulty choosing clothing that is appropriate for the weather manifests as Alzheimer's
disease progresses. However, EBP indicates that another manifestation is expected to occur first.
c. A change in personality manifests as Alzheimer's disease progresses. However, EBP indicates
that another manifestation is expected to occur first.
59. A nurse is caring for a group of patient. Which of the following findings should the nurse
report?
a. A patient who is taking clozapine and has a WBC count of 7,500/mm3
b. b. A patient who is taking lamotrigine and has developed a rash
c. A patient who is taking valproate and has a platelet count of 150,000/mm3
d. A patient who is taking lithium and has a lithium level of 1.2mEq/L
Answer: b. A patient who is taking lamotrigine and has developed a rash
Rationale:
b. Lamotrigine is an anticonvulsant medication that is used as a mood stabilizer. The nurse
should identify that a rash is a potentially life-threatening adverse effect of the medication and
report this finding immediately
a. Clozapine can result in agranulocytosis, a potentially fatal disorder that increases the patient's
risk for infection. However, a WBC count of 7,500/mm3 is within the expected reference range
c. Valproate is a medication used in the treatment of bipolar disorder. The nurse should identify
that decreased platelets is an adverse effect of the medication. However, a platelet count of
150,000/mm3 is within the expected reference range
d. Lithium is a medication used for mood stabilization for patients who have bipolar disorder.
The nurse should identify that the lithium toxicity can result in serious complications, including
death. However, a lithium level of 1.2mEq/L is within the therapeutic range
60. A nurse is caring for a patient whose child has a terminal illness. The patient requests
information about how to deal with the upcoming loss. Which of the following statements should
the nurse make?
a. It will be better for you to keep busy to avoid thinking about your child's death
b. You will complete the grieving process about a year after your child's death
c. The grief process will start once your child actually dies
d. It is not uncommon to feel angry toward yourself or others
Answer: d. It is not uncommon to feel angry toward yourself or others.
Rationale:
d. Feelings of blame and anger towards oneself or others are an expected reaction when a patient
is experiencing a loss
a. Encouraging the mother to avoid thinking about the child's death will not allow her to begin
anticipatory grieving
b. The grief process has no timeline. It varies for each individual
c. The mother can begin anticipatory grieving during the child's illness
61. A nurse on a mental health unit is caring for a recently admitted patient.
Answer: Vital Signs
Rationale:
0800:Blood pressure 110/78 mm Hg Heart rate 76/min Respiratory rate 18/min Temperature 37°
C
(98.6° F)1200:Blood pressure 116/80 mm Hg Heart rate 88/min Respiratory rate
20/min Temperature 38° C (100.4° F)
Medical History
22-year-old client admitted following episodes of hallucinations and delusions. Outpatient
treatment has been ineffective. Client has been unable to maintain a job and friends have said the
client has been acting different than usual. Family members have noticed that the client no
longer maintains a clean and neat appearance.
62. For each potential assessment finding, click to specify if it is a positive or negative symptom
of schizophrenia.
Answer: Absence of intonation in speech
Alogia
Clang associations
Delusions of grandeur
Withdrawal from social activity
Catatonia
Positive symptoms: Delusions of grandeur, clang associations, and catatonia
Negative symptoms: Absence of intonation in speech, alogia, and withdrawal from social
activities
63. A nurse is caring for a client in an outpatient psychiatric clinic who has been applying a
selegiline 12 mg transdermal patch once daily.
Answer: Exhibit 1: Nurses' Notes
Tuesday:
Client diagnosed with major depressive disorder 15 years ago. Visits clinic twice a week for
outpatient group therapy with social worker and follow-up with nurse. Client actively
participates in therapy. Acknowledges that relationship with family members has improved and
there are fewer verbal altercations.
Thursday:
Client presents with irritability, diaphoresis, and severe headache, and states, "I am really feeling
bad. My heart is pounding." Was excited to share they had met a friend for lunch before coming
to the clinic. "Maybe it's something I ate, but we both had the same thing - corned beef sandwich
with Swiss cheese. Do you think it is food poisoning?"
Exhibit 2: Vital Signs
Tuesday:
Temperature 37° C (98.6° F) Blood pressure 114/78 mm Hg Heart rate 84/min Respiratory rate
16/min
Thursday:
Temperature 38.2° C (100.8 F°)Blood pressure 178/98 mm Hg Heart rate 128/min Respiratory
rate 24/min
64. Complete the following sentence by using the list of options.
The patient is at risk for developing ______________ due to ______________ Dropdown 1
Answer: Hypertensive crisis
Rationale:
Selegiline is a MAOI medication used to treat depression. Foods that contain tyramine, such as
aged cheese, yeast, and smoked or aged meats should not be consumed because this can cause a
hypertensive crisis. Other manifestations of hypertensive crisis include chest pain, severe
headache, nausea and vomiting, tachycardia, palpitations, and fever.
Dropdown 2
Consuming foods high in tyramine is correct.
The nurse should identify that consuming foods high in tyramine while taking an MAOI can lead
to a hypertensive crisis. Selegiline is a MAOI medication used to treat depression. Foods that
contain tyramine, such as aged cheese, yeast, and smoked or aged meats should not be
consumed. Other manifestations of hypertensive crisis include chest pain, severe headache,
nausea and vomiting, tachycardia, palpitations, and fever.
Dropdown 1 Incorrect rationales:
Extrapyramidal side effects (EPS) is incorrect. EPS are movement disorders caused by first
generation antipsychotic medication. Selegiline is not an antipsychotic medication. Dry mouth is
incorrect. Dry mouth is an anticholinergic reaction due to taking a tricyclic antidepressant.
Selegiline is not a tricyclic antidepressant.
Dropdown 2 Incorrect Rationales:
Taking an antipsychotic medication is incorrect. Antipsychotic medications, such as a first
generation antipsychotic, can cause extrapyramidal side effects. Selegiline is not an
antipsychotic medication.
Anticholinergic reaction is incorrect. An anticholinergic reaction can be caused by taking an
SSRI. Selegiline is not an SSRI.
65. A nurse is caring for a patient who has alcohol use disorder
Answer: Exhibit 1: Vital Signs
0800:
Blood pressure 116/68 mm Hg Heart rate 80/min Respiratory rate 14/min Temperature 36.8° C
(98.2° F) 1200:
Blood pressure 120/84 mm Hg Heart rate 96/min Respiratory rate 20/min Temperature 37° C
(98.6° F)
Exhibit 2: Nurses' Notes
0800:
Client alert and oriented to time, place, person, and situation. Visiting with other clients in the
dayroom. Attended group session this morning and stated, "I think I'm beginning to see what I
need to do to get better." Eager to have family visit with partner later this morning.
1230:
Client attended lunch with other clients but refused to eat or drink today. Staring intently at other
clients and nursing staff. Posture is rigid and jaw is clenched. Pacing and restless.
66. Complete the following sentence by using the list of options
The patient is at greatest risk for __________ as evidenced by the patient's _________
Answer: Violent behavior; Agitation
Rationale:
Drop down 1 Ineffective coping is incorrect. The nurse should continue to monitor the client for
ineffective coping and encourage the client to use coping techniques. However, this is not the
greatest risk for this client.
Dehydration is incorrect. The nurse should monitor the client's intake and encourage the client to
eat and drink. However, this is not the greatest risk for this client.
Violent behavior is correct. The greatest risk for the client is engaging in violent behavior due to
the withdrawal of alcohol, which is causing them increasing agitation. The nurse should closely
monitor the client and be prepared to intervene to protect the client and others from injury.
Drop down 2Agitation is correct. The client is at greatest risk of engaging in violent behavior as
evidenced by the client's agitation, which can be indicated by pacing, restlessness, staring,
silence, rigid posture, and clenched jaw. The nurse should closely monitor the client and be
prepared to intervene to protect the client and others from injury.
Loss of appetite is incorrect. The nurse should monitor the client's intake and encourage the
client to eat and drink. However, this is not the greatest risk for the client. Loss of appetite is an
expected finding for a client who is experiencing alcohol withdrawal.
Inability to perform simple tasks is incorrect. The nurse should monitor the client's ability to
perform simple tasks and encourage use of coping strategies. However, this is not the greatest
risk for the client.
67. A nurse is caring for a group of patients. Which of the following findings is the nurse
required to report?
a. A patient who has bipolar disorder and tested positive for genital herpes simplex virus reports
having multiple sexual partners
b. A patient who has depression reports having a lack of interest in assisting their partner in the
care of their children
c. A patient who has borderline personality disorder threatened to harm their roommate
d. An adolescent patient who has anorexia nervosa has a BMI of 17
Answer: c. A patient who has borderline personality disorder threatened to harm their roommate
Rationale:
c. Manifestations of borderline personality disorder include disturbed interpersonal relationships
accompanies by threats and other-directed violence. While it is important for the nurse to
maintain the patient's confidentiality, on occasions when another individual's life might be in
danger, the nurse is required by law to report it to the authorities
a. The nurse has a duty to maintain confidentiality regarding the patient's conversations with the
nurse. Since genital herpes simplex virus is not a condition that needs to be reported, the nurse is
not obligated to report the infection. The nurse should encourage the patient to contact that
patient's sexual partners to inform them of the need to obtain testing and treatment if necessary.
b. Anhedonia and loss of interest in the one's life are manifestation of depression. While a child
who is in danger of abuse or neglect is reportable, a lack of interest in assisting with the care of
children does not need to be reported.
c. A BMI of 17 is an indication of mild anorexia and, while this information is a part of the
patient's medical record, it does not need to be reported
