ATI Mental Health Proctored Exam With NGN Version 1 With Answers-206 Solved Questions

ATI MENTAL HEALTH PROCTORED EXAM
VERSION 1
A nurse manager is discussing the care of a client who has a personality disorder with a newly
licensed nurse. Which of the following statements by the newly licensed nurse indicates an
understanding of the teaching?
A. “I can promote my client’s sense of control by establishing a schedule.”
B. “I should encourage clients who have a schizoid personality disorder to increase
socialization.”
C. “I should practice limit-setting to help prevent client manipulation.”
D. “I should implement assertiveness training with clients who have antisocial personality
disorder.”
Answer: C. “I should practice limit-setting to help prevent client manipulation.”
A nurse is caring for a client who has avoidant personality disorder. Which of the following
statements is expected from a client who has this type of personality disorder?
A. “I’m scared that you’re going to leave me.”
B. “I’ll go to group therapy if you’ll let me smoke.”
C. “I need to feel that everyone admires me.”
D. “I sometimes feel better if I cut myself.”
Answer: A. “I’m scared that you’re going to leave me.”
A nurse is caring for a client who has borderline personality disorder. The client says, “The nurse
on the evening shift is always nice! You are the meanest nurse ever!” The nurse should recognize
the client’s statement as an example of which of the following defense mechanisms?
A. Regression.
B. Splitting.
C. Undoing.
D. Identification.
Answer: B. Splitting.

A nurse is assisting with a court-ordered evaluation of a client who has antisocial personality
disorder. Which of the following findings should the nurse expect? (Select all that apply.)
A. Demonstrates extreme anxiety when placed in a social situation.
B. Has difficulty making even simple decisions.
C. Attempts to convince other clients to give him their belongings.
D. Becomes agitated if his personal area is not neat and orderly.
E. Blames others for his past and current problems.
Answer: C. Attempts to convince other clients to give him their belongings.
E. Blames others for his past and current problems.
A charge nurse is preparing a staff education session on personality disorders. Which of the
following personality characteristics associated with all of the personality disorders should the
charge nurse include in the teaching?
A. Difficulty in getting along with other members of a group.
B. Belief in the ability to become invisible during times of stress.
C. Display of defense mechanisms when routines are changed.
D. Claiming to be more important than other persons.
E. Difficulty understanding why it is inappropriate to have a personal relationship with staff.
Answer: A. Difficulty in getting along with other members of a group.
C. Display of defense mechanisms when routines are changed.
E. Difficulty understanding why it is inappropriate to have a personal relationship with staff.
Chapter 21 Medications for Anxiety and Trauma- and Stressor-Related Disorders
A nurse working in a mental health clinic is providing teaching to a client who has a new
prescription for diazepam for generalized anxiety disorder.
Which of the following information should the nurse provide?
A. Three to six weeks of treatment is required to achieve therapeutic benefit.
B. Combining alcohol with diazepam will produce a paradoxical response.
C. Diazepam has a lower risk for dependence than other antianxiety medications.
D. Report confusion as a potential indication of toxicity.

Answer: D. Report confusion as a potential indication of toxicity.
A nurse working in an emergency department is caring for a client who has benzodiazepine
toxicity due to an overdose. Which of the following actions is the nurse’s priority?
A. Administer flumazenil.
B. Identify the client’s level of orientation.
C. Infuse IV fluids.
D. Prepare the client for gastric lavage.
Answer: B. Identify the client’s level of orientation.
A nurse is caring for a client who is to begin taking fluoxetine for treatment of generalized
anxiety disorder. Which of the following statements indicates the client understands the use of
this medication?
A. “I will take the medication at bedtime.”
B. “I will follow a low-sodium diet while taking this medication.”
C. “I will need to discontinue this medication slowly.”
D. “I will be at risk for weight loss with long-term use of this medication.”
Answer: C. “I will need to discontinue this medication slowly.”
A nurse is assessing a client 4 hr after receiving an initial dose of fluoxetine. Which of the
following findings should the nurse report to the provider as indications of serotonin syndrome?
(Select all that apply.)
A. Hypothermia.
B. Hallucinations.
C. Muscular flaccidity.
D. Diaphoresis.
E. Agitation.
Answer: B. Hallucinations.
D. Diaphoresis.
E. Agitation.

A nurse is caring for a client who takes paroxetine to treat posttraumatic stress disorder. The
client states that he grinds his teeth during the night, which causes pain in his mouth. The nurse
should identify which of the following interventions as possible measures to manages the client’s
bruxism? (Select all that apply.)
A. Concurrent administration of buspirone.
B. Administration of a different SSRI.
C. Use of a mouth guard.
D. Changing to a different class of antianxiety medication.
E. Increasing the dose of paroxetine.
Answer: A. Concurrent administration of buspirone.
C. Use of a mouth guard.
D. Changing to a different class of antianxiety medication.
Chapter 22 Medications for Depressive Disorders
A nurse is providing teaching to a client who has a new prescription for amitriptyline. Which of
the following statements by the client indicates an understanding of the teaching?
A. “While taking this medication, I’ll need to stay out of the sun to avoid a skin rash.”
B. “I may feel drowsy for a few weeks after starting this medication.”
C. “I cannot eat my favorite pizza with pepperoni while taking this medication.”
D. “This medication will help me lose the weight that I have gained over the last year.”
Answer: B. “I may feel drowsy for a few weeks after starting this medication.”
A nurse is caring for a client who is taking phenelzine. For which of the following adverse
effects should the nurse monitor? (Select all that apply.)
A. Elevated blood glucose levels.
B. Orthostatic hypotension.
C. Priapism.
D. Headache.
E. Bruxism.
D. Headache.

Answer: B. Orthostatic hypotension.
A nurse is reviewing the medical record of a client who has a new prescription for bupropion for
depression. Which of the following findings is the priority for the nurse to report to the provider?
A. The client has a family history of seasonal pattern depression.
B. The client currently smokes 1.5 packs of cigarettes per day.
C. The client had a motor vehicle crash last year and sustained a head injury.
D. The client has a BMI of 25 and has gained 10 lb over the last year.
Answer: C. The client had a motor vehicle crash last year and sustained a head injury.
A nurse is teaching a client who has a new prescription for imipramine how to minimize
anticholinergic effects. Which of the following instructions should the nurse include in the
teaching? (Select all that apply.)
A. Void just before taking the medication.
B. Increase the dietary intake of potassium
C. Wear sunglasses when outside.
D. Change positions slowly when getting up.
E. Chew sugarless gum.
Answer: A. Void just before taking the medication.
C. Wear sunglasses when outside.
E. Chew sugarless gum.
A charge nurse is discussing mirtazapine with a newly licensed nurse. Which of the following
statements by the newly licensed nurse indicates understanding?
A. “This medication increases the release of serotonin and norepinephrine.”
B. “I will need to monitor the client for hyponatremia while taking this medication.”
C. “This medication is contraindicated for clients who have an eating disorder.”
D. “Sexual dysfunction is a common adverse effect of this medication.”
Answer: A. “This medication increases the release of serotonin and norepinephrine.”
Chapter 23 Medications for Bipolar Disorders

A nurse is caring for a client who is prescribed lithium therapy. The client states that he wants to
take ibuprofen for osteoarthritis pain relief. Which of the following statements should the nurse
make?
A. “That is a good choice. Ibuprofen does not interact with lithium.”
B. “Regular aspirin would be a better choice than ibuprofen.”
C. “Lithium decreases the effectiveness of ibuprofen.”
D. “The ibuprofen will make your lithium level fall too low.”
Answer: B. “Regular aspirin would be a better choice than ibuprofen.”
A nurse is discussing early indications of toxicity with a client who has a new prescription for
lithium carbonate for bipolar disorder. The nurse should include which of the following
manifestations in the teaching? (Select all that apply.)
A. Constipation.
B. Polyuria.
C. Rash.
D. Muscle weakness.
E. Tinnitus.
Answer: B. Polyuria.
D. Muscle weakness.
A nurse is discussing routine follow-up needs with a client who has a new prescription for
valproate. The nurse should inform the client of the need for routine monitoring of which of the
following?
A. AST/ALT and LDH.
B. Creatinine and BUN.
C. WBC and granulocyte counts.
D. Serum sodium and potassium.
Answer: A. AST/ALT and LDH.

A nurse is caring for a client who is experiencing extreme mania due to bipolar disorder. Prior to
administration of lithium carbonate, the client’s lithium blood level is 1.2 mEq/L. Which of the
following actions should the nurse take?
A. Administer the next dose of lithium carbonate as scheduled.
B. Prepare for administration of aminophylline.
C. Notify the provider for a possible increase in the dosage of lithium carbonate.
D. Request a stat repeat of the client’s lithium blood level.
Answer: A. Administer the next dose of lithium carbonate as scheduled.
A nurse is admitting a client who has a new diagnosis of bipolar disorder and is scheduled to
begin lithium therapy. When collecting a medical history from the client’s adult daughter, which
of the following statements is the priority to report to the provider?
A. “My mother has diabetes that is controlled by her diet.”
B. “My mother recently completed a course of prednisone for acute bronchitis.”
C. “My mother received her flu vaccine last month.”
D. “My mother is currently on furosemide for her congestive heart failure.”
Answer: D. “My mother is currently on furosemide for her congestive heart failure.”
A nurse is providing teaching for a client who is scheduled to receive ECT for the treatment of
major depressive disorder. Which of the following client statements indicates understanding of
the teaching?
A. “It is common to treat depression with ECT before trying medications.”
B. “I can have my depression cured if I receive a series of ECT treatments.”
C. “I should receive ECT once a week for 6 weeks.”
D. “I will receive a muscle relaxant to protect me from injury during ECT.”
Answer: D. “I will receive a muscle relaxant to protect me from injury during ECT.”
A charge nurse is discussing TMS with a newly licensed nurse. Which of the following
statements by the newly licensed nurse indicates an understanding of the teaching?
A. “TMS is indicated for clients who have schizophrenia spectrum disorders.”
B. “I will provide post anesthesia care following TMS.”

C. “TMS treatments usually last 5 to 10 minutes.”
D. “I will schedule the client for daily TMS treatments for the first several weeks.”
Answer: D. “I will schedule the client for daily TMS treatments for the first several weeks.”
A nurse is assessing a client immediately following an ECT procedure. Which of the following
findings should the nurse expect? (Select all that apply.)
A. Hypotension.
B. Paralytic ileus.
C. Memory loss.
D. Nausea.
E. Confusion.
Answer: C. Memory loss.
D. Nausea.
E. Confusion.
A nurse is leading a peer group discussion about the indications for ECT. Which of the following
indications should the nurse include in the discussion?
A. Borderline personality disorder.
B. Acute withdrawal related to a substance use disorder.
C. Bipolar disorder with rapid cycling.
D. Dysphoric disorder.
Answer: C. Bipolar disorder with rapid cycling.
A nurse is planning care for a client following surgical implantation of a VNS device. The nurse
should plan to monitor for which of the following adverse effects? (Select all that apply.)
A. Voice changes.
B. Seizure activity.
C. Disorientation.
D. Dysphagia.
E. Neck pain.
Answer: A. Voice changes.

D. Dysphagia.
E. Neck pain.
Chapter 16 Personality Disorders
A nurse manager is discussing the care of a client who has a personality disorder with a newly
licensed nurse. Which of the following statements by the newly licensed nurse indicates an
understanding of the teaching?
A. “I can promote my client’s sense of control by establishing a schedule.”
B. “I should encourage clients who have a schizoid personality disorder to increase
socialization.”
C. “I should practice limit-setting to help prevent client manipulation.”
D. “I should implement assertiveness training with clients who have antisocial personality
disorder.”
Answer: C. “I should practice limit-setting to help prevent client manipulation.”
A nurse is caring for a client who has avoidant personality disorder. Which of the following
statements is expected from a client who has this type of personality disorder?
A. “I’m scared that you’re going to leave me.”
B. “I’ll go to group therapy if you’ll let me smoke.”
C. “I need to feel that everyone admires me.”
D. “I sometimes feel better if I cut myself.”
Answer: A. “I’m scared that you’re going to leave me.”
A nurse is caring for a client who has borderline personality disorder. The client says, “The nurse
on the evening shift is always nice! You are the meanest nurse ever!” The nurse should recognize
the client’s statement as an example of which of the following defense mechanisms?
A. Regression.
B. Splitting.
C. Undoing.
D. Identification.

Answer: B. Splitting.
A nurse is assisting with a court-ordered evaluation of a client who has antisocial personality
disorder. Which of the following findings should the nurse expect? (Select all that apply.)
A. Demonstrates extreme anxiety when placed in a social situation.
B. Has difficulty making even simple decisions.
C. Attempts to convince other clients to give him their belongings.
D. Becomes agitated if his personal area is not neat and orderly.
E. Blames others for his past and current problems.
Answer: C. Attempts to convince other clients to give him their belongings.
E. Blames others for his past and current problems.
A charge nurse is preparing a staff education session on personality disorders. Which of the
following personality characteristics associated with all of the personality disorders should the
charge nurse include in the teaching?
A. Difficulty in getting along with other members of a group.
B. Belief in the ability to become invisible during times of stress.
C. Display of defense mechanisms when routines are changed.
D. Claiming to be more important than other persons.
E. Difficulty understanding why it is inappropriate to have a personal relationship with staff.
Answer: A. Difficulty in getting along with other members of a group.
C. Display of defense mechanisms when routines are changed.
E. Difficulty understanding why it is inappropriate to have a personal relationship with staff.
Chapter 21 Medications for Anxiety and Trauma- and Stressor-Related Disorders
A nurse working in a mental health clinic is providing teaching to a client who has a new
prescription for diazepam for generalized anxiety disorder.
Which of the following information should the nurse provide?
A. Three to six weeks of treatment is required to achieve therapeutic benefit.
B. Combining alcohol with diazepam will produce a paradoxical response.

C. Diazepam has a lower risk for dependence than other antianxiety medications.
D. Report confusion as a potential indication of toxicity.
Answer: D. Report confusion as a potential indication of toxicity.
A nurse working in an emergency department is caring for a client who has benzodiazepine
toxicity due to an overdose. Which of the following actions is the nurse’s priority?
A. Administer flumazenil.
B. Identify the client’s level of orientation.
C. Infuse IV fluids.
D. Prepare the client for gastric lavage.
Answer: B. Identify the client’s level of orientation.
A nurse is caring for a client who is to begin taking fluoxetine for treatment of generalized
anxiety disorder. Which of the following statements indicates the client understands the use of
this medication?
A. “I will take the medication at bedtime.”
B. “I will follow a low-sodium diet while taking this medication.”
C. “I will need to discontinue this medication slowly.”
D. “I will be at risk for weight loss with long-term use of this medication.”
Answer: C. “I will need to discontinue this medication slowly.”
A nurse is assessing a client 4 hr after receiving an initial dose of fluoxetine. Which of the
following findings should the nurse report to the provider as indications of serotonin syndrome?
(Select all that apply.)
A. Hypothermia.
B. Hallucinations.
C. Muscular flaccidity.
D. Diaphoresis.
E. Agitation.
Answer: B. Hallucinations.
D. Diaphoresis.

E. Agitation.
A nurse is caring for a client who takes paroxetine to treat posttraumatic stress disorder. The
client states that he grinds his teeth during the night, which causes pain in his mouth. The nurse
should identify which of the following interventions as possible measures to manages the client’s
bruxism? (Select all that apply.)
A. Concurrent administration of buspirone.
B. Administration of a different SSRI.
C. Use of a mouth guard.
D. Changing to a different class of antianxiety medication.
E. Increasing the dose of paroxetine.
Answer: A. Concurrent administration of buspirone.
C. Use of a mouth guard.
D. Changing to a different class of antianxiety medication.
Chapter 24 Medications for Psychotic Disorders
A nurse is caring for a client who has schizophrenia and exhibits a lack of grooming and a flat
affect. The nurse should anticipate a prescription of which of the following medications?
A. Chlorpromazine.
B. Thiothixene.
C. Risperidone.
D. Haloperidol.
Answer: C. Risperidone.
A nurse is caring for a client who takes ziprasidone. The client reports difficulty swallowing the
oral medication and becomes extremely agitated with injectable administration. The nurse should
contact the provider to discuss a change to which of the following medications? (Select all that
apply.)
A. Olanzapine.
B. Quetiapine.

C. Aripiprazole.
D. Clozapine.
E. Asenapine.
Answer: C. Aripiprazole.
D. Clozapine.
E. Asenapine.
A charge nurse is discussing manifestations of schizophrenia with a newly licensed nurse. Which
of the following manifestations should the charge nurse identify as being effectively treated by
first-generation antipsychotics?
(Select all that apply.)
A. Auditory hallucinations.
B. Withdrawal from social situations.
C. Delusions of grandeur.
D. Severe agitation.
E. Anhedonia.
Answer: A. Auditory hallucinations.
C. Delusions of grandeur.
D. Severe agitation.
A nurse is assessing a client who is currently taking perphenazine. Which of the following
findings should the nurse identify as an extrapyramidal symptom (EPS)? (Select all that apply.)
A. Decreased level of consciousness.
B. Drooling.
C. Involuntary arm movements.
D. Urinary retention.
E. Continual pacing.
Answer: B. Drooling.
C. Involuntary arm movements.
E. Continual pacing.

A nurse is providing discharge teaching for a client who has schizophrenia and a new
prescription for iloperidone. Which of the following client statements indicates understanding of
the teaching?
A. “I will be able to stop taking this medication as soon as I feel better.”
B. “If I feel drowsy during the day, I will stop taking this medication and call my provider.”
C. “I will be careful not to gain too much weight while taking this medication.”
D. “This medication is highly addictive and must be withdrawn slowly.”
Answer: C. “I will be careful not to gain too much weight while taking this medication.”
Chapter 25 Medications for Children and Adolescents Who Have Mental Health Issues
A nurse is teaching the parents of a child who has autism spectrum disorder and a new
prescription for imipramine about indications of toxicity. Which of the following should the
nurse include in the teaching? (Select all that apply.)
A. Seizures.
B. Agitation.
C. Photophobia.
D. Dry mouth.
E. Irregular pulse.
Answer: A. Seizures.
B. Agitation.
E. Irregular pulse.
A nurse is providing teaching to an adolescent client who has a new prescription for
clomipramine for OCD. Which of the following information should the nurse provide?
A. Eat a diet high in fiber.
B. Check temperature daily.
C. Take medication first thing in the morning before eating.
D. Add extra calories to the diet as between-meal snacks.
Answer: A. Eat a diet high in fiber.

A nurse is providing teaching to an adolescent client who is to begin taking atomoxetine for
ADHD. The nurse should instruct the client to monitor for which of the following adverse
effects? (Select all that apply.)
A. Somnolence.
B. Yellowing skin.
C. Increased appetite.
D. Fever.
E. Malaise.
Answer: B. Yellowing skin.
D. Fever.
E. Malaise.
A nurse is caring for a school age child who has conduct disorder and a new prescription for
methylphenidate transdermal patches. Which of the following information should the nurse
provide about the medication?
A. Apply the patch once daily at bedtime.
B. Place the patch carefully in a trash can after removal.
C. Apply the transdermal patch to the anterior waist area.
D. Remove the patch each day after 9 hr.
Answer: D. Remove the patch each day after 9 hr.
A nurse is teaching a client who has intermittent explosive disorder about a new prescription for
fluoxetine. Which of the following information should the nurse provide? (Select all that apply.)
A. An adverse effect of this medication is CNS depression.
B. Administer the medication in the morning.
C. Monitor for weight loss while taking this medication.
D. Therapeutic effects of this medication will take 1 to 3 weeks to fully develop.
E. This medication blocks the synaptic reuptake of serotonin in the brain.
Answer: B. Administer the medication in the morning.
C. Monitor for weight loss while taking this medication.
E. This medication blocks the synaptic reuptake of serotonin in the brain.

Chapter 26 Medications for Substance Use Disorders
A nurse is providing teaching to a client who has alcohol use disorder and a new prescription for
carbamazepine. Which of the following information should the nurse include in the teaching?
A. “This medication will help prevent seizures during alcohol withdrawal.”
B. “Taking this medication will decrease your cravings for alcohol.”
C. “This medication maintains your blood pressure at a normal level during alcohol withdrawal.”
D. “Taking this medication will improve your ability to maintain abstinence from alcohol.”
Answer: A. “This medication will help prevent seizures during alcohol withdrawal.”
A nurse is assisting in the discharge planning for a client following alcohol detoxification. The
nurse should anticipate prescriptions for which of the following medications to promote longterm abstinence from alcohol? (Select all that apply.)
A. Lorazepam.
B. Diazepam.
C. Disulfiram.
D. Naltrexone.
E. Acamprosate.
Answer: C. Disulfiram.
D. Naltrexone.
E. Acamprosate.
A nurse is evaluating a client’s understanding of a new prescription for clonidine for the
treatment of opioid use disorder. Which of the following statements by the client indicates an
understanding of the teaching?
A. “Taking this medication will help reduce my craving for heroin.”
B. “While taking this medication, I should keep a pack of sugarless gum.”
C. “I can expect some diarrhea from taking this medicine.”
D. “Each dose of this medication should be placed under my tongue to dissolve.”
Answer: B. “While taking this medication, I should keep a pack of sugarless gum.”

A nurse is teaching a client who has tobacco use disorder about the use of nicotine gum. Which
of the following information should the nurse include in the teaching?
A. Chew the gum for no more than 10 minutes.
B. Rinse out the mouth immediately before chewing the gum.
C. Avoid eating 15 minutes prior to chewing the gum.
D. Use of the gum is limited to 90 days.
Answer: C. Avoid eating 15 minutes prior to chewing the gum.
A nurse is discussing the use of methadone with a newly licensed nurse. Which of the following
statements by the newly licensed nurse indicates an understanding of the teaching? (Select all
that apply.)
A. “Methadone is a replacement for physical dependence to opioids.”
B. “Methadone reduces the unpleasant effects associated with abstinence syndrome.”
C. “Methadone can be used during opioid withdrawal and to maintain abstinence.”
D. “Methadone increases the risk for acetaldehyde syndrome.”
E. must be prescribed and dispensed by an approved treatment center.”
F. “Methadone
Answer: A. “Methadone is a replacement for physical dependence to opioids.”
B. “Methadone reduces the unpleasant effects associated with abstinence syndrome.”
C. “Methadone can be used during opioid withdrawal and to maintain abstinence.”
E. must be prescribed and dispensed by an approved treatment center.”
ATI Mental Health Proctored
A charge nurse is discussing mental status exams with a newly licensed nurse. Which of the
following statements by the newly licensed nurse indicates an understanding of the teaching?
(Select all that apply)
A. “To assess cognitive ability, I should ask the client to count backward by sevens”
B. “To assess affect, I should observe the client’s facial expression.”
C. “To assess language ability, I should instruct the client to write a sentence.”

D. "To assess remote memory, I should have the client repeat a list of have the client repeat a list
of objects."
E. "To assess the client's abstract thinking, I should ask the client to identify our most recent
presidents."
Answer: A. “To assess cognitive ability, I should ask the client to count backward by sevens”
B. “To assess affect, I should observe the client’s facial expression.”
C. “To assess language ability, I should instruct the client to write a sentence.”
A nurse is planning care for a client who has a mental health disorder. Which of the following
actions should the nurse include as a psychobiological intervention?
A. Assist the client with systematic desensitization therapy.
B. Teach the client appropriate coping mechanisms.
C. Assess the client for comorbid health conditions.
D. Monitor the client for adverse effects of the medications.
Answer: D. Monitor the client for adverse effects of the medications.
A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview.
When conducting the interview, which of the following actions should the nurse identify as the
priority?
A. Coordinate holistic care with social services.
B. Identify the client's perception of her mental health status.
C. Include the client's family in the interview.
D. Teach the client about her current mental health disorder.
Answer: B. Identify the client's perception of her mental health status.
A nurse is told during change of shift report that a client is stuporous. When assessing the client,
which of the following findings should the nurse expect?
A. The client arouses briefly in response to a sternal rub.
B. The client has a glasgow coma scale score less than 7.
C. The client exhibits decorticate rigidity.
D. The client is alert but disoriented to time and place.

Answer: A. The client arouses briefly in response to a sternal rub.
A nurse is planning a peer group discussion about the DSM-5. Which of the following
information is appropriate to include in the discussion? (Select all that apply)
A. The DSM-5 includes client education handouts for mental health disorders.
B. The DSM-5 establishes diagnostic criteria for individual mental health disorders.
C. The DSM-5 indicates recommended pharmacological treatment for mental health disorders.
D. The DSM-5 assists nurses in planning care for client's who have mental health disorders.
E. The DSM-5 indicates expected assessment findings of mental health disorders.
Answer: B. The DSM-5 establishes diagnostic criteria for individual mental health disorders.
D. The DSM-5 assists nurses in planning care for client's who have mental health disorders.
E. The DSM-5 indicates expected assessment findings of mental health disorders.
A nurse in an emergency mental health facility is caring for a group of clients. The nurse should
identify that which of the following clients requires a temporary emergency admission?
A. A client who has schizophrenia with delusions of grandeur
B. A client who has manifestations of depression and attempted suicide a year ago
C. A client who has borderline personality disorder and assaulted a homeless man with a metal
rod
D. A client who has bipolar disorder and paces quickly around the room while talking to himself
Answer: C. A client who has borderline personality disorder and assaulted a homeless man with
a metal rod
A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the
unit is very short-staffed, and the client frequently fights with other clients. The nurse's actions
are an example of which of the following torts?
A. Invasion of privacy
B. False imprisonment
C. Assault
D. Battery
Answer: B. False imprisonment

A client tells a nurse, "Don't tell anyone but I hid a sharp knife under my mattress in order to
protect myself from my roommate, who is always yelling at me and threatening me." Which of
the following actions should the nurse take?
A. Keep the client's communication confidential, but talk to the client daily, using therapeutic
communication to convince him to admit to hiding the knife.
B. Keep the client's communication confidential, but watch the client and his roommate closely.
C. Tell the client that this must be reported to the health care team because it concerns the health
and safety of the client and others.
D. Report the incident to the health care team, but do not inform the client of the intention to do
so.
Answer: D. Report the incident to the health care team, but do not inform the client of the
intention to do so.
A nurse is caring for a client who is in mechanical restraints. Which of the following statements
should the nurse include in the documentation? (Select all that apply)
A. "Client ate most of his breakfast."
B. "Client was offered 8 oz of water every hr."
C. "Client shouted obscenities at assistive personnel."
D. "Client received chlorpromazine 15 mg by mouth at 1000."
E. "Client acted out after lunch."
Answer: B. "Client was offered 8 oz of water every hr."
C. "Client shouted obscenities at assistive personnel."
D. "Client received chlorpromazine 15 mg by mouth at 1000."
A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with
another nurse. Which of the following actions should the nurse take first?
A. Notify the nurse manager.
B. Tell the nurse to stop discussing the behavior.
C. Provide an in-service program about confidentiality.
D. Complete an incident report.

Answer: B. Tell the nurse to stop discussing the behavior.
A nurse is caring for the parents of a child who has demonstrated changes in behavior and mood.
When the mother of the child asks the nurse for reassurance about her son's condition, which of
the following responses should the nurse make?
A. "I think your son is getting better. What have you noticed."
B. "I'm sure everything will be okay. It just takes time to heal."
C. "I'm not sure whats wrong. Have you asked the doctor about your concerns?"
D. "I understand you're concerned. Let's discuss what concerns you specifically."
Answer: D. "I understand you're concerned. Let's discuss what concerns you specifically."
A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm coughing
because I have that cold that everyone has been getting." The nurse should identify that the client
is using which of the following defense mechanisms?
A. Reaction formation
B. Denial
C. Displacement
D. Sublimation
Answer: B. Denial
A nurse is providing preoperative teaching for a client who was just informed that she requires
emergency surgery. The client has a respiratory rate 30/min and says, "This is difficult to
comprehend. I feel shaky and nervous." The nurse should identify that the client is experiencing
which of the following levels of anxiety?
A. Mild
B. Moderate
C. Severe
D. Panic
Answer: B. Moderate

A nurse is caring for a client who is experiencing moderate anxiety. Which of the following
actions should the nurse take when trying to give necessary information to the client? (Select all
that apply.)
A. Reassure the client that everything will be okay.
B. Discuss prior use of coping mechanisms with the client.
C. Ignore the client's anxiety so that she will not be embarrassed.
D. Demonstrate a calm manner while using simple and clear directions.
E. Gather information from the client using closed-ended questions.
Answer: B. Discuss prior use of coping mechanisms with the client.
D. Demonstrate a calm manner while using simple and clear directions.
A nurse is talking with a client who is at risk for suicide following the death of his spouse. Which
of the following statements should the nurse make?
A. "I feel very sorry for the loneliness you must be experiencing."
B. "Suicide is not the appropriate way to cope with loss."
C. "Losing someone close to you must be very upsetting."
D. "I know how difficult it is to lose a loved one."
Answer: C. "Losing someone close to you must be very upsetting."
A charge nurse is discussing the characteristics of a nurse-client relationship with a newly
licensed nurse. Which of the following characteristics should the nurse include in the discussion?
(Select all that apply)
A. The needs of both participants are met.
B. An emotional commitment exists between the participants.
C. It is goal-directed.
D. Behavioral change is encouraged.
E. A termination date is established.
Answer: C. It is goal-directed.
D. Behavioral change is encouraged.
E. A termination date is established.

A nurse is in the working phase of a therapeutic relationship with a client who has
methamphetamine use disorder. Which of the following actions indicates transference behavior?
A. The client asks the nurse whether she will go out to dinner with him.
B. The client accuses the nurses of telling him what to do just like his ex-Girlfriend.
C. The client reminds the nurse of a friend who died from a substance overdose.
D. The client becomes angry and threatens to harm him-self.
Answer: B. The client accuses the nurses of telling him what to do just like his ex-Girlfriend.
A nurse is planning care for the termination phase of a nurse-client relationship. Which of the
following actions should the nurse include in the plan of care?
A. Discussing ways to use new behaviors
B. Practicing new problem-solving skills
C. Developing goals
D. Establishing boundaries
Answer: A. Discussing ways to use new behaviors
A nurse is orienting a new client to a mental health unit. When explaining the unit's community
meetings, which of the following statements should the nurse make?
A. "You and a group of other clients will meet to discuss your treatment plans."
B. "Community meetings have a specific agenda that is established by staff."
C. "You and the other clients will meet with staff to discuss common problems."
D. "Community meetings are an excellent opportunity to explore your personal mental health
issues."
Answer: C. "You and the other clients will meet with staff to discuss common problems."
A nurse is caring several clients who are attending community-based mental health programs.
Which of the following clients should the nurse plan to visit first?
A. A client who recently burned her arm while using a hot iron at home.
B. A client who requests that her antipsychotic medication be changed due to some new adverse
effects.
C. A client who says he is hearing a voice that tells him he is not worth living anymore.

D. A client who tells the nurse he experienced manifestations of severe anxiety before and during
a job interview.
Answer: C. A client who says he is hearing a voice that tells him he is not worth living anymore.
A community mental health nurse is planning care to address the issue of depression among
older adult clients in the community. Which of the following interventions should the nurse plan
as a method of tertiary prevention?
A. Educating clients on health promotion techniques to reduce the risk of depression
B. Performing screenings for depression at community health programs
C. Establishing rehabilitation programs to decrease the effects of depression
D. Providing support groups for clients at risk for depression
Answer: C. Establishing rehabilitation programs to decrease the effects of depression
A nurse is working in a community mental health facility. Which of the following services does
this type of program provide? (Select all that apply)
A. Educational groups
B. Medication dispensing programs
C. Individual counseling programs
D. Detoxification programs
E. Family therapy
Answer: A. Educational groups
B. Medication dispensing programs
C. Individual counseling programs
E. Family therapy
A nurse in an acute mental health facility is assisting with discharge planning for a client who has
a severe mental illness and requires supervision much of the time. The client's wife works all day
but is home by late afternoon. Which of the following strategies should the nurse suggest as
appropriate follow-up care?
A. Receiving daily care from a home health aide
B. Having a weekly visit from a nurse case worker

C. Attending a partial hospitalization program
D. Visiting a community mental health center on a daily basis
Answer: C. Attending a partial hospitalization program
A nurse is caring for a group of clients. Which of the following clients should a nurse consider
for referral to an assertive community treatment (ACT) group?
A. A client in an cute care mental health facility who has fallen several times while running down
the hallway
B. A client who lives at home and keeps "forgetting" to come in for his monthly antipsychotic
injection for schizophrenia
C. A client in a day treatment program who says he is becoming more anxious during group
therapy
D. A client in a weekly grief support group who says she still misses her deceased husband who
has been dead for 3 months
Answer: B. A client who lives at home and keeps "forgetting" to come in for his monthly
antipsychotic injection for schizophrenia
A nurse is teaching a client who has an anxiety disorder and is scheduled to begin classical
psychoanalysis. Which of the following client statements indicates an understanding of this form
of therapy?
A. "Even if my anxiety improves, I will need to continue this therapy for 6 weeks."
B. "The therapist will focus on my past relationships during our sessions.”
C. "Psychoanalysis will help me reduce my anxiety by changing my behaviors."
D. "This therapy will address my conscious feelings about stressful experiences."
Answer: B. "The therapist will focus on my past relationships during our sessions.”
A nurse is discussing free association as a therapeutic tool with a client who has major depressive
disorder. Which of the following client statements indicates understanding of this technique?
A. "I will write down my dreams as soon as I wake up."
B. "I may begin to associate my therapist with important people in my life."
C. "I can learn to express myself in a nonaggressive manner."

D. "I should say the first thing that comes to my mind."
Answer: D. "I should say the first thing that comes to my mind."
A nurse is preparing to implement cognitive reframing techniques for a client who has an anxiety
disorder. Which of the following techniques should the nurse include in the plan of care? (Select
all that apply)
A. Priority restructuring
B. Monitoring thoughts
C. Diaphragmatic breathing
D. Journal keeping
E. Meditation
Answer: A. Priority restructuring
B. Monitoring thoughts
D. Journal keeping
A nurse is caring for a client who has a new prescription for disulfiram for treatment of alcohol
use disorder. The nurse informs the client that this medication can cause nausea and vomiting if
he drinks alcohol. Which of the following types of treatment is this method an example?
A. Aversion therapy
B. Flooding
C. Biofeedback
D. Dialectical behavior therapy
Answer: A. Aversion therapy
A nurse is assisting with systematic desensitization for a client who has an extreme fear of
elevators. Which of the following actions should the nurse implement with this form of therapy?
A. Demonstrate riding in an elevator, and then ask the client to imitate the behavior.
B. Advise the client to say "stop" out loud every time he begins to feel an anxiety response
related to an elevator.
C. Gradually expose the client to an elevator while practicing relaxation techniques.
D. Stay with the client in an elevator until his anxiety response diminishes.

Answer: C. Gradually expose the client to an elevator while practicing relaxation techniques.
A nurse wants to use democratic leadership with a group whose purpose is to learn appropriate
conflict resolution techniques. The nurse is correct in implementing this form of group leadership
when she demonstrates which of the following actions?
A. Observes group techniques without interfering with the group process
B. Discusses a technique and then directs members to practice the technique
C. Asks for group suggestions of techniques and then support discussion
D. Suggests techniques and asks group members to reflect on their use
Answer: A. Observes group techniques without interfering with the group process
A nurse is planning group therapy for clients dealing with bereavement. Which of the following
activities should the nurse include in the initial phase? (Select all that apply)
A. Encourage the group to work toward goals
B. Define the purpose of the group
C. Discuss termination of the group
D. Identify informal roles of members within the group
E. Establish an expectation of confidentiality within the group
Answer: B. Define the purpose of the group
C. Discuss termination of the group
E. Establish an expectation of confidentiality within the group
A nurse working on an acute mental health unit forms a group to focus on self-management of
medications. At each of meetings, two of the members use the opportunity to discuss their
common interest in gambling on sports. This is an example of which of the following concepts?
A. Triangulation
B. Group process
C. Subgroup
D. Hidden agenda
Answer: D. Hidden agenda

A nurse is conducting a family therapy session. The adolescent son tells the nurse that he plans
ways to make his sister look bad so his parents will think he's the better sibling, which he
believes will give him more privileges. The nurse should identify this dysfunctional behavior as
which of the following?
A. Placation
B. Manipulation
C. Blaming
D. Distraction
Answer: B. Manipulation
A nurse is working with an established group and identifies various member roles. Which of the
following should the nurse identify as an individual role?
A. A member who praises input from other members
B. A member who follows the direction of other members
C. A member who brags about accomplishments
D. A member who evaluates the group's performance toward a standard
Answer: C. A member who brags about accomplishments
A nurse is preparing to provide an educational seminar on stress to other nursing staff. Which of
the following information should the nurse include in the discussion?
A. Excessive stressors cause the client to experience distress.
B. The body's initial adaptive response to stress is denial.
C. Absence of stressors results in homeostasis.
D. Negative, rather than positive, stressors produce a biological response.
Answer: A. Excessive stressors cause the client to experience distress.
A nurse is discussing acute vs prolonged stress with a client. Which of the following effects
should the nurse identify as an acute stress response? (Select all that apply)
A. Chronic pain
B. Depressed immune system
C. Increased blood pressure

D. Panic attacks
E. Unhappiness
Answer: B. Depressed immune system
C. Increased blood pressure
E. Unhappiness
A nurse is teaching a client about stress-reduction techniques. Which of the following client
statements indicates understanding of the teaching?
A. "Cognitive reframing will help me change my irrational thoughts to something positive."
B. "Progressive muscle relaxation uses a mechanical device to help me gain control over my
pulse rate."
C. "Biofeedback causes my body to release endorphins so that I feel less stress and anxiety."
D. "Mindfulness allows me to prioritize the stressors that I have in my life so that I have less
anxiety."
Answer: A. "Cognitive reframing will help me change my irrational thoughts to something
positive."
A client says she is experiencing increased stress because her significant other is "pressuring me
and my kids to go live with him. I love him, but I'm not ready to do that." Which of the following
recommendations should the nurse make to promote a change in the client's situation?
A. Learn to practice mindfulness
B. Use assertiveness techniques
C. Exercise regularly
D. Rely on the support of a close friend
Answer: B. Use assertiveness techniques
A nurse is caring for a client who states, "I'm so stressed at work because of my coworker. He
expects me to finish his work because he's too lazy!" When discussing effective communication,
which of the following statements by the client to his coworker indicates client understanding?
A. "You really should complete your own work. I don't think it's right to expect me to complete
your responsibilities."

B. "Why do you expect me to finish your work? You must realize that I have my own
responsibilities."
C. "It is not fair to expect me to complete your work. If you continue, then I will report your
behavior to our supervisor."
D. "When I have to pick up extra work, I feel very overwhelmed. I need to focus on my own
responsibilities."
Answer: D. "When I have to pick up extra work, I feel very overwhelmed. I need to focus on my
own responsibilities."
A nurse is providing teaching for a client who is scheduled to receive ECT for the treatment of
major depressive disorder. Which of the following client statements indicates understanding of
the teaching?
A. "It is common to treat depression with ECT before trying medications."
B. "I can have my depression cured if I receive a series of ECT treatments."
C. "I should receive ECT once a week for 6 weeks."
D. "I will receive a muscle relaxant to protect me from injury during ECT."
Answer: D. "I will receive a muscle relaxant to protect me from injury during ECT."
A charge nurse is discussing TMS with a newly licensed nurse. Which of the following
statements by the newly licensed nurse indicates an understanding of the teaching?
A. "TMS is indicated for clients who have schizophrenia spectrum disorders."
B. "I will provide postanesthesia care following TMS."
C. "TMS treatments usually last 5-10 minutes."
D. "I will schedule the client for daily TMS treatments for the first several weeks."
Answer: D. "I will schedule the client for daily TMS treatments for the first several weeks."
A nurse is assessing a client immediately following an ECT procedure. Which of the following
findings should the nurse expect? (Select all that apply)
A. Hypotension
B. Paralytic ileus
C. Memory loss

D. Nausea
E. Confusion
Answer: C. Memory loss
D. Nausea
E. Confusion
A nurse is leading a peer group discussion about the indications for ECT. Which of the following
indications should the nurse include in the discussion?
A. Borderline personality disorder
B. Acute withdrawal related to a substance use disorder
C. Bipolar disorder with rapid cycling
D. Dysphoric disorder
Answer: C. Bipolar disorder with rapid cycling
A nurse is planning care for a client following surgical implantation of a VNS device. The nurse
should plan to monitor for which of the following adverse effects? (Select all that apply)
A. Voice changes
B. Seizure activity
C. Disorientation
D. Dysphagia
E. Neck pain
Answer: A. Voice changes
D. Dysphagia
E. Neck pain
A nurse observes a client who has OCD repeatedly applying, removing, and then reapplying
makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of
the following underlying reasons?
A. Narcissistic behavior
B. Fear of rejection from staff
C. Attempt to reduce anxiety

D. Adverse effect of antidepressant medication
Answer: C. Attempt to reduce anxiety
A nurse is caring for a client who is experiencing a panic attack. Which of the following actions
should the nurse take?
A. Discuss new relaxation techniques
B. Show the client how to change his behavior
C. Distract the client with a television show
D. Stay with the client and remain quiet
Answer: D. Stay with the client and remain quiet
A nurse is assessing a client who has generalized anxiety disorder. Which of the following
findings should the nurse expect? (Select all that apply)
A. Excessive worry for 6 months
B. Impulsive decision making
C. Delayed reflexes
D. Restlessness
E. Need for reassurance
Answer: A. Excessive worry for 6 months
D. Restlessness
E. Need for reassurance
A nurse is caring for a client who has body dysmorphic disorder. Which of the following actions
should the nurse plan to take first?
A. Assessing the client's risk for self harm
B. Instilling hope for positive outcomes
C. Encouraging the client to participate in group therapy sessions
D. Encouraging the client to participate in treatment decisions
Answer: A. Assessing the client's risk for self harm

A nurse is caring for a client who has acute stress disorder and is experiencing severe anxiety.
Which of the following statements should the nurse make?
A. "Tell me about how you are feeling right now."
B. "You should focus on the positive things in your life to decrease your anxiety."
C. "Why do you believe you are experiencing this anxiety?"
D. "Let's discuss the medications your provider is prescribing to decrease your anxiety."
Answer: A. "Tell me about how you are feeling right now."
A nurse working on an acute mental health unit is caring for a client who has PTSD. Which of
the following findings should the nurse expect? (Select all that apply)
A. Difficulty concentrating on tasks
B. Obsessive need to talk about the traumatic event
C. Negative self-image
D. Recurring nightmares
E. Diminished reflexes
Answer: A. Difficulty concentrating on tasks
C. Negative self-image
D. Recurring nightmares
A nurse is involved in a serious and prolonged mass casualty incident in the emergency
department. Which of the following strategies should the nurse use to help prevent developing a
trauma-related disorder? (Select all that apply)
A. Avoid thinking about the incident when it is over
B. Take breaks during the incident for food and water
C. Debrief with others following the incident
D. Hold emotions in check in the days following the incident
E. Take advantage of offered counseling
Answer: B. Take breaks during the incident for food and water
C. Debrief with others following the incident
E. Take advantage of offered counseling

A nurse is collecting an admission history for a client who has acute stress disorder (ASD).
Which of the following information should the nurse expect to collect?
A. The client remembers many details about the traumatic incident
B. The client expresses heightened elation about what is happening
C. The client states he first noticed manifestations of the disorder 6 weeks after the traumatic
incident occurred.
D. The client expresses a sense of unreality about the traumatic event
Answer: D. The client expresses a sense of unreality about the traumatic event
A nurse is caring for a client who has derealization disorder. Which of the following findings
should the nurse identify as an indication of derealization?
A. The client explains that her body seems to be floating above the ground
B. The client has the idea that someone is trying to kill her and steal her money
C. The client states that the furniture in the room seems to be small and far away
D. The client cannot recall anything that happened during the past 2 weeks
Answer: C. The client states that the furniture in the room seems to be small and far away
A nurse in an acute mental health facility is planning care for a client who has dissociative fugue.
Which of the following interventions should the nurse add to the plan of care?
A. Teach the client to recognize how stress brings on a personality change in the client
B. Repeatedly present the client with information about past events
C. Make decisions for the client regarding routine daily activities
D. Work with the client on grounding techniques
Answer: D. Work with the client on grounding techniques
A nurse working in an acute mental health facility is caring for a 35-year-old female client who
has manifestations of depression. The client lives at home with her partner and two young
children. She currently smokes and has a history of chronic asthma. Which of the following
factors put the client at risk for depression? (Select all that apply)
A. Age
B. Gender

C. History of chronic asthma
D. Smoking
E. Being married
Answer: A. Age
B. Gender
C. History of chronic asthma
E. Being married
A nurse working on an acute mental health unit is admitting a client who has major depressive
disorder and comorbid anxiety disorder. Which of the following actions is the nurse's priority?
A. Placing the client on one-to-one observation
B. Assisting the client to perform ADLs
C. Encouraging the client to participate in counseling
D. Teaching the client about medication adverse effects
Answer: A. Placing the client on one-to-one observation
A nurse working in an outpatient clinic is providing teaching to a client who has a new diagnosis
of premenstrual dysphoric disorder (PMDD). Which of the following statements by the client
indicates understanding of the teaching?
A. "I can expect my problems with PMDD to be worst when I'm menstruating."
B. "I will use light therapy 30 min a day to prevent further recurrences of PMDD."
C. "I am aware that my PMDD causes me to have rapid mood swings."
D. "I should increase my caloric intake with a nutritional supplement when my PMDD is active."
Answer: C. "I am aware that my PMDD causes me to have rapid mood swings."
A charge nurse is discussing the care of a client who has MDD with a newly licensed nurse.
Which of the following statements by the newly licensed nurse indicates an understanding of the
teaching?
A. "Care during the continuation phase focuses on treating continued manifestations of MDD."
B. "The treatment of MDD during the maintenance phase lasts for 6-12 weeks."
C. "The client is at greatest risk for suicide during the first weeks of an MDD episode."

D. "Medication and psychotherapy are most effective during the acute phase of MDD."
Answer: C. "The client is at greatest risk for suicide during the first weeks of an MDD episode."
A nurse is interviewing a 25-year-old client who has a new diagnosis of dysthymic disorder.
Which of the following findings should the nurse expect?
A. Wide fluctuations of mood
B. Report of a minimum of 5 clinical findings of depression
C. Presence of manifestations for at least 2 years
D. Inflated sense of self-esteem
Answer: C. Presence of manifestations for at least 2 years
A nurse is planning care for a client who has bipolar disorder and is experiencing a manic
episode. Which of the following interventions should the nurse include in the plan of care?
(Select all that apply)
A. Provide flexible client behavior expectations
B. Offer concise explanations
C. Establish consistent limits
D. Disregard client complaints
E. Use a firm approach with communication
Answer: B. Offer concise explanations
C. Establish consistent limits
E. Use a firm approach with communication
A nurse is teaching a newly licensed nurse about the use of ECT for the treatment of bipolar
disorder. Which of the following statements by the newly licensed nurse indicates
understanding?
A. "ECT is the recommended initial treatment for bipolar disorder."
B. "ECT is contraindicated for clients who have suicidal ideation."
C. "ECT is effective for client's who are experiencing severe mania."
D. "ECT is prescribed to prevent relapse of bipolar behavior."
Answer: C. "ECT is effective for client's who are experiencing severe mania."

A nurse is caring for a client who has bipolar disorder. The client states, "I am very rich, and I
feel I must give my money to you." Which of the following responses should the nurse make?
A. "Why do you think you feel the need to give money away?"
B. "I am here to provide care and cannot accept this from you."
C. "I can request that your case manager discuss appropriate charity options with you."
D. "You should know that giving away your money is inappropriate."
Answer: B. "I am here to provide care and cannot accept this from you."
A nurse in an acute mental health facility is caring for a client who has bipolar disorder. Which of
the following is the priority nursing action?
A. Set consistent limits for expected client behavior
B. Administer prescribed medications as scheduled
C. Provide the client with step by step instructions during hygiene activities
D. Monitor the client for escalating behavior
Answer: D. Monitor the client for escalating behavior
A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the
following information should the nurse include in the teaching? (Select all that apply)
A. Use caffeine in moderation to prevent relapse
B. Difficulty sleeping can indicate a relapse
C. Begin taking your medications as soon as a relapse begins
D. Participating in psychotherapy can help prevent a relapse
E. Anhedonia is a clinical manifestation of a depressive relapse
Answer: B. Difficulty sleeping can indicate a relapse
D. Participating in psychotherapy can help prevent a relapse
E. Anhedonia is a clinical manifestation of a depressive relapse
A nurse is caring for a client who has substance-induced psychotic disorder and is experiencing
auditory hallucinations. The client states, "The voices won't leave me alone!" Which of the
following statements should the nurse make? (Select all that apply)

A. "When did you start hearing the voices?"
B. "The voices are not real, or else we would both hear them."
C. "It must be scary to hear voices."
D. "Are the voices telling you to hurt yourself?"
E. "Why are the voices talking to only you?"
Answer: A. "When did you start hearing the voices?"
C. "It must be scary to hear voices."
D. "Are the voices telling you to hurt yourself?"
A nurse is completing an admission assessment for a client who has schizophrenia. Which of the
following findings should the nurse document as positive symptoms? (Select all that apply)
A. Auditory hallucination
B. Lack of motivation
C. Use of clang association
D. Delusion of persecution
E. Constantly waving arms
F. Flat affect
Answer: A. Auditory hallucination
C. Use of clang association
D. Delusion of persecution
E. Constantly waving arms
A nurse is caring for a client who has schizoaffective disorder. Which of the following statements
indicates the client is experiencing depersonalization?
A. "I am a superhero and am immortal."
B. "I am no one, and everyone is me."
C. "I feel monsters pinching me all over."
D. "I know that you are stealing my thoughts."
Answer: B. "I am no one, and everyone is me."

A nurse is caring for a client on an acute mental health unit The client reports hearing voices that
are telling her to "kill your doctor." Which of the following actions should the nurse take first?
A. Use therapeutic communication to discuss the hallucination with the client
B. Initiate one-to-one observation of the client
C. Focus the client on reality
D. Notify the provider of the client's statement
Answer: B. Initiate one-to-one observation of the client
A nurse is speaking with a client who has schizophrenia when he suddenly seems to stop
focusing on the nurse's questions and begins looking at the ceiling and talking to himself. Which
of the following actions should the nurse take?
A. Stop the interview at this point, and resume later when the client is better able to concentrate.
B. Ask the client, "Are you seeing something on the ceiling?"
C. Tell the client, "You seem to be looking at something on the ceiling. I see something there,
too."
D. Continue the interview without comment on the client's behavior.
Answer: B. Ask the client, "Are you seeing something on the ceiling?"
A nurse manager is discussing the care of a client who has a personality disorder with a newly
licensed nurse. Which of the following statements by the newly licensed nurse indicates an
understanding of the teaching?
A. "I can promote my client's sense of control by establishing a schedule."
B. "I should encourage clients who have a schizoid personality disorder to increase
socialization."
C. "I should practice limit-setting to help prevent client manipulation."
D. "I should implement assertiveness training with clients who have antisocial personality
disorder."
Answer: C. "I should practice limit-setting to help prevent client manipulation."
A nurse is caring for a client who has avoidant personality disorder. Which of the following
statements is expected from a client who has this type of personality disorder?

A. "I'm scared that you're going to leave me."
B. "I'll go to group therapy if you'll let me smoke."
C. "I need to feel that everyone admires me."
D. "I sometimes feel better if I cut myself."
Answer: A. "I'm scared that you're going to leave me."
A nurse is caring for a client who has borderline personality disorder. The client says, "The nurse
on the evening shift is always nice! You are the meanest nurse ever!" The nurse should recognize
the client's statement as an example of which of the following defense mechanisms?
A. Regression
B. Splitting
C. Undoing
D. Identification
Answer: B. Splitting
A nurse is assisting with a court-ordered evaluation of a client who has antisocial personality
disorder. Which of the following findings should the nurse expect? (Select all that apply)
A. Demonstrates extreme anxiety when placed in a social situation
B. Has difficulty making even simple decisions
C. Attempts to convince other clients to give him their belongings
D. Becomes agitated if his personal area is not neat and orderly
E. Blames others for his past and current problems
Answer: C. Attempts to convince other clients to give him their belongings
E. Blames others for his past and current problems
A charge nurse is preparing a staff education session on personality disorders. Which of the
following personality characteristics associated with all of the personality disorders should the
charge nurse include in the teaching? (Select all that apply)
A. Difficulty in getting along with other members of a group
B. Belief in the ability to become invisible during times of stress
C. Display of defense mechanisms when routines are changed

D. Claiming to be more important than other persons
E. Difficulty understanding why it is inappropriate to have a personal relationship with staff
Answer: A. Difficulty in getting along with other members of a group
C. Display of defense mechanisms when routines are changed
E. Difficulty understanding why it is inappropriate to have a personal relationship with staff
A nurse is caring for a client who has early stage Alzheimer's disease and a new prescription for
donepezil. The nurse should include which of the following statements when teaching the client
about the medication?
A. "You should avoid taking over-the-counter acetaminophen while on donepezil."
B. "You can expect the progression of cognitive decline to slow with donepezil."
C. "You will be screened for underlying kidney disease prior to starting donepezil."
D. "You should stop taking donepezil if you experience nausea or diarrhea."
Answer: B. "You can expect the progression of cognitive decline to slow with donepezil."
A nurse in a long-term care facility is caring for a client who has major neurocognitive disorder
and attempts to wander out of the building. The client states, "I have to get home." Which of the
following statements should the nurse make?
A. "You have forgotten that this is your home."
B. "You cannot go outside without a staff member."
C. "Why would you want to leave? Aren't you happy with your care?"
D. "I am your nurse. Let's walk together to your room."
Answer: D. "I am your nurse. Let's walk together to your room."
A home health nurse is making a visit to a client who has Alzheimer's disease to assess the home
for safety. Which of the following suggestions should the nurse make to decrease the client's risk
for injury? (Select all that apply)
A. Install childproof door locks.
B. Place rugs over electrical cords.
C. Mark cleaning supplies with colored tape.
D. Place the client's mattress on the floor.

E. Install light fixtures above stairs.
Answer: A. Install childproof door locks.
D. Place the client's mattress on the floor.
E. Install light fixtures above stairs.
A nurse is making a home visit to a client who is in the late stage of Alzheimer's disease. The
client's partner, who is the primary caregiver, wishes to discuss concerns about the client's
nutrition and the stress of providing care. Which of the following actions should the nurse take?
A. Verify that a current power of attorney document is on file.
B. Instruct the client's partner to offer finger foods to increase oral intake.
C. Provide information on resources for respite care.
D. Schedules the client for placement of an enteral feeding tube.
Answer: C. Provide information on resources for respite care.
A nurse is performing an admission assessment for a client who has delirium related to an acute
UTI. Which of the following findings should the nurse expect? (Select all that apply)
A. History of gradual memory loss
B. Family report of personality changes
C. Hallucinations
D. Unaltered level of consciousness
E. Restlessness
Answer: B. Family report of personality changes
C. Hallucinations
E. Restlessness
A nurse is planning a staff education program on substance use in older adults. Which of the
following is appropriate for the nurse to include in the presentation?
A. Older adults require higher doses of a substance to achieve a desired effect.
B. Older adults commonly use rationalization to cope with a substance use disorder.
C. Older adults are at an increased risk for substance use following retirement.
D. Older adults develop substance use to mask manifestations of dementia.

Answer: C. Older adults are at an increased risk for substance use following retirement.
A nurse is assessing a client who has alcohol use disorder and is experiencing withdrawal. Which
of the following findings should the nurse expect? (Select all that apply)
A. Bradycardia
B. Fine tremors of both hands
C. Hypotension
D. Vomiting
E. Restlessness
Answer: B. Fine tremors of both hands
D. Vomiting
E. Restlessness
A nurse is planning care for a client who is experiencing benzodiazepine withdrawal. Which of
the following interventions should the nurse identify as the priority?
A. Orient the client frequently to time, place, and person.
B. Offer fluids and nourishing diet as tolerated.
C. Implement seizure precautions.
D. Encourage participation in group therapy sessions.
Answer: C. Implement seizure precautions.
A nurse is caring for a client who has alcohol use disorder. The client is no longer experiencing
withdrawal manifestations. Which of the following medications should the nurse anticipate
administering to assist the client with maintaining abstinence from alcohol?
A. Chlordiazepoxide
B. Bupropion
C. Disulfiram
D. Carbamazepine
Answer: C. Disulfiram

A nurse is providing teaching to the family of a client who has a substance use disorder. Which
of the following statements by a family member indicate an understanding of the teaching?
(Select all that apply)
A. "We need to understand that she is responsible for her disorder."
B. "Eliminating any codependent behavior will promote her recovery."
C. "She should participate in an Al-Anon group to help her recover."
D. "The primary goal of her treatment is abstinence from substance use."
E. "She needs to discuss her feelings about substance use to help her recover."
Answer: B. "Eliminating any codependent behavior will promote her recovery."
D. "The primary goal of her treatment is abstinence from substance use."
E. "She needs to discuss her feelings about substance use to help her recover."
A nurse is preparing to obtain a nursing history from a client who has a new diagnosis of
anorexia nervosa. Which of the following questions should the nurse include in the assessment?
(Select all that apply)
A. "What is your relationship like with your family."
B. "Why do you want to lose weight?"
C. "Would you describe your current eating habits?"
D. "At what weight do you believe you will look better?"
E. "Can you discuss your feelings about your appearance?"
Answer: A. "What is your relationship like with your family."
C. "Would you describe your current eating habits?"
E. "Can you discuss your feelings about your appearance?"
A nurse is caring for an adolescent client who has anorexia nervosa with rapid weight loss and a
current weight of 90 lb. Which of the following statements indicates the client is experiencing
the cognitive distortion catastrophizing?
A. "Life isn't worth living if I gain weight."
B. "Don't pretend like you don't know how fat I am."
C. "If I could be skinny, I know I'd be popular."
D. "When I look in the mirror, I see myself as obese."

Answer: D. "When I look in the mirror, I see myself as obese."
A nurse is performing an admission assessment of a client who has bulimia nervosa with purging
behavior. Which of the following is an expected finding? (Select all that apply)
A. Amenorrhea
B. Hypokalemia
C. Mottling of the skin
D. Slightly elevated body weight
E. Presence of lanugo on the face
Answer: B. Hypokalemia
D. Slightly elevated body weight
A nurse on an acute care unit is planning care for a client who has anorexia nervosa with bingeeating and purging behavior. Which of the following nursing actions should the nurse include in
the client's plan of care?
A. Allow the client to select preferred meal times.
B. Establish consequences for purging behavior.
C. Provide the client with a high-fat diet at the start of treatment.
D. Implement one-to-one observation during meal times.
Answer: B. Establish consequences for purging behavior.
D. Implement one-to-one observation during meal times.
A nurse is caring for a client who has bulimia nervosa and has stopped purging behavior. The
client tells the nurse that she is afraid she is going to gain weight. Which of the following
responses should the nurse make?
A. "Many clients are concerned about their weight. However the dietitian will ensure that you
don't get too many calories in your diet."
B. "Instead of worrying about your weight, try to focus on other problems at this time."
C. "I understand you have concerns about your weight, but first, let's talk about your recent
accomplishments."

D. "You are not overweight, and the staff will ensure that you do not gain weight while you are
in the hospital. We know that is important to you."
Answer: D. "You are not overweight, and the staff will ensure that you do not gain weight while
you are in the hospital. We know that is important to you."
A nurse is discussing the risk factors for somatic symptom disorder with a newly licensed nurse.
Which of the following risk factors should the nurse include? (Select all that apply)
A. Age older than 65 years
B. Anxiety disorder
C. Female gender
D. Coronary artery disease
E. Obesity
Answer: B. Anxiety disorder
C. Female gender
E. Obesity
A nurse is reviewing the medical record of a client who has conversion disorder. Which of the
following findings should the nurse identify as placing the client as risk for conversion disorder?
A. Death of a child 2 months ago
B. Recent weight loss of 30 lb
C. Retirement 1 year ago
D. History of migraine headaches
Answer: A. Death of a child 2 months ago
A nurse is assessing a client who has illness anxiety disorder. Which of the following findings
should the nurse expect? (Select all that apply)
A. Obsessive thoughts about disease
B. History of childhood abuse
C. Avoidance of health care providers
D. Depressive disorder
E. Narcissistic personality

Answer: A. Obsessive thoughts about disease
C. Avoidance of health care providers
D. Depressive disorder
A nurse is developing a plan of care for a client who has conversion disorder. Which of the
following actions should the nurse include?
A. Encourage the client to spend time alone in his room
B. Monitor the client for self-harm once per day
C. Allow the client unlimited time to discuss physical manifestations
D. Discuss alternative coping strategies with the client
Answer: D. Discuss alternative coping strategies with the client
A nurse is counseling a client who has factitious disorder imposed on another. Which of the
following client statements should the nurse expect?
A. "I had to pretend I was injured in order to get disability benefits."
B. "I know that my abdominal pain is caused by a malignant tumor."
C. "I needed to make my son sick so that someone else would take care of him for a while."
D. "I became deaf when I heard that my husband was having an affair with my best friend."
Answer: C. "I needed to make my son sick so that someone else would take care of him for a
while."
A nurse working in a mental health clinic is providing teaching to a client who has a new
prescription for diazepam for generalized anxiety disorder. Which of the following information
should the nurse provide?
A. Three to six weeks of treatment is required to achieve therapeutic benefit
B. Combining alcohol with diazepam will produce a paradoxical response
C. Diazepam has a lower risk for dependence than other antianxiety medications
D. Report confusion as a potential indication of toxicity
Answer: D. Report confusion as a potential indication of toxicity

A nurse working in an emergency department is caring for a client who has benzodiazepine
toxicity due to an overdose. Which of the following actions is the nurse's priority?
A. Administer flumazenil
B. Identify the client's level of orientation
C. Infuse IV fluids
D. Prepare the client for gastric lavage
Answer: A. Administer flumazenil
A nurse is caring for a client who is to begin taking fluoxetine for treatment of generalized
anxiety disorder. Which of the following statements indicates the client understands the use of
this medication?
A. "I will take the medication at bedtime."
B. "I will follow a low-sodium diet while taking this medication."
C. "I will need to discontinue this medication slowly."
D. "I will be at risk for weight loss with long term use of this medication."
Answer: C. "I will need to discontinue this medication slowly."
A nurse is assessing a client 4 hr after receiving an initial dose of fluoxetine. Which of the
following findings should the nurse report to the provider as indications of serotonin syndrome?
(Select all that apply)
A. Hypothermia
B. Hallucinations
C. Muscular flaccidity
D. Diaphoresis
E. Agitation
Answer: B. Hallucinations
D. Diaphoresis
E. Agitation
A nurse is caring for a client who takes paroxetine to treat PTSD. The client states that he grinds
his teeth during the night, which causes pain in his mouth. The nurse should identify which of

the following interventions as possible measures to manage the client's bruxism? (Select all that
apply)
A. Concurrent administration of buspirone
B. Administration of a different SSRI
C. Use of a mouth guard
D. Changing to a different class of antianxiety medication
E. Increasing the dose of paroxetine
Answer: A. Concurrent administration of buspirone
C. Use of a mouth guard
D. Changing to a different class of antianxiety medication
• A, C, & D. Concurrent administration of buspirone, using a mouth guard, and changing to a
different class are effective measures.
• Other SSRIs will have the same effect. Increasing the dose will worsen the bruxism.
A nurse is providing teaching to a client who has a new prescription for amitriptyline. Which of
the following statements by the client indicates an understanding of the teaching?
A. "While taking this medication, I'll need to stay out of the sun to avoid a skin rash."
B. "I may feel drowsy for a few weeks after starting this medication."
C. "I cannot eat my favorite pizza with pepperoni while taking this medication."
D. "This medication will help me lose the weight that I have gained over the last year."
Answer: B. "I may feel drowsy for a few weeks after starting this medication."
A nurse is caring for a client who is taking phenelzine. For which of the following adverse
effects should the nurse monitor? (Select all that apply)
A. Elevated blood glucose level
B. Orthostatic hypotension
C. Priapism
D. Headache
E. Bruxism
Answer: B. Orthostatic hypotension
D. Headache

E. Bruxism
A nurse is review the medical record of a client who has a new prescription for bupropion for
depression. Which of the following findings is the priority for the nurse to report to the provider?
A. The client has a family history of SAD.
B. The client currently smokes 1.5 packs of cigarettes per day.
C. The client had a motor vehicle crash last year and sustained a head injury.
D. The client has a BMI of 25 and has gained 10 lb over the last year.
Answer: C. The client had a motor vehicle crash last year and sustained a head injury.
A nurse is teaching a client who has a new prescription for imipramine how to minimize
anticholinergic effects. Which of the following instructions should the nurse include in the
teaching? (Select all that apply)
A. Void just before taking the medication
B. Increase the dietary intake of potassium
C. Wear sunglasses when outside
D. Change positions slowly when getting up
E. Chew sugarless gum
Answer: A. Void just before taking the medication
D. Change positions slowly when getting up
E. Chew sugarless gum
A charge nurse is discussing mirtazapine with a newly licensed nurse. Which of the following
statements by the newly licensed nurse indicates understanding?
A. "This medication increases the release of serotonin and norepinephrine."
B. "I will need to monitor the client for hyponatremia while taking this medication."
C. "This medication is contraindicated for clients who have an eating disorder."
D. "Sexual dysfunction is a common adverse effect of this medication."
Answer: D. "Sexual dysfunction is a common adverse effect of this medication."

A nurse is caring for a client who is prescribed lithium therapy. The client states that he wants to
take ibuprofen for osteoarthritis pain relief. Which of the following statements should the nurse
make?
A. "That is a good choice. Ibuprofen does not interact with lithium."
B. "Regular aspirin would be a better choice than ibuprofen."
C. "Lithium decreases the effectiveness of ibuprofen."
D. "The ibuprofen will make your lithium level fall too low."
Answer: D. "The ibuprofen will make your lithium level fall too low."
A nurse is discussing early indications of toxicity with a client who has a new prescription for
lithium carbonate for bipolar disorder. The nurse should include which of the following
manifestations in the teaching? (Select all that apply)
A. Constipation
B. Polyuria
C. Rash
D. Muscle weakness
E. Tinnitus
Answer: B. Polyuria
C. Rash
D. Muscle weakness
E. Tinnitus
A nurse is discussing routine follow-up needs with a client who has a new prescription for
valproate. The nurse should inform the client of the need for routine monitoring of which of the
following?
A. AST/ALT and LDH
B. Creatinine and BUN
C. WBC and granulocyte counts
D. Serum sodium and potassium
Answer: C. WBC and granulocyte counts

A nurse is caring for a client who is experiencing extreme mania due to bipolar disorder. Prior to
administration of lithium carbonate, the client's lithium blood level 1.2 mEq/L. Which of the
following actions should the nurse take?
A. Administer the next dose of lithium carbonate as scheduled.
B. Prepare for administration of aminophylline.
C. Notify the provider for a possible increase in the dosage of lithium carbonate.
D. Request a stat repeat of the client's lithium blood level.
Answer: D. Request a stat repeat of the client's lithium blood level.
A nurse is admitting a client who has a new diagnosis of bipolar disorder and is scheduled to
begin lithium therapy. When collecting a medical history from the client's adult daughter, which
of the following statements is the priority to report to the provider?
A. "My mother has diabetes that is controlled by her diet."
B. "My mother recently completed a course of prednisone for acute bronchitis."
C. "My mother received her flu vaccine last month."
D. "My mother is currently on furosemide for her congestive heart failure."
Answer: D. "My mother is currently on furosemide for her congestive heart failure."
A nurse is caring for a client who has schizophrenia and exhibits a lack of grooming and a flat
affect. The nurse should anticipate a prescription of which of the following medications?
A. Chlorpromazine
B. Thiothixene
C. Risperidone
D. Haloperidol
Answer: C. Risperidone
A nurse is caring for a client who takes ziprasidone. The client reports difficulty swallowing the
oral medication and becomes extremely agitated with injectable administration. The nurse should
contact the provider to discuss a change in which of the following medications? (Select all that
apply)
A. Olanzapine

B. Quetiapine
C. Aripiprazole
D. Clozapine
E. Asenapine
Answer: A. Olanzapine
B. Quetiapine
A charge nurse is discussing manifestations of schizophrenia with a newly licensed nurse. Which
of the following manifestations should the charge nurse identify as being effectively treated by
first generation antipsychotics? (Select all that apply)
A. Auditory hallucinations
B. Withdrawal from social situations
C. Delusions of grandeur
D. Severe agitation
E. Anhedonia
Answer: A. Auditory hallucinations
C. Delusions of grandeur
D. Severe agitation
A nurse is assessing a client who is currently taking perphenazine. Which of the following
findings should the nurse identify as an extrapyramidal symptom (EPS)? (Select all that apply)
A. Decreased LOC
B. Drooling
C. Involuntary arm movements
D. Urinary retention
E. Continual pacing
Answer: B. Drooling
C. Involuntary arm movements
E. Continual pacing

A nurse is providing discharge teaching for a client who has schizophrenia and a new
prescription for iloperidone. Which of the following client statements indicates understanding of
the teaching?
A. "I will be able to stop taking this medication as soon as I feel better."
B. "If I feel drowsy during the day, I will stop taking this medication and call my provider."
C. "I will be careful not to gain too much weight while taking this medication."
D. "This medication is highly addictive and must be withdrawn slowly."
Answer: C. "I will be careful not to gain too much weight while taking this medication."
A nurse is teaching the parents of a child who has autism spectrum disorder and a new
prescription for imipramine about indications of toxicity. Which of the following should the
nurse include in the teaching? (Select all that apply)
A. Seizures
B. Agitation
C. Photophobia
D. Dry mouth
E. Irregular pulse
Answer: A. Seizures
B. Agitation
E. Irregular pulse
A nurse is providing teaching to an adolescent client who has a new prescription for
clomipramine for OCD. Which of the following information should the nurse provide?
A. Eat a diet high in fiber
B. Check temperature daily
C. Take medication first thing in the morning before eating
D. Add extra calories to the diet as between-meal snacks
Answer: C. Take medication first thing in the morning before eating

A nurse is providing teaching to an adolescent client who is to begin taking atomoxetine for
ADHD. The nurse should instruct the client to monitor for which of the following adverse
effects? (Select all that apply)
A. Somnolence
B. Yellowing skin
C. Increased appetite
D. Fever
E. Malaise
Answer: A. Somnolence
C. Increased appetite
A nurse is caring for a school age child who has conduct disorder and a new prescription for
methylphenidate transdermal patches. Which of the following information should the nurse
provide about the medication?
A. Apply the patch once daily at bedtime
B. Place the patch carefully in a trash can after removal
C. Apply the transdermal patch to the anterior waist area
D. Remove the patch each day after 9 hr
Answer: C. Apply the transdermal patch to the anterior waist area
A nurse is teaching a client who has intermittent explosive disorder about a new prescription for
fluoxetine. Which of the following information should the nurse provide? (Select all that apply)
A. An adverse effect of this medication is CNS depression
B. Administer the medication in the morning
C. Monitor for weight loss while taking this medication
D. Therapeutic effects of this medication will take 1-3 weeks to fully develop
E. This medication blocks the synaptic reuptake of serotonin in the brain.
Answer: B. Administer the medication in the morning
D. Therapeutic effects of this medication will take 1-3 weeks to fully develop
E. This medication blocks the synaptic reuptake of serotonin in the brain.

A nurse is providing teaching to a client who has alcohol use disorder and a new prescription for
carbamazepine. Which of the following information should the nurse include in the teaching?
A. "This medication will help prevent seizures during alcohol withdrawal."
B. "Taking this medication will decrease your cravings for alcohol."
C. "This medication maintains your blood pressure at a normal level during alcohol withdrawal."
D. "Taking this medication will improve your ability to maintain abstinence from alcohol."
Answer: A. "This medication will help prevent seizures during alcohol withdrawal."
A nurse is assisting in the discharge planning for a client following alcohol detoxification. The
nurse should anticipate prescriptions for which of the following medications to promote longterm abstinence from alcohol? (Select all that apply)
A. Lorazepam
B. Diazepam
C. Disulfiram
D. Naltrexone
E. Acamprosate
Answer: C. Disulfiram
D. Naltrexone
E. Acamprosate
A nurse is evaluating a client's understanding of a new prescription for clonidine for the
treatment or opioid use disorder. Which of the following statements by the client indicates an
understanding of the teaching?
A. "Taking this medication will help reduce my craving for heroin."
B. "While taking this medication, I should keep a pack of sugarless gum."
C. "I can expect some diarrhea from taking this medicine."
D. "Each dose of this medication should be placed under my tongue to dissolve."
Answer: A. "Taking this medication will help reduce my craving for heroin."

A nurse is discussing the use of methadone with a newly licensed nurse. Which of the following
statements by the newly licensed nurse indicates an understanding of the teaching? (Select all
that apply)
A. "Methadone is a replacement for physical dependence to opioids."
B. "Methadone reduces the unpleasant effects associated with abstinence syndrome."
C. "Methadone can be used during opioid withdrawal and to maintain abstinence."
D. "Methadone increases the risk for acetaldehyde syndrome." E. "Methadone must be
prescribed and dispensed by an approved treatment center."
Answer: A. "Methadone is a replacement for physical dependence to opioids."
B. "Methadone reduces the unpleasant effects associated with abstinence syndrome."
C. "Methadone can be used during opioid withdrawal and to maintain abstinence."
A nurse is teaching a client who has tobacco use disorder about the use of nicotine gum. Which
of the following information should the nurse include in the teaching?
A. Chew the gm for no more than 10 min.
B. Rinse out the mouth immediately before chewing the gum.
C. Avoid eating 15 min prior to chewing the gum.
D. Use of the gum is limited to 90 days.
Answer: C. Avoid eating 15 min prior to chewing the gum.
A nurse is caring for a client following the loss of her partner due to a terminal illness. Identify
the sequence of Engel's five stages of grief that the nurse should expect the client to experience.
(Select the stages of grief in the order of occurrence. All steps must be used.)
A. Developing awareness
B. Restitution
C. Shock and disbelief
D. Recovery
E. Resolution of the loss
Answer: C. Shock and disbelief
A. Developing awareness
B. Restitution

D. Recovery
E. Resolution of the loss
A charge nurse is reviewing Kugler-Ross: Five Stages of Grief with a group of newly licensed
nurses. Which of the following stages should the charge nurse include in the teaching? (Select all
that apply)
A. Disequilibrium
B. Denial
C. Bargaining
D. Anger
E. Depression
Answer: B. Denial
C. Bargaining
D. Anger
E. Depression
A nurse is working with a client who has recently lost his mother. The nurse recognizes that
which of the following factors influence a client's grief and coping ability? (Select all that apply)
A. Interpersonal relationships
B. Culture
C. Birth order
D. Religious beliefs
E. Prior experience with loss
Answer: A. Interpersonal relationships
B. Culture
D. Religious beliefs
E. Prior experience with loss
A nurse is discussing normal grief with a client who recently lost a child. Which of the following
statements made by the client indicates understanding? (Select all that apply)
A. "I may experience feelings of resentment."

B. "I will probably withdraw from others."
C. "I can expect to experience changes in sleep."
D. "It is possible that I will experience suicidal thoughts."
E. "It is expected that I will have a loss of self-esteem."
Answer: A. "I may experience feelings of resentment."
B. "I will probably withdraw from others."
C. "I can expect to experience changes in sleep."
E. "It is expected that I will have a loss of self-esteem."
A nurse is caring for a client who lost his mother to cancer last month. The client states, "I'd still
have my mother if the doctor would have diagnosed her sooner." Which of the following
responses should the nurse make?
A. "You sound angry. Anger is a normal feeling associated with loss."
B. "I think you would feel better if you talked about your feelings with a support group."
C. "I understand just how you feel. I felt the same when my mother died."
D. "Do other members of your family also feel this way?"
Answer: A. "You sound angry. Anger is a normal feeling associated with loss."
A nurse is assisting the parents of a school-age child who has oppositional defiant disorder in
identifying strategies to promote positive behavior. Which of the following is an appropriate
strategy for the nurse to recommend? (Select all that apply)
A. Allow the child to choose consequences for negative behavior
B. Use role-playing to act out unacceptable behavior
C. Develop a reward system for acceptable behavior
D. Encourage the child to participate in school sports
E. Be consistent when addressing unacceptable behavior
Answer: C. Develop a reward system for acceptable behavior
E. Be consistent when addressing unacceptable behavior
A nurse is performing an admission assessment on an adolescent client who has depression.
Which of the following manifestations should the nurse expect (Select all that apply)

A. Fear of being alone
B. Substance use
C. Weight gain
D. Irritability
E. Aggressiveness
Answer: B. Substance use
D. Irritability
E. Aggressiveness
A nurse is obtaining a health history from the parents of a 12 year old client who has conduct
disorder. Which of the following findings should the nurse expect? (Select all that apply)
A. Bullying of others
B. Threats of suicide
C. Law-breaking activities
D. Narcissistic behavior
E. Flat affect
Answer: A. Bullying of others
C. Law-breaking activities
A nurse in a podiatric clinic is caring for a preschool-age child who has a new diagnosis of
ADHD. When teaching the parent about this disorder, which of the following statements should
the nurse include in the teaching?
A. "Behaviors associated with ADHD are present prior to age 3."
B. "This disorder is characterized by argumentativeness."
C. "Below-average intellectual functioning is associated with ADHD."
D. "Because of this disorder, your child is at increased risk for injury."
Answer: D. "Because of this disorder, your child is at increased risk for injury."
A nurse is assessing a 4-year-old child for indications of autism spectrum disorder. For which of
the following manifestations should the nurse assess?
A. Impulsive behavior

B. Repetitive counting
C. Destructiveness
D. Somatic problems
Answer: B. Repetitive counting
A nurse is conducting chart reviews of multiple clients at a community mental health facility.
Which of the following events is an example of client experiencing a maturational crisis?
A. Rape
B. Marriage
C. Severe physical illness
D. Job loss
Answer: B. Marriage
A nurse is caring for a client who is experiencing a crisis. Which of the following medications
might the provider prescribe? (Select all that apply)
A. Lithium carbonate
B. Paroxetine
C. Risperidone
D. Haloperidol
E. Lorazepam
Answer: C. Risperidone
D. Haloperidol
E. Lorazepam
A nurse is assessing a client who has major depressive disorder. The nurse should identify which
of the following client statements as an overt comment about suicide? (Select all that apply)
A. "My family will be better off if I'm dead."
B. "The stress in my life is too much to handle."
C. "I wish my life was over."
D. "I don't feel like I can ever be happy again."
E. "If I kill myself then my problems will go away."

Answer: A. "My family will be better off if I'm dead."
C. "I wish my life was over."
E. "If I kill myself then my problems will go away."
A nurse is caring for a client who states, "I plan to commit suicide." Which of the following
assessments should the nurse identify as the priority?
A. Client's educational and economic background
B. Lethality of the method and availability of means
C. Quality of the client's social support
D. Client's insight into the reasons for the decision
E. The greatest risk to the client is self-harm as a result of carrying out a suicide plan.
Answer: B. Lethality of the method and availability of means
A nurse is assisting with the development of protocols to address the increasing number of
suicide attempts in the community. Which of the following interventions should the nurse
include as a primary intervention? (Select all that apply)
A. Conducting a suicide risk screening on all new clients
B. Creating a support group for family members of clients who completed suicide
C. Educating high school teens about suicide prevention
D. Initiating one-on-one observation for a client who has suicidal ideation
E. Teaching middle-school educators about warning indicators of suicide
Answer: A. Conducting a suicide risk screening on all new clients
C. Educating high school teens about suicide prevention
E. Teaching middle-school educators about warning indicators of suicide
A nurse is caring for a client who is on suicide precautions. Which of the following interventions
should the nurse include in the plan of care?
A. Assign the client to a private room
B. Document the client's behavior every hour
C. Allow the client to keep perfume in her room
D. Ensure that the client swallows medication

Answer: B. Document the client's behavior every hour
A nurse is conducting a class for a group of newly licensed nurses on caring for clients who at
risk for suicide. Which of the following information should the nurse include in the teaching?
A. A client's verbal threat of suicide is attention-seeking behavior
B. Interventions are ineffective for clients who really want to commit suicide
C. Using the term suicide increases the client's risk for a suicide attempt
D. A no-suicide contract decreases the client's risk for a suicide attempt
Answer: B. Interventions are ineffective for clients who really want to commit suicide
A nurse is conducting group therapy with a group of clients. Which of the following statements
made by a client is an example of aggressive communication?
A. "I wish you could not make me angry."
B. "I feel angry when you leave me."
C. "It makes me angry when you interrupt me."
D. "You'd better listen to me."
Answer: D. "You'd better listen to me."
A nurse is caring for a client who is speaking in a loud voice with clenched fists. Which of the
following actions should the nurse take?
A. Insist that the client stop yelling
B. Request that other staff members remain close by
C. Move as close to the client as possible
D. Walk away from the client
Answer: B. Request that other staff members remain close by
A nurse is assessing a client in an inpatient mental health unit. Which of the following findings
should the nurse expect if the client is in the preassaultive stage of violence? (Select all that
apply)
A. Lethargy
B. Defensive responses to questions

C. Disorientation
D. Facial grimacing
E. Agitation
Answer: B. Defensive responses to questions
D. Facial grimacing
E. Agitation
A nurse is caring for a client in an inpatient mental health facility who gets up from a chair and
throws it across the day room. Which of the following is the priority nursing action?
A. Encourage the client to express her feelings
B. Maintain eye contact with the client
C. Move the client away from others
D. Tell the client that the behavior is not acceptable
Answer: C. Move the client away from others
A nurse is caring for a client who is screaming at staff members and other clients. Which of the
following is a therapeutic response by the nurse to the client?
A. "Stop screaming, and walk with me outside."
B. "Why are you so angry and screaming at everyone?"
C. "You will not get your way by screaming."
D. "What was going through your mind when you started screaming?"
Answer: C. "You will not get your way by screaming."
A charge nurse is leading a peer group discussion about family and community violence. Which
of the following statements by a member of the group indicates an understanding of the
teaching?
A. "Children older than 3 are at greater risk for abuse."
B. "Substance use disorder does not increase the risk for violence."
C. "Entering an intimate relationship increases the risk for violence."
D. "Pregnancy increases the risk for violence toward the intimate partner."
Answer: D. "Pregnancy increases the risk for violence toward the intimate partner."

A nurse is preparing to assess an infant who has shaken baby syndrome. Which of the following
is an expected finding? (Select all that apply)
A. Sunken fontanels
B. Respiratory distress
C. Retinal hemorrhage
D. Altered LOC
E. Increase in head circumference
Answer: C. Retinal hemorrhage
D. Altered LOC
A nurse working in an emergency department is assessing a preschool-age child who reports
abdominal pain. When conducting a head-to-toe assessment, which of the following findings
should alert the nurse to possible abuse?
A. Abrasions on knees
B. Round burn marks on forearms
C. Mismatched clothing
D. Abdominal rebound tenderness
E. Areas of ecchymosis on torso
Answer: B. Round burn marks on forearms
E. Areas of ecchymosis on torso
A nurse is preparing a community education seminar about family violence. When discussing
types of violence, the nurse should include which of the following?
A. Refusing to pay bills for a dependent, even when funds are available, is neglect.
B. Intentionally causing an older adult to fall is an example of physical violence.
C. Striking an intimate partner is an example of sexual violence.
D. Failure to provide a stimulating environment for normal development is emotional abuse.
Answer: A. Refusing to pay bills for a dependent, even when funds are available, is neglect.

A nurse is caring for an adult client who has injuries resulting from intimate partner abuse. The
client does not wish to report the violence to law enforcement authorities. Which of the
following nursing actions is the highest priority?
A. Advise the client about the location of women's shelters
B. Encourage the client to participate in a support group for survivors of abuse
C. Implement case management to coordinate community and social services
D. Educate the client about the use of stress management techniques
Answer: A. Advise the client about the location of women's shelters
A nurse is discussing silent rape reaction with a newly licensed nurse. The nurse should identify
which of the following characteristics as expected for this type of reaction? (Select all that apply)
A. Sudden development of phobias
B. Development of substance use disorder
C. Increased level of anxiety during interview
D. Reactivation of a prior physical disorder
E. Unwillingness to discuss the sexual assault
Answer: D. Reactivation of a prior physical disorder
E. Unwillingness to discuss the sexual assault
A nurse is assessing a client who experienced sexual assault. Which of the following findings
indicate the client is experiencing an emotional reaction of rape-trauma syndrome? (Select all
that apply)
A. Genitourinary soreness
B. Difficulties with low self-esteem
C. Sleep disturbances
D. Emotional outburst
E. Difficulty making decisions
Answer: B. Difficulties with low self-esteem
C. Sleep disturbances
D. Emotional outburst
E. Difficulty making decisions

A nurse is discussing the care of a client following a sexual assault with a newly licensed nurse.
Which of the following statements by the newly licensed nurse indicates an understanding of the
teaching?
A. "I will administer prophylactic treatment for sexually transmitted infections."
B. "I am not required to obtain informed consent before the sexual assault nurse examiner
collects forensic evidence."
C. "I can expect manifestations of rape-trauma syndrome to be similar to bipolar disorder."
D. "I should use narrative documentation when documenting subjective data."
Answer: A. "I will administer prophylactic treatment for sexually transmitted infections."
A nurse is caring for a client who was recently raped. The client states, "I never should have been
out on the street alone at night." Which of the following responses should the nurse make?
A. "Your actions had nothing to do with what happened."
B. "You should focus on recovery rather than blaming yourself for what happened."
C. "You believe this wouldn't have happened if you hadn't been out alone?"
D. "Why do you feel that you should not have been alone on the street at night?"
Answer: C. "You believe this wouldn't have happened if you hadn't been out alone?"
A community health nurse is leading a discussion about rape with a neighborhood task force.
Which of the following statements by a neighborhood citizen indicates an understanding of the
teaching?
A. "Rape is a crime of passion."
B. "Acquaintance rape often involves alcohol."
C. "Young adults are the typical victims of sexual assault."
D. "The majority of rapists are unknown to the victims."
Answer: B. "Acquaintance rape often involves alcohol."
Mental Health Basics

• Levels of Consciousness (alphabetic until C)

o Alert : patient is responsive, opening eyes spontaneously, respond to question appropriately
o Lethargic: falls asleep easily, opens eyes, responsive
o Obtunded: respond to light shaking, confused, slow to respond
o Stuporous: patient barely responds to painful stimuli (ex: rubbing sternum)
o Comatose: unresponsive and abnormal posturing may be present ▪ 1 . decorticate: arms are
flexed and internally rotated towards core, legs extends and internally rotated
▪ 2. Decerebrate: both arms and legs extended, head arched back
• Nursing Ethics
o Autonomy: patient has right to make own decision, even if it’s not in their best interest
o Beneficence: doing what is best for patient
o Fidelity: loyal, keeping promises
o Justice: provide fairness in care and allocation in resources across patients
o Non-maleficence: doing no harm
o Veracity: telling the truth, being honest
• Patient rights
o Right to refuse treatment – applies to patients who are involuntary admitted
o Confidentiality: patients medical information is protected by HIPPA and cannot be released
unless permission given
o Mandatory reporting: nurses are required to report suspicion of abuse, and to warn/protect third
parties who are at risk for harm.
• Informed Consent:
o Provider Responsibilities:
▪ Communicates purpose of procedure, and complete description of procedure in the patient’s
primary language
▪ Explain risks vs. benefits
▪ Describe other options to treat condition
o RN
▪ Make sure provider gave the patient the above information
▪ Ensure the patient is competent to give informed consent (i.e. patient is an adult or emancipated
minor, not impaired)

▪ Have patient sign consent document
▪ Notify provider if patient has more questions or doesn’t understand any information
• Restraints:
o Always have alternatives before restraints.
o Can do restraint in emergency BUT need written prescription from provider quickly after (1hr)
o Provider will need to re-write prescription every 24 hours, no PRN prescription
o Best Practice:
▪ Wrist – two fingers
▪ Quick release knot (slip knot, NOT SQURE)
▪ Use a movable part of the bed frame so if you move the bed the restraints move with them
o Types of restraints: physical (vest, belt, mitten) or chemical (sedative or antipsychotic
medication)
o Alternatives: provide verbal interventions, diversions, calm/quiet environment
o Prescription:
▪ Prescription must be in writing
▪ If need for constraints continue, provider must re-write prescription every 24 hours
▪ In an emergency situation, a nurse can use restraints but must
obtain a written prescription per facility policy (15-30 minutes)
o Time limits:
▪ Adults: 4 hours
▪ 9-17: 2 hours
▪ =1 week. Usually requires hospitalization.
▪ Hypomania – less severe form of mania, does not require hospitalization
▪ Rapid cycling - >= 4 episodes of mania or hypomania within 1 year.
o Types of Bipolar:
▪ Bipolar I: at least one episode of mania alternating with major depression
▪ Bipolar II: one or more hypomania episodes, alternating w/ major depression.
▪ Cyclothymic disorder: two years of repeated hypomanic episodes alternating w/ minor
depression.
o Risk factors:
▪ Genetics, psychological stressors, neurological disorders, substance use disorder
o Mania s/s:
▪ Mood swings, restlessness, flight of ideas, pressured speech, grandiosity, impulsiveness, poor
judgment, decreased attention span, insomnia (risk of physical examination), neglect of ADLs
(including eating, drinking), possible hallucinations or delusions.
o Depressive s/s:
▪ Anergy, flat affect, anhedonia, crying, difficulty concentrating, possible risk for suicide, lack of
grooming/hygiene, changes in sleep and appetite.
o Nursing Care during manic episodes:
▪ Provide safe environment. Protect patient from poor judgement (i.e. giving away money, sexual
indiscretions).
▪ Decrease stimulation
▪ 1:1 observation, seclusion, or restraints may be necessary if patient poses a risk to self or
others.

▪ Provide frequent rest periods.
▪ Monitor sleep, fluid and food intake. Provide high-calorie portable snacks (finger foods)
▪ Set limits, give concise explanations, use a calm approach.
o Medications: lithium, anticonvulsants, antipsychotic meds, anti-anxiety meds, antidepressants.
• Psychotic Disorders
o Schizophrenia: Psychotic thinking/behavior for >=6 months. Functioning and relationships
significantly impaired.
o Schizotypal personality disorder: personality impaired, but not as severe as schizophrenia.
o Schizophreniform disorder: psychotic thinking/behavior for 1-6
months. May not affect social and occupational functioning. o Schizoaffective disorder: patients
meets criteria for schizophrenia AND depressive or bipolar disorder.
o Psychotic disorders s/s:
▪ Positive symptoms: presence of things not normally present – hallucinations, delusions, strange
motor activity, speech alterations, agitation
▪ Negative symptoms: affect, alogia, anergia, ahnedonia, avolition
▪ Other s/s: disordered thinking, poor problem solving, difficulty concentrating, memory issues,
hopelessness, possible suicide ideation, depersonalization, derealization.
o Psychotic disorders: alterations in speech
▪ Flight of ideas: each sentence relates to a different topic. Listener unable to follow patient’s
thoughts.
▪ Neologisms: made-up words that only the patient understands.
▪ Echolalia: patient repeats exactly what is said to him/her.
▪ Clang associations: meaningless rhyming of words
▪ Word salad: words are jumbled together in a meaningless way.
o Psychotic disorders: hallucinations
▪ Sensory perception that do not have an external stimulus.
Types:
• Auditory: patient hears voices or sounds
o Command hallucinations: voice instructs patients to perform action (at risk to hurt self or
others)

• Visual: patient sees person or things.
• Olfactory: patient smells odors.
• Gustatory: patient experiences tastes.
• Tactile: patient feels body sensations.
o Nursing Care:
▪ Provides safe, structured environment
▪ Attempt to identify and reduce symptoms triggers
▪ Decrease environment stimuli
▪ Priority: ask patient directly about hallucinations, including command hallucinations! Provide
safety of patient and/or others (1:1 observation)
▪ Do not argue or agree with hallucinations or delusions ex: “I don’t hear anything, but it must be
scary to hear voices”
o Medications:
▪ Conventional and atypical antipsychotics
• Personality Disorders
o Types:
▪ Paranoid: distrust and suspiciousness of others
▪ Schizoid: emotional detachment, indifference
▪ Schizotypal: magical thinking, odd beliefs, perceptual distortions.
▪ Antisocial: exploitation, manipulation, and deceit of others. Verbally charming. Fails to accept
personal responsibility.
▪ Borderline: splitting behavior (characterize people or things as ALL good or ALL bad),
emotional lability, impulsive behaviors, high risk of self-injury or suicide.
▪ Histrionic: attention-seeking, seductive, flirtatious.
▪ Narcissistic: arrogant, need for constant admiration, lack of empathy towards others.
▪ Avoidant: avoids social situations and interpersonal contact due to extreme fear of rejection,
abandonment.
▪ Dependent: extreme dependency in a close relationships. Needs excessive input from others to
make decisions.
▪ OCD: focus perfection, order, and control that may prevent patient from completing a task.

o Nursing: mod
▪ Provide safety for patients at risks for self-injury or violence (ex: borderline personality
disorder at high risk for self-injury)
▪ Provide limits and consistency (especially for borderline and antisocial personality disorders)
▪ Provide assertiveness training for dependent and histrionic personality disorders.
▪ Respect the need for patients with schizoid and schizotypal personality disorder to isolate
themselves.
• Alzheimer’s Disease
o Non-reversible neurocognitive disorder (i.e. dementia), resulting in memory loss, problems w/
judgement, and changes in personality.
▪ Stage 1 (mild): memory lapses, frequently misplacing items, difficulty concentrating, no issues
w/ ADLs.
▪ Stage 2 (moderate): difficulty planning/organizing, wandering, personality and behavior
changes.
▪ Stage 3 (severe): assistance needed w/ ADLs, incontinent, loss of ability to move, death
(usually due to infection or choking)
o Defense mechanisms:
▪ Denial: refusal to believe changes
▪ Confabulation: patient makes up stories to prevent admitting that she/he does not remember
things
▪ Preservation: patient repeat
o Medications:
▪ Donepezil (cholinesterase inhibitor): slows cognitive deterioration and improves ability
perform ADLs. Side effect includes GI upset, bradycardia. Administer once daily at bedtime.
o Nursing care:
▪ Provide safe environment (protect from falls, wandering)
▪ Use monitors and bed alarams as needed
▪ Place patient in room near nurses station
▪ Provide prominently displaced calendar and clock.
▪ Reorient patient as needed
▪ Maintain consistently w/ caregivers

▪ Use calm voice, short sentences
▪ Limit choices
o Home Safety
▪ No scatter rugs
▪ Install door locks
▪ Lock away cleaning supplies
▪ Provide good lighting (especially over stairs)
▪ Mark step edges w/ colored tape
▪ Install handrails in bathroom
▪ Place mattress on the floor
▪ Secure electrical cord to baseboards
▪ Remove clutter
• Dementia vs Delirium
o Dementia
▪ Gradual onset
▪ Level of consciousness, vital signs unchanged
▪ RT to neurological disorder (alzheimer’s disease, traumatic brain injury, parkinson’s, etc).
▪ Progressive, irreversible
o Delirium
▪ Rapid onset
▪ Level of consciousness altered, vital signs may become unstable
▪ Extreme distractibility
▪ Caused secondary to a medical condition (infection, electrolyte imbalances, substance abuse,
et.)
▪ Reversible if underlying cause corrected
• Alcohol
o S&S of intoxication: slurred speech, decreased motor skills, decreased level of consciousness,
memory impairment, BAC >= 0.08 is considered legally intoxicated in most states.
o Withdrawal:

▪ Timing: starts within 4-12 hours of last drink, peaks at 24-48
hours
▪ S&S: vomiting, tremors, restlessness, tachycardia, tachypnea, hypertension, fever, seizures.
o Alcohol withdrawal delirium
▪ Timing: 2-3 days after cessation of alcohol
▪ S&S: hallucinations, severe HTN, delirium, cardiac dysrhythmias
▪ **most important question: “when did you have your last drink?”
o AA
▪ Purpose: to stay sober and help other alcoholics achieve sobriety. AA encourages recovery
through peer support
▪ Key principles/points:
• Total abstinence is the only cure for alcohol use disorder
• Individuals should take responsibility for recovery rather than the addition
• Individuals with an addiction cannot place blame on other people or issues for their addiction.
• Individuals with an addiction must face their problems and their feelings.
• Program is not intended for addiction to other substances
• Securing a sponsor improves chance of recovery
• Cocaine, Opioids
o Cocaine
▪ S&S intoxication: tachycardia, hypertension, dilated pupils, chest pain, tremor/seizures,
irritability/agitation
▪ S&S of withdrawal: fatigue, depression, decreased motor skills, disturbing dreams, agitation
o Opioids
▪ S&S of intoxication: slurred speech, decreased RR, decreased LOC, impaired judgement and
memory
▪ S&S of withdrawal: sweating, rhinorrhea, pupil dilation, tremors, irritability, insomnia, GI
upset, muscle spasms
• Anorexia Nervosa
o Eating disorder characterized by distorted body image that causes an individual to restrict
calorie intake.

o S&S: low body weight, low BP, decrease pulse, decreased body temperature, constipation,
lanugo, mottled/cool extremities, poor skin turgor, amenorrhea
o Criteria for hospitalization:
▪ Weight loss > 30% over 6 months
▪ Heart rate <40 /min
▪ SBP <70 mmHg
▪ Body temperature = 4 episodes of mania or hypomania within 1 year.
o Types of Bipolar:
▪ Bipolar I: at least one episode of mania alternating with major depression
▪ Bipolar II: one or more hypomania episodes, alternating w/major depression.
▪ Cyclothymic disorder: two years of repeated hypomanic episodes alternating w/ minor
depression.
o Risk factors:
▪ Genetics, psychological stressors, neurological disorders, substance use disorder
o Mania s/s:
▪ Mood swings, restlessness, flight of ideas, pressured speech, grandiosity, impulsiveness, poor
judgment, decreased attention span, insomnia (risk of physical examination), neglect of ADLs
(including eating, drinking), possible hallucinations or delusions.
o Depressive s/s:
▪ Anergy, flat affect, anhedonia, crying, difficulty concentrating, possible risk for suicide, lack of
grooming/hygiene, changes in sleep and appetite.
o Nursing Care during manic episodes:
▪ Provide safe environment. Protect patient from poor judgement (i.e. giving away money, sexual
indiscretions).
▪ Decrease stimulation
▪ 1:1 observation, seclusion, or restraints may be necessary if patient poses a risk to self or
others.
▪ Provide frequent rest periods.
▪ Monitor sleep, fluid and food intake. Provide high-calorie portable snacks (finger foods)
▪ Set limits, give concise explanations, use a calm approach.
o Medications: lithium, anticonvulsants, antipsychotic meds, anti-anxiety meds, antidepressants.
• Psychotic Disorders
o Schizophrenia: Psychotic thinking/behavior for >=6 months. Functioning and relationships
significantly impaired.
o Schizotypal personality disorder: personality impaired, but not as severe as schizophrenia.

o Schizophreniform disorder: psychotic thinking/behavior for 1-6 months. May not affect social
and occupational functioning.
o Schizoaffective disorder: patients meets criteria for schizophrenia AND depressive or bipolar
disorder.
o Psychotic disorders s/s:
▪ Positive symptoms: presence of things not normally present – hallucinations, delusions, strange
motor activity, speech alterations, agitation
▪ Negative symptoms: affect, alogia, anergia, ahnedonia, avolition
▪ Other s/s: disordered thinking, poor problem solving, difficulty concentrating, memory issues,
hopelessness, possible suicide ideation, depersonalization, derealization.
o Psychotic disorders: alterations in speech
▪ Flight of ideas: each sentence relates to a different topic. Listener unable to follow patient’s
thoughts.
▪ Neologisms: made-up words that only the patient understands.
▪ Echolalia: patient repeats exactly what is said to him/her.
▪ Clang associations: meaningless rhyming of words
▪ Word salad: words are jumbled together in a meaningless way.
o Psychotic disorders: hallucinations
▪ Sensory perception that do not have an external stimulus.
Types:
• Auditory: patient hears voices or sounds
o Command hallucinations: voice instructs patients to perform action (at risk to hurt self or
others)
• Visual: patient sees person or things.
• Olfactory: patient smells odors.
• Gustatory: patient experiences tastes.
• Tactile: patient feels body sensations.
o Nursing Care:
▪ Provides safe, structured environment
▪ Attempt to identify and reduce symptoms triggers

▪ Decrease environment stimuli
▪ Priority: ask patient directly about hallucinations, including command hallucinations! Provide
safety of patient and/or others (1:1 observation)
▪ Do not argue or agree with hallucinations or delusions ex: “I don’t hear anything, but it must be
scary to hear voices”
o Medications:
▪ Conventional and atypical antipsychotics
• Personality Disorders
o Types:
▪ Paranoid: distrust and suspiciousness of others
▪ Schizoid: emotional detachment, indifference
▪ Schizotypal: magical thinking, odd beliefs, perceptual distortions.
▪ Antisocial: exploitation, manipulation, and deceit of others. Verbally charming. Fails to accept
personal responsibility.
▪ Borderline: splitting behavior (characterize people or things as ALL good or ALL bad),
emotional lability, impulsive behaviors, high risk of self-injury or suicide.
▪ Histrionic: attention-seeking, seductive, flirtatious.
▪ Narcissistic: arrogant, need for constant admiration, lack of empathy towards others.
▪ Avoidant: avoids social situations and interpersonal contact due to extreme fear of rejection,
abandonment.
▪ Dependent: extreme dependency in a close relationships. Needs excessive input from others to
make decisions.
▪ OCD: focus perfection, order, and control that may prevent patient from completing a task.
o Nursing: mod
▪ Provide safety for patients at risks for self-injury or violence (ex: borderline personality
disorder at high risk for self-injury)
▪ Provide limits and consistency (especially for borderline and antisocial personality disorders)
▪ Provide assertiveness training for dependent and histrionic personality disorders.
▪ Respect the need for patients with schizoid and schizotypal personality disorder to isolate
themselves.
• Alzheimer’s Disease

o Non-reversible neurocognitive disorder (i.e. dementia), resulting in memory loss, problems w/
judgement, and changes in personality.
▪ Stage 1 (mild): memory lapses, frequently misplacing items, difficulty concentrating, no issues
w/ ADLs.
▪ Stage 2 (moderate): difficulty planning/organizing, wandering, personality and behavior
changes.
▪ Stage 3 (severe): assistance needed w/ ADLs, incontinent, loss of ability to move, death
(usually due to infection or choking)
o Defense mechanisms:
▪ Denial: refusal to believe changes
▪ Confabulation: patient makes up stories to prevent admitting that she/he does not remember
things
▪ Preservation: patient repeat
o Medications:
▪ Donepezil (cholinesterase inhibitor): slows cognitive deterioration and improves ability
perform ADLs. Side effect includes GI upset, bradycardia. Administer once daily at bedtime.
o Nursing care:
▪ Provide safe environment (protect from falls, wandering)
▪ Use monitors and bed alarams as needed
▪ Place patient in room near nurses station
▪ Provide prominently displaced calendar and clock.
▪ Reorient patient as needed
▪ Maintain consistently w/ caregivers
▪ Use calm voice, short sentences
▪ Limit choices
o Home Safety
▪ No scatter rugs
▪ Install door locks
▪ Lock away cleaning supplies
▪ Provide good lighting (especially over stairs)

▪ Mark step edges w/ colored tape
▪ Install handrails in bathroom
▪ Place mattress on the floor
▪ Secure electrical cord to baseboards
▪ Remove clutter
• Dementia vs Delirium
o Dementia
▪ Gradual onset
▪ Level of consciousness, vital signs unchanged
▪ RT to neurological disorder (alzheimer’s disease, traumatic brain injury, parkinson’s, etc).
▪ Progressive, irreversible
o Delirium
▪ Rapid onset
▪ Level of consciousness altered, vital signs may become unstable
▪ Extreme distractibility
▪ Caused secondary to a medical condition (infection, electrolyte imbalances, substance abuse,
et.)
▪ Reversible if underlying cause corrected
• Alcohol
o S&S of intoxication: slurred speech, decreased motor skills, decreased level of consciousness,
memory impairment, BAC >= 0.08 is considered legally intoxicated in most states.
o Withdrawal:
▪ Timing: starts within 4-12 hours of last drink, peaks at 24-48 hours
▪ S&S: vomiting, tremors, restlessness, tachycardia, tachypnea, hypertension, fever, seizures.
o Alcohol withdrawal delirium
▪ Timing: 2-3 days after cessation of alcohol
▪ S&S: hallucinations, severe HTN, delirium, cardiac dysrhythmias
▪ **most important question: “when did you have your last drink?”
o AA

▪ Purpose: to stay sober and help other alcoholics achieve sobriety. AA encourages recovery
through peer support
▪ Key principles/points:
• Total abstinence is the only cure for alcohol use disorder
• Individuals should take responsibility for recovery rather than the addition
• Individuals with an addiction cannot place blame on other people or issues for their addiction.
• Individuals with an addiction must face their problems and their feelings.
• Program is not intended for addiction to other substances
• Securing a sponsor improves chance of recovery
• Cocaine, Opioids
o Cocaine
▪ S&S intoxication: tachycardia, hypertension, dilated pupils, chest pain, tremor/seizures,
irritability/agitation
▪ S&S of withdrawal: fatigue, depression, decreased motor skills, disturbing dreams, agitation
o Opioids
▪ S&S of intoxication: slurred speech, decreased RR, decreased LOC, impaired judgement and
memory
▪ S&S of withdrawal: sweating, rhinorrhea, pupil dilation, tremors, irritability, insomnia, GI
upset, muscle spasms
• Anorexia Nervosa
o Eating disorder characterized by distorted body image that causes an individual to restrict
calorie intake.
o S&S: low body weight, low BP, decrease pulse, decreased body temperature, constipation,
lanugo, mottled/cool extremities, poor skin turgor, amenorrhea
o Criteria for hospitalization:
▪ Weight loss > 30% over 6 months
▪ Heart rate <40 /min
▪ SBP <70 mmHg
▪ Body temperature <36 degrees C
▪ EKG abnormalities

▪ Electrolyte imbalances
• Bulimia Nervosa
o Eating disorder characterized by the ingestion of an abnormally large amount of food in shortterm period, followed by an attempt to avoid gaining weight by purging what was consumed
(though vomiting, diuretics, and/or enemas).
o S&S: normal (or slightly higher) body weight calluses on knuckles (Russel’s sign) from selfinduced vomiting, enlargement of parotid gland, tooth erosion, hypokalemia, metabolic alkalosis
(from vomiting) or metabolic acidosis (from laxative use)
• Eating Disorders: Nursing Care
o Offer rewards for the amount of calories consumes, not the amount of weight gained.
o Monitor VS, I/O, weight (weigh patient each morning before the intake of foods or fluids).
o Restrict caffeine due to its stimulative and diuretic effects.
o Provide a high-fiber diet to control constipation
o Monitor and restrict the client’s exercise
o Provide small, frequent meals at scheduled times
o Closely monitor patient during and after meals
• Somatic Symptom Disorder
o Form a mental illness where the patient experiences physical manifestations that are the result
of psychological factors (no underlying physical pathology). RT: conversion disorder.
o Risk factors: female gender, teen/young adult, childhood trauma, mental illness (depression,
anxiety, personality, disorder), recent stressful event.
o Nursing care: acknowledge symptoms as being real to the patients
o Reattribution treatment: helps patients identify the link between psychological factors and
physical manifestations.
o Administer medications as prescribed: antidepressants, anxiolytics.
• Factitious Disorder
o Form of mental illness that drives an individual to report non-existent physical or
psychological symptoms in an effort to fill an emotional need for attention
▪ Factitious disorder imposed on another: an individual deliberately causes injury/illness to a
vulnerable person in order to get attention (or get relief from responsibility)
o Nursing care: avoid confrontation, build rapport/trust with patient, ensure safety of vulnerable
persons, communicate suspicion of factitious disorder of the health care team

o Malingering: not a mental illness. Exaggeration of ling about symptoms to escape duty/work or
collect disability.
• Oppositional defiant disorder
o Disorder in a child or adolescent characterized by defiant behavior against authority figures,
such as parents or teachers. Individuals view their behavior as a response to unreasonable
demands. Can develop into conduct disorder.
o Manifestations: disobedience, hostility, stubbornness, argumentativeness, limit testing, refusal
to compromise or take responsibility for misbehavior.
o Interventions: use calm, firm approach. Provide short, clear expectations. Set clear limits for
behavior. Incorporate physical activities to help child use energy. Model and reward acceptable
behavior.
• Conduct Disorder
o Conduct disorder: persistent behavior in children or adolescents that violates the rights of
others and disregards societal norms
o Risk factors: neglect of abuse by parents, large family size, lack of supervision, difficult
temperament as baby.
o Manifestations: bullying behavior, recklessness, volatile, temper, cruelity towards animals or
other people, destroys property, lies and steals, low self-esteem, suicide ideation.
o Interventions: reduce environment stimuli. Use calm, frim approach. Provide short, clear
expectations. Set clear limits for behavior. Incorporate physical activities to help child use
energy. Model and reward acceptable behavior.
• Attention deficit hyperactivity disorder (ADHD)
o ADHD: condition characterized by inattention (difficulty paying attention and focusing,
hyperactivity) (inability to sit still) and impulsivity (acting without regard to consequences).
Increase risk for injury.
o Interventions: use calm, firm approach. Set clear limits for behavior and consequences for
unacceptable behavior. Incorporate physical activities to help child use energy. Provide safe
environment (remove unnecessary equipment from child’s environment). Give positive feedback
when child completes a task. Decrease distractions during meal time.
o Meds: methylphenidate (Ritalin, methylin), amphetamine mixture
• Autism
o Genetic neurodevelopment disorder that affects an individual’s ability to communicate and
interact with other people. Abilities range from highly functional to poor functioning.

o S&S: lack of eye contact, repetitive actions, strict observance routines, language delay, sleep
disorders, digestive problems, epilepsy, allergies
o Interventions: provide referral for early intervention, provide structured environment, use
short/concise communication, give plenty of notice before changing routines, determine
emotional triggers, encourage verbal communication.

Pharmacological Interventions

Anxiety Medications
• Benzodiazepines
o Alprazolam (Xanax)
▪ Other benzodiazepoines: diazepam, lorazepam (many end w/pam except chlordiazepoxide)
▪ Indications: anxiety, seizures, muscle spasms, alcohol withdrawal, and induce/maintain
anesthesia.
▪ Mode of action: enhances GABA effect in the CNS
▪ Side effects: sedation, amnesia, dependency / withdrawal, respiratory depression
▪ Key points: short-term use only! Do not DC abrupt. Antidote is flumazenil.
• Atypical Anxiokytics
o Buspirone (BuSpar)
▪ Indications: anxiety, panic disorder, OCD, PTSD
▪ Side effect: dizziness, nausea, headache
▪ Key points: no sedation. Dependency not likely, long-term use ok. Full effects not felt for
several weeks. Take with meals to decrease GI upset.
Anxiety and Depression
• SSRIs:
o Fluoxetine (Prozac)
▪ Other SSRIs: sertraline, paroxetine (many end with -ine)
▪ Indications: anxiety, depression, OCD, PTSD
▪ Mode of action: inhibits serotonin reuptake (i.e. increases serotonin)
▪ Side effects: sexual dysfunction, weight gain, insomnia

▪ Key points: watch for serotonin syndrome (symptoms: agitation, hallucinations, fever,
diaphoresis, tremors). Do not wake with St. John’s wort as this increases the risk for serotonin
syndrome. Full effects not felt up to a month.
Depression
• TCA:
o Amitriptyline (Elavil)
▪ Other TCA: imipramine
▪ Indications: depression, neuropathy, fibromyalgia, anxiety, insomnia
▪ Side effects: sedation, orthostatic hypotension, anticholinergic side effects (urinary retention,
constipation, dry mouth, blurry vision, photophobia, tachycardia), sweating, seizures.
▪ Key points: to counteract anticholinergic side effects – chew gum, wear sunglasses, high fiber
diet, increase fluid intake.

• MAOI:
o Phenelizine (Nardil)
▪ Other MAOI: tranylcypromine
o Indications: depression
o Side effects: agitation/anxiety, orthostatic hypotension, HTN crisis o Key points: interactions
w/ many other medications (including OTC cold medications, which can result in severe HTN).
Do no eat food rich in tyramine such as: aged cheese, avacadoe, bananas, red wine,
salami/pepperoni, chocolate (i.e. all the yummy foods!_.
• Atypical Antidepressants
o Bupropion (Wellbutrin)
▪ Indications: depression and as an aid to quit smoking
▪ Side effects: insomnia, HA, GI distress, weight loss, agitation, seizures
▪ Other atypical antidepressant: trazodone (major side effect is sedation)
Bipolar Medications
• Mood stabilizer
o Lithium
▪ Indications: bipolar disorder

▪ Side effects: GI upset, fine hand tremors, polyuria, weight gain, kidney toxicity, electrolyte
imbalances
▪ Key points: monitor plasma levels. Toxicity over 1.5 meq/L. Symptoms of toxicity: coarse
tremors, confusion, hypotension, seizures, tinnitus, coma/death. NO diuretics, anticholinergics,
or NSAIDs. Contraindicated for patients with renal disease.
Closely monitor sodium levels. Need adequate fluid intake (203 L) and sodium intake.
• Antiepileptics
o Carbamazepine (tegretol), valproic acid (Depakote)
▪ Indications: bipolar disorder and used as an anticonvulsant / antiepileptic
▪ Carbamazepine side effects: blood dyscrasias (anemia, leukopenia, thrombocytopenia), vision
issues (nystagmus, double vision), hypo-osmolarity, rash.
▪ Valproic acid side effects: GI upset, hepatotoxicity, pancreastitis, thrombocytopenia
Antipsychotic medications
• Conventional
o Chlorpromazine (thorazine), haloperidol (Haldol)
▪ Indications: schizophrenia, psychotic disorders, mainly controls positive symptoms (delusions,
hallucinations)
▪ Side effect (MANY):
• EPS: dystonia, parkinson’s symptoms (shuffling gait, rigidity), tardive dyskinesia (lip
smacking, tongue rolling), akathisia
• Neuroleptic malignant syndrome (NMS): fever, dysrhythmias, BP fluctuations, muscle rigidity
• Others: agranulocytosis, anticholinergic effects, orthostatic hypotension, sedation, seizures
▪ Key points: monitor VS every 1-2 hours. Anticholinergics (benzotropine, diphenhydramine)
can be used to control EPS symptoms. Muscle relaxant (dantrolene) can be used to NMS.
• Atypical
o Risperidone (Risperdal)
▪ Other atypical antipsychotic: clozapine, olanzapine
▪ Indications: schizophrenia. Controls positive and negative symptoms (anergia, anhedonia,
social withdrawal)
▪ Side effects: diabetes, weight gain, increased cholesterol, sedation, orthostatic hypotension,
anticholinergic effects, menorrhagia, decreased libido, clozapine carries risk for agranulocytosis

▪ Key points: risperidone can be administered by IM injection 1 2 weeks (for non-compliant
patients). Avoid alcohol. ADHD medications
• Methylphenidate (Ritalin, Methylin)
o Other ADHD medication: amphetamine mixture (Adderall)
o Indications: ADHD and conduct disorders
o Side effects: insomnia, dysrhythmias, decreased appetite, weight loss
o Key points: do not administer at night, give medication immediately before or after meals,
monitor childs weight during therapy. Alcohol Abuse
• Medications during alcohol withdrawal
o Benzodiazepines: chlordiazepoxide, diazepam, lorazepam – used to stabilize VS, decrease risk
of seizures, decrease withdrawal manifestations
o Carbamazepine: decrease risk of seizures
o Clonidine: decreases autonomic response (decrease BP, HR)
o Beta blockers: propranolol, atenolol – decreases autonomic response (decrease BP, HR) and
craving
• Medications to promote abstinence
o Disulfiram (Antabuse): if patients ingests alcohol, they will get many unpleasant side effects,
including: N/V, sweating, palpitations, and hypotension.
o Naltrexone (vivitrol): suppresses craving of alcohol (also available as monthly IM injections)
o Acamprosate (Campral): decreases abstinence symptoms (anxiety, restlessness) Medications
for Opioids and Nicotine Withdrawal
• Opioid Withdrawal
o Methadone – used for withdrawal and long-term maintenance
• Nicotine withdrawal
o Bupropion (Wellbutrin)
o Nicotine replacements- gum, patch, nasal spray
o Varencline (Chantix)- reduce cravings and withdrawal symptoms;
monitor patients closely for depression/suicidal thoughts.

Loss/grief and psychological interventions

• Types of loss

o Actual loss: loss of a valued person or object, recognized by others (ex: loss of a spouse)
o Perceived loss: loss felt by patient, but not obvious to others (ex: loss of financial
independence)
o Maturational loss: loss experienced during normal life transitions (ex: child leaving for college)
o Situational loss: unexpected loss caused by external event (ex: tornado, car accident)
• Kubler Ross 5 stages of grief
o Denial: individual does not accept the reality of the situation
o Anger: individual expresses anger at others
o Bargaining: individual tries to negotiate for more time (or a cure). Uses “If only” statements.
o Depression: individual is sad, mournful.
o Acceptance: individual acknowledges loss and moves forward in his/her life, emotions are
more stable
• Grief
o Normal grief: individual has some acceptance by 6 months
o Anticipatory grief: grieving before an actual loss
o Maladaptive (complicated) grief: grief is prolonged, severe, interferes, with normal functioning
months after loss. No acceptance after 6 months.
o Nursing care:
▪ Use therapeutic communication (“You sound angry. Angry is a normal feeling when you lose
someone. Tell me more”
▪ Encourage individual to share memories about loved one
▪ Encourage individual to use coping mechanisms successfully used in the past.
• Crisis management
o Types of crisis:
▪ Situational: crisis RT unanticipated loss of change (ex: physical illness, job loss)
▪ Maturational: crisis associated with developmental stage. Naturally occurring event during the
life span (ex: retirement, child leaving college).

▪ Adventitious: crisis RT natural disaster or crime (ex: rape, hurricane)
o Nursing care: provide for patient safety. Remain w/ patient, use therapeutic communication.
Assess past ways of coping. Help patient develop an action plan.
• Suicide
o Risk factors: untreated depression or other mental illness, family history, prior suicide attempt,
chronic health problems, substance use disorder (alcohol, drugs), loss of job or loved one.
Cultural risk factors: American Indian, Alaskan native ethnic groups. o Protective factors:
religious beliefs, social support network, effective coping skills, access to health care.
o Priority assessments:
▪ Assess patients risk of suicide: does the patient have a plan? How lethal is it? Does the patient
have access to intended method?
▪ Is the patient thinking about hurting himself/herself?
▪ Has the patient had a sudden change in mood from sad to happy/peaceful? This may indicate an
intention to commit suicide.
o Nursing care:
▪ Provide one-on-one constant supervision
▪ Document patient behavior every 15 minutes
▪ Search belongings at admission. Remove dangerous objects: metal silverware, belts, shoelaces,
tweezers, razors, plastic objects, glass, shampoo, perfume.
▪ Do not place patient in private room.
▪ Ask patient to agree to a no-suicide contract (does not replace other suicide prevention
interventions)
▪ Make sure patient swallows all medication
▪ Recognize behaviors that may indicate intention to commit suicide (ex: giving away
possessions, sudden change in mood, having more energy, showing appreciation to loved ones,
getting affairs in order)
• Anger Management
o Aggressive behavior
▪ Provide safe environment for patient and others
▪ Encourage patient to express feelings verbally
▪ Provide for as much personal space as possible
▪ Sit/stand at eye level, maintain eye contact

▪ Set limits, present options clearly, and inform patient of consequences of behaviors.
▪ Provide medications if limit setting is not effective.
▪ Have 4-6 staff members visible as “show of force” and to assist if necessary.
o Verbal abuse: leave the room immediately and return later to check on patient. Refrain from
arguing with patient.
• Violent/Abuse Risk factors
o Female partner
o Pregnancy
o History of violence family
o Substance abuse (drugs, alcohol)
o Children under 3
o Physically or mentally disabled children, children from unwanted pregnancies
o Older adults, due to poor health and dependence on caregiver
o Individuals trying to leave an abusive relationship.
o Most common within family groups (vs. strangers)
o Occurs across all economic/education levels.
• Family Violence
o Cycle of violence
▪ Tension-building phase: minor episodes of anger, verbal abuse, vulnerable person is tense
▪ Acute battering phase: serious abuse takes place
▪ Honeymoon phase: abuser becomes loving is sorry for behavior. Abuser promises to change.
▪ **after honeymoon phase, cycle beings again and again with periods of escalation and deescalation (decreasing time between two over time)
• Types of Violence
o Physical violence: physical harm is directed towards another child (ex: child, intimate partner,
older adult at home)
o Sexual violence: sexual contact w/out consent
o Neglect: failure to provide physical care (ex: food, clean clothes), emotional care (ex:
interaction w/ child), education, and/or health care.

o Economic maltreatment: failure to provide for needs of vulnerable person when funds are
available
• Signs of abuse
o Infants:
▪ Signs of shaken baby syndrome: respiratory distress, bulging fontanels, increase in head
circumference
▪ Bruising on infants under 6 months of age
o Preschoolers and older:
▪ Unusual location of bruising (abdomen, back, buttocks). Note: bruising is expected on arms,
legs
▪ Bruises in different stages of healing
▪ Forearm spiral fractures
▪ Presence of multiple fractures
▪ Small round burns (possibly cigarettes)
▪ Burns covering hands or feet (possibly from immersion in boiling water)
• Sexual assault
o Forced sexual contact. It is a crime of violence, aggression, and power (NOT a crime of
passion)
▪ Majority of perpetrators are known to be the victim
▪ Alcohol or other drugs are often associated with acquaintenance rape.
o Rape-trauma syndrome: response to sexual assault that can include:
▪ Expressed reaction: crying, anger, hysteria
▪ Controlled reaction: confusion, numb feeling
▪ Somatic reaction: physical manifestations such as headache, muscle tension, GI manifestations,
genitourinary manifestations
o PTSD: reliving assault, flashbacks, hyperarousal, exaggerated startle response, fears/phobias,
difficulty with ADLs, depression, sexual dysfunction
o Compound rape reaction: mental health issues (depression, substance use disorder), physical
illness
o Silent rape reaction: nightmares, changes in sexual behavior, sudden onset of phobia, no
verbalization of sexual assault

o ***patient showing interest in intimate relationships is an indication of recovery from a rapetrauma event.
o Nursing care:
▪ Sexual assault nurse examiner (SANE): trained nurse that examines and collects forensic
evidence (ex: blood, oral samples, hair samples, nail samples, genital swabs, and anal swabs).
Requires informed consent.
▪ Provide for patient safety
▪ Administer prophylactic treatment for sexually transmitted diseases.
▪ Administer emergency contraception for pregnancy risk.
▪ Provide 24 hour hotline for rape survivors
▪ Provide referrals (individual or group therapy)