ATI Mental Health Proctored Exam With NGN Version 8-14 With Answers-170 Solved Questions

VERSION 8
ATI MENTAL HEALTH POST ASSESSMENT: COMPLTE SOLUTION
A nurse is admitting a new client on the mental health unit. During the conversation the nurse
should be aware that countertransference can occur if the nurse display what feeling?
Answer: Occurs when a health care team member displaces characteristics of people in her
past onto a client.
Behaviors:
• Nurse overly identifies with client
• Nurse competes with client
• Nurse argues with client
Example: a nurse may feel defensive and angry with a client for no apparent reason if the
client reminds her of a friend who often elicited those feelings.
Nursing implications: a nurse should be aware that clients who induce very strong personal
feelings may become objects of countertransference.
A client on the mental health unit is being discharge to a community base program referred to
as Assertive Community Treatment. (ACT) What should the nurse explain to the client about
this program?
Answer: • This includes nontraditional case management and treatment by an
interprofessional team for clients who have severe mental illness and are noncompliant with
traditional treatment.
• ACT helps to reduce reoccurrences of hospitalizations and provides crisis intervention,
assistance with independent living, and information regarding resources for necessary support
services.
What are the legal rights of a person admitted to an inpatient mental health facility?
Answer: • Informed consent and the right to refuse treatment
• Confidentiality
• A written plan of care/treatment that includes discharge follow-up, as well as participation
in the care plan and review of that plan
• Communication with people outside the mental health facility, including family members,
attorneys, and other health care professionals

• Provision of adequate interpretive services if needed.Care provided with respect, dignity,
and without discrimination
• Freedom from harm related to physical or pharmalogical restraint, seclusion, and any
physical or mental abuse or neglect
• A psychiatric advance directive that includes the client’s treatment preference in the event
that an involuntary admission if necessary
• Provision of care with the least restrictive interventions necessary to meet the client’s needs
without allowing him to be a threat to himself or others
A nurse is caring for a client who is admitted to the unit for self-mutilation. What type of
behavioral therapy would the nurse expect to be ordered for this client?
Answer: Dialectical behavior therapy is a cognitive-behavioral therapy used for clients who
exhibit self-injurious behavior. It focused on gradual behavior changes and provides
acceptance and validation for these clients.
The client states that she is going through a divorce and her anxiety is extremely high. The
nurse needs to assess the client’s ability to adapt and cope with this situation. What would
this include?
Answer: Assessing the client’s ability to adapt and cope includes the following:
• Health status and functional abilities
• Living arrangements and employability
• Personality factors (e.g. attitudes)
• Client, caregiver and family assessments
• Levels of information (e.g. community programs)
• Medication use and supplemental services
Evaluating whether client has successfully adapted includes the following:
• Able to state positive coping behaviors
• Able to identify maladaptive coping behaviors
• Able to participate in community resources
• Able to list stress reduction techniques
• Able to maintain housing and employment
A nurse is caring for a client in the manic phase of bipolar disorder. Identify five (5) clinical
manifestations associated with this phase of the bipolar disorder.

Answer: • Labile mood with euphoria
• Agitation and irritability
• Restlessness
• Dislike interference and intolerance of criticism
• Increase in talking and activity
• Flight of ideas: rapid, continuous speech with sudden and frequent topic change
• Grandiose view of self and abilities (grandiosity)
• Impulsivity: spending money, giving away money or possessions
• Demanding and manipulative behavior
• Distractibility and decreased attention span
• Poor judgement
• Attention-seeking behavior: flashy dress and makeup, inappropriate behavior
• Impairment in social and occupational functioning
• Decreased sleep
Neglect of ADLs, including nutrition and hydration
• Possible presence of delusions and hallucinations
• Denial of illness
A nurse is completing a physical assessment on a child. What are three (3) potential signs of
neglect?
Answer: • Assess for unusual bruising, such as abdomen, back, and buttocks. Bruising is
common on arms and legs in these age groups.
• Assess the mechanism of injury, which might not be congruent with the physical appearance
of the injury. Numerous bruises at different stages of healing can indicate ongoing beatings.
Be suspicious of bruises or welts that resemble the shape of a belt buckle or other object.
• Assess for burns. Burns covering “glove” or “stocking” areas of the hands or feet can
indicate forces immersion into boiling water. Small, round burns can be from lit cigarettes.
• Assess for fractures with unusual features, such as forearm spiral fractures, which could be a
result of twisting the extremity forcefully. The presence of multiple fractures is suspicious.
• Assess for human bite marks.
• Assess for head injuries: level of consciousness, equal and reactive pupils, and
nausea/vomiting.
What are the main types of consequences for children that are misbehaving?

Answer: Children undergo outcomes for misbehavior. Consequences can be a natural
occurrence (missing a treat by not showing up on time), logical (not being able to go outside
to play until toys are picked up) or unrelated (having privileges taken away or being placed in
time-out).
A nurse is facilitating group therapy and the group is currently in the working phase of group
development. What is the primary focus during this phase?
Answer: Primary focus: promote problem-solving skills to facilitate behavioral changes.
Power and control issues may dominate in this phase.
Responsibilities:
• The group leader uses therapeutic communication to encourage group work toward meeting
goals.
• Members take informal roles within the group, which may interfere with, or favor, group
progress toward goals.
A nurse is caring for an adolescent client with Autism Spectrum Disorder. Define Autism
Spectrum Disorder. What are common manifestations of Autism Spectrum Disorder?
Answer: Autism Spectrum Disorder is a complex neurodevelopmental disorder thought to be
of genetic origin with a wide spectrum of behaviors affecting an individual’s ability to
communicate and interact with others.
• Cognitive and language development are typically delayed.
• Characteristic behaviors include inability to maintain eye contact, repetitive actions, and
strict observance of routines.
• This type of disorder is present in early childhood and is more common in boys than girls.
Physical difficulties experienced by the child who has autism spectrum disorder include
sensory integration dysfunction, sleep disorders, digestive disorders, feeding disorders,
epilepsy, and/or allergies.
• There is a wide variability in functioning. Abilities can range from poor (inability to
perform self-are, inability to communicate and relate to others) to high (ability to function at
near normal levels).
Mental Health

Mental health nursing is an important role in the world of nursing and is essential in
promoting and supporting a person’s mental health recovery and enabling them to have more
involvement and control over their condition.
Tricyclic antidepressants - Amitriptyline
Selective serotonin reuptake inhibitors – Fluoxetine
Monoamine oxidase inhibitors – Phenelzine
Atypical antidepressants – Bupropion
The complications/adverse effects (differences)
Tricyclic antidepressant- Orthostatic hypotension, anticholinergic effects, sedation, toxicity,
decreased seizure threshold, excessive sweating, and increase appetite
Selective serotonin reuptake inhibitors – Sexual dysfunction, CNS stimulation, insomnia,
agitation, anxiety. Weight changes, serotonin syndrome
Monoamine oxidase inhibitors - CNS stimulation, orthostatic hypotension, Hypertensive
crisis, local rash
Atypical antidepressants - Headache, dry mouth, GI distress, constipation, increase heart rate,
nausea, restlessness, insomnia, weight loss. Seizures at high doses
Mental Health ATI Proctor Focus Review
VERSION 11

1) Findings to share w/ treatment team
a) Pt at risk for suicide (especially w/ personal & family history)
b) Comorbid anxiety disorder or panic attacks
2) Anorexia Nervosa S&S
a) Pt. preoccupied w/ food & rituals of eating
b) Refusal to eat
c) Most often in females around adolescence to young adulthood
d) Stress can cause an onset such as college
3) Applying restraints
a) Must obtain order within 15 to 30 min of ER situation
b) D/C when pt. is calmer, safer, & quieter
c) Document every 15 to 30 min include: time Tx. begin, med admin., starting events &
behaviors, alternative actions taken to avoid seclusion, pt.
behavior, foods offered, needs provided, vital signs
4) Sexual assault
a) Priority interventions
i) Perform self-assessment
ii) Provide pt. safety and ensure they know they are safe iii) Assess for suicidal ideation
iv) Perform an initial & ongoing assessment of the client’s level of anxiety, coping
mechanisms, & support system
v) Assess for emotional and/or physical trauma
vi) Give the pt. a private environment for the exam vii) Provide a SANE & specially trained
nurse-advocate viii) Provide nonjudgmental & empathetic care ix) Treat injuries & document
care given x) Give prophylactic tx for STIs xi) Provide D/C care
(1) Therapy referral
(2) Hotline numbers
5) Maladaptive (chronic or prolonged) grief response
a) Can last for varying lengths of time requiring the pt. to work through the stages/tasks of
grief
b) Pt. can remain in denial stage & unable to accept reality of the loss
c) Can results in the pt. being unable to perform ADLs
6) Deep breathing teaching
a) Used to decrease rapid breathing & promote relaxation

b) Slow breaths in through the nose out through the mouth
7) Opioid use disorder
a) Withdrawal S&S
i) Sweating, rhinorrhea ii) Tremors
iii) Irritability followed by severe weakness iv) Diarrhea v) Fever vi) Insomnia
vii) Dilated pupils viii) Nausea & vomiting
ix) Pain in the bones & muscles, muscle spasms
Mental Health ATI Proctored Exam Focused Review
VERSION 10
Ch. 26
Alcohol withdrawal:
• Manifestations usually start within 4 to 12 hr of the last intake of alcohol and can continue 5
to 7 days.
• Intended effects of Benzodiazepines for alcohol withdrawal: Decrease in the risk of
seizures, maintenance of vitals, decrease in intensity of withdrawal manifestations,
substitution therapy during withdrawal.
Buproprion—Avoid with asthma
Ch. 24
Medication for Psychotic Disorders---Risperidone:
• Relief of psychotic manifestations in other disorders, such as bipolar disorder
• Impulse control disorders
Ch. 26
Naltrexone: Suppresses the craving and pleasurable effects of alcohol. (also used for opioid
withdrawal)
Ch. 23 Effectiveness of mood stabilizers:
• Relief of acute manic manifestations
• Verbalization of improvement in mood
• Ability to perform ADLs
Ch. 22
Emergency Care for indications of Neuroleptic Malignant Syndrome:
• Stop antipsychotic medication
• Apply cooling blankets

• Increase fluid intake
• Administer dantrolene or bromocriptine to induce muscle relaxation
• Administer medication as prescribed to treat arrhythmias.
Ch. 28
Care for a child with ADHD:
• Set clear limits on unacceptable behaviors and be consistent.
Ch. 30
Risk factors for suicide:
• White females are more likely to attempt suicide
• Adolescent, middle, and older adult males are more likely to have a completed suicide
Ch. 8
Recognizing boundaries with family therapy:
• In healthy families, clear boundaries define roles of each member and are understood by all.
Each family member is able to function appropriately.
Ch. 32
Priority nursing for suspected child abuse:
• All states have mandatory reporting laws that require nurses to report suspected abuse.
• Document data obtained during assessment
Evaluating Priority Outcome following intimate partner abuse:
• Help client develop a safety plan
• Identify behaviors and situations that might trigger violence
• Provide information regarding safe places to live
Ch. 33
Sexual Assault: Priority interventions:
• Perform an initial and ongoing assessment of the client’s level of anxiety, coping
mechanisms, and available support systems.
• Assess for indications of emotional and/or physical trauma.
Ch. 19
Diagnostic Procedures for Bulimia Nervosa:
• ECG changes (prolonged QT interval)
• Abnormal blood glucose level
Eating Disorders: Expected Lab values:
• Hypokalemia
• Hyponatremia

• Hypomagnesemia
• Hypophosphatemia
• Decreased estrogen
• Decreased testosterone
Ch. 17
Contributing factors for dementia:
• Impairments do not change throughout the day
• Level of consciousness is usually unchanged
Ch. 18
Heroin withdrawal:
• Very unpleasant but not life-threatening
• Tremors, severe weakness, diarrhea, fever, insomnia, pupil dilation, nausea and vomiting,
pain in the muscles and bones, and muscle spasms
VERSION 11
Psychotic Disorders: Initial Plan of Care for a Client Who Has Schizophrenia (RN QSEN Patient-centered Care, Active Learning Template - System Disorder, RM MH RN 10.0 Chp
15)
• Provide a structured, safe environment (milieu) for the client to decrease anxiety and to
distract the client from constant thinking about hallucinations
• Promote therapeutic communication to lower anxiety, decrease defensive patterns, and
encourage participation in the milieu.
• Program of assertive community treatment (PACT): Intensive case management and
interprofessional team approach to assist clients with community‑living needs.
Depressive Disorders: Priority Findings to Share with Treatment Team (RN QSEN Teamwork and Collaboration, Active Learning Template - System Disorder, RM MH RN
10.0 Chp 13)
• Suicide risk: Assess the client’s risk for suicide and implement appropriate safety
precautions.
• Self‑care: Monitor the client’s ability to perform activities of daily living and encourage
independence as much as possible.

• Communication: Make observations rather than asking direct questions, which can cause
anxiety in the client. For example, the nurse might say, “I noticed that you attended the unit
group meeting today,” rather than asking, “Did you enjoy the group meeting
Legal and Ethical Issues: Right to Refuse Treatment (RN QSEN - Patient-centered Care,
Active Learning Template - Basic Concept, RM MH RN 10.0 Chp 2)
• Freedom from harm related to physical or pharmacological restraint, seclusion, and any
physical or mental abuse or neglect
• A psychiatric advance directive that includes the client’s treatment preferences if an
involuntary admission is necessary
• Provision of care with the least restrictive interventions necessary to meet the client’s needs
without allowing him to be a threat to himself or others
Sexual Assault: Communicating with a Client (RN QSEN - Safety , Active Learning
Template - Basic Concept, RM MH RN 10.0 Chp 33)
• Perform a self‑assessment. It is vital that the nurse who works with the client who has been
sexually assaulted be empathetic, objective, and nonjudgmental. If the nurse feels emotional
about the assault due to some event or person in his own past, it can be better to allow another
nurse to care for the client.
• Perform an initial and ongoing assessment of the client’s level of anxiety, coping
mechanisms, and available support systems. The nurse should also assess for indications of
emotional and/or physical trauma.
• Provide a private environment for an examination with a specially trained nurse‑advocate, if
available. A sexual assault nurse examiner (SANE) is a specially trained nurse who performs
such examinations and collects forensic evidence.
Brain Stimulation Therapies: Transcranial Magnetic Stimulation (Active Learning
Template - Therapeutic Procedure, RM MH RN 10.0 Chp 10)
• TMS is a noninvasive therapy that uses magnetic pulsations to stimulate the cerebral cortex
of the brain
• TMS is approved by the United States Food and Drug Administration (FDA) for the
treatment of major depressive disorder for clients who are not responsive to pharmacological
treatment.

• TMS is commonly prescribed daily for a period of 4 to 6 weeks.•TMS can be performed as
an outpatient procedure.•The TMS procedure lasts 30 to 40 min.•A noninvasive
electromagnet is placed on the client’s scalp, allowing the magnetic pulsations to pass
through.•The client is alert during the procedure.•Clients might feel a tapping or knocking
sensation in the head, scalp skin contraction, and tightening of the jaw muscles during the
procedure.
• Common adverse effects include mild discomfort or a tingling sensation at the site of the
electromagnet and headaches.•Monitor for lightheadedness after the procedure.•Seizures are a
rare but potential complication.•TMS is not associated with systemic adverse effects or
neurologic deficits.
Suicide: Risk Factors for Suicide (Active Learning Template - Basic Concept, RM MH RN
10.0 Chp 30)
• While females are more likely to attempt suicide, adolescent, middle, and older adult males
are more likely to have a completed suicide. Other individuals at increased risk for suicide
include active military personnel/veterans; those who are lesbian, gay, bisexual, or
transgender; and people who have a comorbid mental illness, such as depressive disorders,
substance use disorders, schizophrenia, bipolar disorder, and personality disorders.
• OLDER ADULT CLIENTS: Untreated depression
• Loss of employment and finances
• Feelings of isolation, powerlessness
• Prior attempts at suicide (older adult clients are more likely to succeed)
• Change in functional ability
• Alcohol or other substance use disorder
• Loss of loved ones.
• BIOLOGICAL FACTORS
• Family history of suicide
• Physical disorders, such as AIDS, cancer, cardiovascular disease, stroke, chronic kidney
disease, cirrhosis, dementia, epilepsy, head injury, Huntington’s disease, and multiple
sclerosis.
• ENVIRONMENTAL FACTORS
• Access to lethal methods, such as firearms
• Lack of access to adequate mental health care
• Unemployment.

Medications for Psychotic Disorders: Assessment Tools to Determine Adverse Effects of
Medication (Active Learning Template - Medication, RM MH RN 10.0 Chp 24).
• Abnormal Involuntary Movement Scale (AIMS): This tool is used to monitor involuntary
movements and tardive dyskinesia in clients who take antipsychotic medication.
• World Health Organization Disability Assessment Schedule (WHODAS): This scale helps
to determine the client’s level of global functioning.
Mental Health Issues of Children and Adolescents: Behavioral Management of Autism
Spectrum Disorder (RN QSEN - Patient-centered Care, Active Learning Template - System
Disorder, RM MH RN 10.0 Chp 28)
• Encourage parents to participate in the child’s care and treatment plan as much as possible.
• Use short, concise, and developmentally appropriate communication.
• Identify desired behaviors and reward them.
Substance Use and Addictive Disorders: Interventions for Alcohol Withdrawal (RN
QSEN - Safety , Active Learning Template - System Disorder, RM MH RN 10.0 Chp 18)
• Monitor vital signs and neurological status.
• Provide for client safety by implementing seizure precautions.
• Encourage the client to adhere to the treatment plan
Family and Community Violence: Providing Immediate Safety (RN QSEN - Safety , Active
Learning Template - Basic Concept, RM MH RN 10.0 Chp 32)
• Help client develop a safety plan, identify behaviors and situations that might trigger
violence, and provide information regarding safe places to live.
• Encourage participation in support groups.
• Use case management to coordinate community, medical, criminal justice, and social
services.
• Use crisis intervention techniques to help resolve family or community situations where
violence has been devastating.
Care of Clients Who are Dying and/or Grieving: Planning Care for Bereavement (RN QSEN
- Patient-centered Care, Active Learning Template - Basic Concept, RM MH RN 10.0 Chp
27)

• Accepting the reality of the loss.
• Processing the pain of grief. The client uses coping mechanisms to deal with the emotional
pain of the loss.
• Adjusting to a world without the lost entity. The client changes the environment to
accommodate the absence of the deceased.
• Finding an enduring connection with the lost entity during embarking on a new life. The
client finds a way to keep the lost entity a part of her life while at the same time moving
forward with life and establishing new relationships.
Anxiety Disorders: Clinical Findings of Posttraumatic Stress Disorder (Active Learning
Template - System Disorder, RM MH RN 10.0 Chp 11)
• Re-experiencing the trauma through intrusive distressing recollections of the event,
flashbacks, and nightmares.
• Emotional numbness and avoidance of places, people, and activities that are reminders of
the trauma.
• Increased arousal such as difficulty sleeping and concentrating, feeling jumpy, and being
easily irritated and angered.
Bipolar Disorders: Manifestations of Mania (Active Learning Template - System Disorder,
RM MH RN 10.0 Chp 14)
• Labile mood with euphoria
• Agitation and irritability
• Restlessness
•Dislike of interference and intolerance of criticism
• Increase in talking and activity
• Flight of ideas: rapid, continuous speech with sudden and frequent topic change
Neurocognitive Disorders: Expected Findings of Alzheimer's Disease (Active Learning
Template - System Disorder, RM MH RN 10.0 Chp 17)
• gradual deterioration of function over months or years
• Impairments in memory, judgment, speech (aphasia), ability to recognize familiar objects
(agnosia), executive functioning (managing daily tasks), and movement (apraxia);
impairments do not change throughout the day.
• Level of consciousness is usually unchanged

Personality Disorders: Manifestations of Borderline Personality Disorder (Active Learning
Template - System Disorder, RM MH RN 10.0 Chp 16)
• inflexibility/maladaptive responses to stress
• Compulsiveness and lack of social restraint
• Inability to emotionally connect in social and professional relationships
• Tendency to provoke interpersonal conflict
• Ability to merge personal boundaries with others
Personality Disorders: Planning Care for a Client Who Has Paranoid Personality Disorder
(RN QSEN - Patient-centered Care, Active Learning Template - System Disorder, RM MH
RN 10.0 Chp 16)
• Clients who have personality disorders can evoke
• intense emotions in the nurse.
• Awareness of personal reactions to stress promotes
• effective nursing care.
• Therapeutic communication and intervention are
• promoted when client behaviors are anticipated
Stress and Defense Mechanisms: Identifying Defense Mechanisms (RN QSEN Patientcentered Care, Active Learning Template - Basic Concept, RM MH RN 10.0 Chp 4)
• Altruism: Dealing with anxiety by reaching out to others
• Sublimation : Dealing with unacceptable feelings or impulses by unconsciously substituting
acceptable forms of expression.
• Rationalization : Creating reasonable and acceptable explanations for unacceptable behavior
Creating and Maintaining a Therapeutic and Safe Environment: Phases of the Therapeutic
Relationship (Active Learning Template - Basic Concept, RM MH RN 10.0 Chp 5)
• Orientation NURSE : introduce self to the client and state purpose.Set the contract: meeting
time, place, frequency, duration, and date of termination. discuss confidentiality. Build trust
by establishing expectations and boundaries. Set goals with the client. explore the client’s
ideas, issues, and needs. explore the meaning of testing behaviors. enforce limits on testing or
other inappropriate behaviors.

• Working NURSE: Maintain relationship according to the contract. perform ongoing
assessment to plan and evaluate therapeutic measures. facilitate the client’s expression of
needs and issues. encourage the client to problem-solve. promote the client’s selfesteem.
foster positive behavioral change. explore and deal with resistance and other defense
mechanisms. recognize transference and countertransference issues. reassess the client’s
problems and goals, and revise plans as necessary. Support the client’s adaptive alternatives
and use of new coping skills.
• Termination NURSE provide opportunity for the client to discuss thoughts and feelings
about termination and loss.discuss the client’s previous experience with separations and
loss.elicit the client’s feelings about the therapeutic work in the nurse-client
relationship.Summarize goals and achievements.review memories of work in the
sessions.express own feelings about sessions to validate the experience with the client.discuss
ways for the client to incorporate new healthy behaviors into life.Maintain limits of final
termination.
Neurocognitive Disorders: Home Safety for a Client Who Has Alzheimer's Disease (RN
QSEN - Safety , Active Learning Template - Basic Concept, RM MH RN 10.0 Chp 17)
• Install childproof door locks.
• Place the client’s mattress on the floor.
• install light fixtures above stairs
Medications for Bipolar Disorders: Adverse Effects of Lamotrigine (Active Learning
Template - Medication, RM MH RN 10.0 Chp 23)
• Double or blurred vision
• dizziness,
• headache, nausea, vomiting
Medications for Psychotic Disorders: Adverse Effects of Thioridazine Therapy (RN QSEN Patient-centered Care, Active Learning Template - Medication, RM MH RN 10.0 Chp 24)
• Agranulocytosis
• Pseudoparkinsonism
• Akathisia

Medications for Children and Adolescents Who Have Mental Health Issues: Evaluating
Client Understanding of Methylphenidate (RN QSEN - Patient-centered Care, Active
Learning Template - Medication, RM MH RN 10.0 Chp 25)
• Monitor the client’s height and weight and compare to baseline height and weight.
• Administer medication right before or after meals.
• Encourage children to eat at regular meal times and to avoid unhealthy food choices.
Medications for Substance Use Disorders: Managing Alcohol Withdrawal (RN QSEN Safety , Active Learning Template - Medication, RM MH RN 10.0 Chp 26)
• Administer around‑the‑clock or PRN.
• Obtain baseline vital signs.
• Monitor vital signs and neurological status on an ongoing basis.
• Provide for seizure precautions.
Medications for Depressive Disorders: Clinical Findings of Serotonin Syndrome (Active
Learning Template - System Disorder, RM MH RN 10.0 Chp 22)
• Mental confusion, difficulty concentrating
• Abdominal pain
• Diarrhea
• Agitation
• Fever
• Anxiety
• Hallucinations
• Hyperreflexia, incoordination
• Diaphoresis
• Tremor
ATI Mental Health
Chapter 10 Brain Stimulation Therapies
VERSION 12
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 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 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.

Answer: B. Orthostatic hypotension.
D. Headache.
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.”
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
long-term abstinence from alcohol? (Select all that apply.)
A. Lorazepam.
B. Diazepam.
C. Disulfiram.
D. Naltrexone.
E. Acamprosate.
Answer: C. Disulfiram.
D. Naltrexone.
E. Acamprosate.
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. “Methadone must be prescribed and dispensed by an approved treatment center.”
Answer: A. “Methadone is a replacement for physical dependence to opioids.”
B. “Methadone reduces the unpleasant effects associated with abstinence syndrome.”
C. “Methadone can be used during opioid withdrawal and to maintain abstinence.”
E. “Methadone must be prescribed and dispensed by an approved treatment center.”
VERSION 13
A nurse is reviewing the medication administration record of a client who has major
depressive disorder and a new prescription for selegiline. The nurse should recognize that
which of the following client medications is contraindicated when taken with selegiline?
A. Wafarin
B. Fluoxetine
C. Calcium carbonate
D. Acetaminophen
Answer: B. Fluoxetine
A nurse in a long-term care facility is assessing a client who has dementia. Which of the
following findings should the nurse identify as a risk for this client?
A. Outside doors have locks
B. The bed is in the low position
C. Hallways are long distances
D. The room has an area rug
Answer: D. The room has an area rug
A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder.
The client repeatedly checks that the doors are locked at night. Which of the following
instructions should the nurse give the client when using thought stopping technique?
A. “Ask a family member to check the locks for you at night”
B. “Keep a journal of how often you check the locks each night”
C. “Snap a rubber band on your wrist when you think about checking the locks”
D. “Focus on abdominal breathing whenever you go to check the locks”

Answer: C. “Snap a rubber band on your wrist when you think about checking the locks”
A nurse in an inpatient mental health facility is assessing a client who has schizophrenia and
is taking haloperidol. Which of the following clinical findings is the nurse’s priority?
A. Insomnia
B. Urinary hesitancy
C. Headache
D. High fever
Answer: D. High fever
A nurse is caring for a client who has Alzheimer’s disease. Which of the following findings
should the nurse expect?
A. Failure to recognize familiar objects
B. Altered level of consciousness
C. Excessive motor activity
D. Rapid mood swings
Answer: A. Failure to recognize familiar objects
A nurse in a mental health facility is interviewing a new client. Which of the following
outcomes must occur if the nurse is to establish a therapeutic nurse-client relationship?
A. The nurse is seen as an authority figure
B. A written contract is established to clarify the steps of the treatment plan
C. The nurse maintains confidentiality unless the client’s safety is compromised
D. The nurse is seen as a friend
Answer: C. The nurse maintains confidentiality unless the client’s safety is compromised
A nurse is teaching a client who has a new prescription for disulfiram. Which of the
following statements by the client indicates an understanding of the teaching?
A. “If I cut myself, I can clean the wound with isopropyl alcohol”
B. “I can wear my cologne on special occasions”
C. “When I bake my favorite cookies, I can use pure vanilla extract for flavoring”
D. “I can continue to eat aged cheese and chocolate”
Answer: D. “I can continue to eat aged cheese and chocolate”

A nurse is planning care for a client who has narcissistic personality disorder. Which of the
following actions is appropriate for the nurse to include in the plan of care?
A. Ask the client to sign a no-suicide contract
B. Remain neutral when communicating with the client
C. Request an antipsychotic medication from the provider
D. Provide the client with high-calorie finger foods
Answer: B. Remain neutral when communicating with the client
A nurse is reviewing the laboratory report of a client who is taking carbamazepine for bipolar
disorder. Which of the following laboratory results should the nurse report to the provider?
A. Urine specific gravity 1.029
B. Platelets 90,000/mm3
C. Urine pH 5.6
D. RBC 4.7/mm3
Answer: B. Platelets 90,000/mm3
A nurse is providing teaching about relapse prevention to a client who has schizophrenia.
Which of the following statements by the client indicates an understanding of the teaching?
A. “I should avoid being around others if I think I’m having a relapse”
B. “I should let my counselor know if I am having trouble sleeping”
C. “I shouldn’t worry about the voices because they are a part of my illness”
D. “I should increase my carbohydrate intake to maintain my energy level”
Answer: B. “I should let my counselor know if I am having trouble sleeping”
A nurse is assessing a client for negative manifestations of schizophrenia. Which of the
following findings should the nurse expect?
A. Echopraxia
B. Delusions
C. Anergia
D. Tangentiality
Answer: C. Anergia

A nurse is preparing for an interprofessional team meeting regarding a newly admitted client
who has major depressive disorder. Which of the following findings obtained during the
initial assessment is the priority to report to other disciplines?
A. Poor problem-solving skills
B. Markedly neglected hygiene
C. Significant weight loss
D. Psychomotor retardation
Answer: D. Psychomotor retardation
A nurse is preparing to administer methylphenidate 25 mg PO to a school age child who has
ADHD. Available is methylphenidate 10mg/5mL liquid. How many mL should the nurse
administer? (Round to nearest tenth)
A. 12.5
B. 2.2
C. 19.8
D. 15.6
Answer: A. 12.5
A nurse is caring for a school age child who has a fractured arm. The child has other injuries
that cause the nurse to suspect abuse. Which of the following actions is appropriate for the
nurse to take when assessing the child’s situation?
A. Ask the parents directly if the child’s fracture is due to physical abuse
B. Direct the parents to the waiting room before interviewing the child
C. Interview the child with the provider and social worker present
D. Ask clarifying questions as the child explains how the injuries occurred
Answer: D. Ask clarifying questions as the child explains how the injuries occurred
A nurse is assisting with obtaining consent for a client who has been declared legally
incompetent. Which of the following actions should the nurse take?
A. Ask the charge nurse to obtain informed consent
B. Contact the facility social worker to obtain consent
C. Request that the client’s guardian sign the consent
D. Explain implied consent to the clients family
Answer: C. Request that the client’s guardian sign the consent

A nurse in a mental health facility is reviewing a client’s medical record. Which of the
following actions should the nurse take first? (Click on the exhibit button for additional
information about the client. There are 3 tabs that contain separate categories of data)
A. Teach the client about nutritional needs
B. Initiate 0.9% sodium chloride with 40 mEq potassium chloride
C. Administer acetaminophen 500 mg PO
D. Encourage the client to attend group therapy sessions
Answer: B. Initiate 0.9% sodium chloride with 40 mEq potassium chloride
A nurse is assessing a client who has delirium. Which of the following findings requires
immediate intervention by the nurse?
A. Rapid mood swings
B. Command hallucinations
C. Impaired memory
D. Inappropriate speech patterns
Answer: A. Rapid mood swings
A nurse is developing a teach plan for the family of an older adult client who is to receive
transcranial magnetic stimulation. Which of the following information should the nurse
include n the teaching plan?
A. The client is at risk for aspiration during treatment
B. The client will experience a seizure during treatment
C. The client will require intubation after treatment
D. The client might have a headache after treatment
Answer: D. The client might have a headache after treatment
A nurse is obtaining a medical history from a client who is requesting a prescription for
bupropion for smoking cessation. Which of the following assessment findings in the client’s
history should the nurse report to the provider?
A. Recent head injury
B. Hypothyroidism
C. Knee arthroplasty 1 month ago
D. Hepatitis B infection

Answer: A. Recent head injury
A nurse is developing a plan of care for a client who has paranoid personality disorder. Which
of the following actions should the nurse include in the plan?
A. Provide written information about the client’s treatment plan
B. Monitor the client for splitting behaviors
C. Encourage countertransference when developing the nurse-client relationship
D. Isolate the client from social or group interactions
Answer: D. Isolate the client from social or group interactions
A nurse is caring for a client who receives lamotrigine daily for bipolar disorder and reports a
rash on his arm. Which of the following actions should the nurse take?
A. Ask the client about a recent change in laundry detergent
B. Explain that the medication causes a temporary rash
C. Apply hydrocortisone cream on the client’s rash
D. Withhold the next dose of the medication
Answer: D. Withhold the next dose of the medication
A nurse is caring for a client who begins yelling and pacing around the room. Which of the
following actions should the nurse take? (select all that apply)
A. Stand directly in front of the client
B. Identify the client’s stressors
C. Request that security guards restrain the client
D. Talk to the client using short, simple sentences
E. Speak to the client in a loud voice
Answer: B. Identify the client’s stressors
D. Talk to the client using short, simple sentences
A nurse is developing a plan of care for a school-age child who has autism spectrum disorder.
Which of the following interventions should the nurse include in the plan?
A. Allow flexibility in the child’s daily schedule
B. Assign the child to a room with another child of the same age
C. Discourage the child from making eye contact with caregivers
D. Use a reward system for appropriate behavior

Answer: D. Use a reward system for appropriate behavior
A nurse is caring for a client who has post-traumatic stress disorder. Which of the following
clinical findings is associated with this disorder?
A. Depersonalization
B. Pressured speech
C. Hypervigilance
D. Compulsive behavior
Answer: A. Depersonalization
A nurse is teaching a client about the use of cognitive reframing for stress management.
Which of the following statements by the client indicates an understanding of the teaching?
A. “I will focus on a mental image while concentration on my breathing.”
B. “I will practice replacing negative thoughts with positive self-statements.”
C. “I will progressively relax each of my muscle groups when feeling stressed.”
D. “I will learn how to voluntarily control my blood pressure and heart rate.”
Answer: B. “I will practice replacing negative thoughts with positive self-statements.”
A nurse is caring for a client who has schizophrenia and has been taking chlorpromazine for 5
years. Which of the following assessment tools should the nurse use to determine if the client
is experiencing adverse effects of the medication?
A. Addiction Severity Index (ASI)
B. Mood Disorder Questionnaire (MDQ)
C. Abnormal Involuntary Movement Scale (AIMS)
D. Hamilton Depression Scale
Answer: C. Abnormal Involuntary Movement Scale (AIMS)
A nurse in a mental health facility is assessing a client for suicide risk factors using the SAD
PERSONS scale. Which of the following finding indicates a risk suicide?
A. The client is married
B. The client has diabetes mellitus
C. The client is 50 years of age
D. The client is female
Answer: B. The client has diabetes mellitus

A nurse is providing crisis intervention for a client who was involved in a violent mass
casualty situation in the community. Which of the following actions should the nurse take
during the initial session with the client?
A. Identify the client’s usual coping style
B. Help the client focus on a wide variety of topics regarding the crisis
C. Tell the client that his life will soon return to normal
D. Encourage the client to display anger toward the cause of the crisis
Answer: A. Identify the client’s usual coping style
A nurse is caring for a client who has schizophrenia and is experiencing auditory
hallucinations. Which of the following actions should the nurse take first?
A. Encourage the client to listen to music
B. Monitor the client for indications of anxiety
C. Ask the client what she is missing
D. Focus the client on reality-based topics
Answer: D. Focus the client on reality-based topics
A nurse is planning to lead a support group for clients who have alcohol use disorder. One of
the group members is a client who speaks a different language than the nurse. The nurse
should ask which of the following individuals to assist with communication?
A. A family member of the client
B. Another client who speaks the same language as the client
C. A translator of the same gender as the client
D. A unit secretary who speaks the same language as the client
Answer: C. A translator of the same gender as the client
A nurse in an emergency department is assessing a client who reports recently using cocaine.
Which of the following clinical manifestations should the nurse expect?
A. Lethargy
B. Hypothermia
C. Hypertension
D. Bradycardia
Answer: C. Hypertension

A nurse is caring for a client who has severe depression and is scheduled to receive
electroconvulsive therapy. The nurse should recognize that the client will receive
succinylcholine to prevent which of the following adverse effects?
A. Muscle distress
B. Aspiration
C. Elevated blood pressure
D. Decreased heart rate
Answer: A. Muscle distress
A nurse in an outpatient clinic is assessing a client who has anorexia nervosa. Which of the
following findings indicates the need for hospitalization?
A. Temperature 35.6 C (96.1 F)
B. Heart rate 56/min
C. Weight 10% below ideal weight
D. Potassium 3.8 mEq/L
Answer: A. Temperature 35.6 C (96.1 F)
A nurse is caring for a client who is under observation for suicidal ideations and has
verbalized a suicide plan. The client demands privacy and to be left alone. Which of the
following statements should the nurse make?
A. “Since you are trying to follow the treatment plan, we can submit your request to the
provider.”
B. “We are concerned about you and need to keep you safe.”
C. “Until your medication has reached therapeutic levels, you will need constant
observation.”
D. “If you complete a contract that states you will not harm yourself, you can be alone.”
Answer: B. “We are concerned about you and need to keep you safe.”
A nurse on a mental health unit is leading a therapy session for a group of clients. One client
challenges the nurse and shows no empathy for others in the group. Which of the following
actions should the nurse take?
A. Request that the client leave the therapy session immediately
B. Place the client in seclusion

C. Reassign the client to another group
D. Ask the client privately what is causing the anger
Answer: D. Ask the client privately what is causing the anger
A nurse in a mental health clinic is assessing a client who has borderline personality disorder.
Which of the following findings should the nurse expect?
A. Inability to maintain employment
B. Intense efforts to avoid abandonment
C. Avoidance of interpersonal relationships
D. Reluctance to discard worthless objects
Answer: B. Intense efforts to avoid abandonment
A nurse in a long-term care facility is assessing an older adult client for depression. Which of
the following findings should the nurse expect?
A. Rapid mood swings
B. Sun downing
C. Insomnia
D. Rambling speech
Answer: C. Insomnia
A nurse is assessing a client who has been taking thioridazine for 2 weeks. The client reports
an inability to be still. Which of the following adverse effects should the nurse suspect?
A. Tardive dyskinesia
B. Pseudo parkinsonism
C. Akathisia
D. Acute dystonia
Answer: C. Akathisia
A nurse in a mental health facility is making plans for a client’s discharge. Which of the
following interdisciplinary team members should the nurse contact to assist the client with
housing placement?
A. Clinical nurse specialist
B. Social worker
C. Occupational therapist

D. Recreational therapist
Answer: B. Social worker
A nurse is interviewing a client who was recently sexually assaulted. The client cannot recall
the attack. The nurse should identify that the client is using which of the following defense
mechanisms?
A. Sublimation
B. Reaction formation
C. Suppression
D. Repression
Answer: D. Repression
A nurse is assessing a client who has antisocial personality disorder. Which of the following
client behaviors should the nurse expect?
A. Attention-seeking
B. Anxious
C. Projects blame
D. Manipulative
Answer: D. Manipulative
A nurse is caring for a client who has physical restraints applied. The nurse determines that
the restraints should be removed when which of the following occurs?
A. The client states that he will harm himself unless the restraints are removed
B. The client refuses to take his medication unless he is released
C. The client demonstrates that he is oriented to person, place, and time
D. The client is able to follow commands
Answer: D. The client is able to follow commands
A nurse is caring for a client who states, “Things will never work out.” Which of the
following responses should the nurse make?
A. “Why do you feel like things will never work?”
B. “Have you been thinking about harming yourself?”
C. “You should try to focus on yourself for a change.”
D. “Maybe an antidepressant will make you feel better.”

Answer: B. “Have you been thinking about harming yourself?”
A nurse in an emergency department is caring for a client who reports a recent sexual assault
by her partner. Which of the following statements is the priority for the nurse make?
A. “I want you to know that you are in a safe place here.”
B. “I can contact a support person for you.”
C. “A trained sexual-assault nurse will be assigned to your care.”
D. “I can provide information about an advocacy group in your area”
Answer: A. “I want you to know that you are in a safe place here.”
After assessing a client in a crisis situation, a nurse determines the client is safe. Which of the
following actions should the nurse take first?
A. Help the client identify social support
B. Involve the client in planning interventions
C. Assist the client to lower his anxiety level
D. Teach the client specific coping skills to handle stressful situations
Answer: C. Assist the client to lower his anxiety level
A nurse is assessing a client who has bulimia nervosa. Which of the following findings
should the nurse expect?
A. Acrocyanosis
B. Amenorrhea
C. Lanugo
D. Hyponatremia
Answer: A. Acrocyanosis
A nurse is caring for client who reports smoking marijuana several times per day. The client
tells the nurse, “ I don’t know what the big deal is marijuana is a harmless herb” The nurse
should identify that the client is displaying which of the following mechanisms?
A. Rationalization
B. reaction formation
C. compensation
D. suppression
Answer: A. Rationalization

A nurse is creating a plan of care for a client who has major depressive disorder. Which of the
following interventions should the nurse include in the plan?
A. identify and schedule alternative group activities for the client
B. encourage physical activity for the client during the day
C. discourage the client from expressing feelings of anger
D. keep a bright light on in the client’s room at night.
Answer: B. encourage physical activity for the client during the day
A nurse is teaching the family of a client who has Alzheimer’s disease about the safety
interventions for nighttime wandering, which of the following interventions should the nurse
include?
A. place rubber backed throw rugs on tile floors
B. encourage the client to take naps during the day
C. install locks at the bottom of exit doors
D. place the clients mattress on the floor.
Answer: C. install locks at the bottom of exit doors
A nurse in a mental health facility is reviewing the lab results of a client who is taking lithium
carbonate. Which of the following findings places the client at risk for lithium toxicity.
A. calcium 10.0
B. WBC 6,0000
C. sodium 132 mEq/L
D. aspartate aminotransferase 40 units/L
Answer: C. sodium 132 mEq/L
a nurse in an acute care facility is planning care for a client who has a history of alcohol use
disorder and is admitted while intoxicated. Which of the following interventions should the
nurse plan for the client
A. monitor for orthostatic hypotension
B. administer methadone hydrochloride
C. implement seizure precautions
D. acidify the client’s urine
Answer: C. implement seizure precautions

a nurse is developing a safety plan for a client who has experienced intimate partner abuse.
Which of the following items should the nurse include in the plan that will provide immediate
safety for the client and her children?
A. the phone numbers for law enforcement agencies
B. a code phrase to use when it is time to leave the house
C. the phone number of the local shelter
D. a referral to a support group
Answer: C. the phone number of the local shelter
A nurse is caring for a client who reports that he is angry with his partner because she thinks
he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes
angry and tells her to leave. Which of the following defense mechanisms is the client
demonstrating?
A. Denial
B. Rationalization
C. displacement
D. compensation
Answer: C. displacement
A nurse is observing a newly licensed nurse administer an IM medication to a client who is
manic and refuses the medication. Which of the following actions should the nurse take first?
A. stop the newly licensed nurse from administering the medication
B. call the provider for an alternate medication route
C. report the occurrence to the nurse manager
D. talk to the newly licensed nurse about the incident
Answer: A. stop the newly licensed nurse from administering the medication
A nurse is planning care for a client who demonstrates prolonged depression related to the
loss of her partner 6 months ago. Which of the following actions should the nurse take?
A. explain that it can take a year or more to learn to live with loss
B. discourage the client from reliving the events surrounding her loss
C. suggest that the client avoid social interactions that remind her of her partner
D. direct the client to maintain an unstructured daily routine

Answer: A. explain that it can take a year or more to learn to live with loss
A nurse is caring for a client who has bipolar disorder. The client is walking in and out of
rooms, speaking inappropriately, and giggling. Which of the following actions should the
nurse take?
A. tell the client there will be negative consequences for her behavior
B. take the client to the day room to watch a movie with the other clients
C. have the client return to her room to read a book
D. lead the client outside for a walk
Answer: D. lead the client outside for a walk
A nurse is admitting a client who has a new diagnosis of schizophrenia and a history of
aggression. Which of the following actions should the nurse include in the clients initial plan
of care?
A. agree with the client when he is upset until he can calm down
B. provide physical exercise activity for the client
C. avoid eye contact with the client for the first few days
D. ignore the clients hallucinations
Answer: B. provide physical exercise activity for the client
a nurse is caring for a client who has bipolar disorder and is exhibiting mania. Which of the
following findings should the nurse expect?
A. disorganized speech
B. heightened concentration
C. hypersomnia
D. agoraphobia
Answer: A. disorganized speech
a nurse is caring for a client who has schizophrenia. The client’s employer calls to discuss the
client’s condition. Which of the following is the appropriate nursing action?
A. consult the client
B. consult the client’s family
C. contact the provider
D. contact the facility legal department

Answer: A. consult the client
A nurse is providing teaching to a client who is prescribed methylphenidate for ADHD.
Which of the following statements by the client indicates accurate understanding of this
medications effects?
A. I know that I will be able to think more clearly now
B. this medicine will help me relax and feel less anxious
C. ill take my medicine at bedtime because it will make my drowsy
D. I need to tell my doctor if I start gaining weight
Answer: A. I know that I will be able to think more clearly now
An older adult client is brought to the mental health clinic by her daughter. The daughter
reports that her mother is not eating and seems very uninterested in routine activities. The
daughter states “ im so worried that my mother is depressed” Which of the following
responses should the nurse take?
A. “you shouldn’t worry about this, because depressive disorder is easily treated”
B. older adults are usually diagnosed with depressive disorder as they age
C. tell me the reasons you think your mother is depressed
D. everyone gets depressed from time to time.
Answer: C. tell me the reasons you think your mother is depressed
A nurse is providing teaching to a client who has a new prescription for tranylcypromine.
Which of the following over the counter medications should the nurse instruct the client to
avoid taking due to adverse interactions?
A. Ranitidine
B. Pseudoephedrine
C. Ibuprofen
D. magnesium hydroxide
Answer: B. Pseudoephedrine
A nurse in the ED is admitting a client who has a history of alcohol use disorder. The client
has a blood alcohol level of 0.26 g/dl. The nurse should anticipate a prescription for which of
the following medications?
A. Disulfiram

B. Cholridiazepoxide
C. Naltrexone
D. Acamprosate
Answer: B. Cholridiazepoxide
A nurse is building a therapeutic relationship with a client who has an eating disorder. Which
of the following activities should the nurse initiate during the relationships orientation phase?
A. Mutually deciding and agreeing on the goals of the relationship
B. using memories to validate the relationship experience
C. discussing the incorporation of new strategies into daily life
D. teaching and encouraging the use of problem solving skills
Answer: A. Mutually deciding and agreeing on the goals of the relationship
A nurse is assessing a client who has schizophrenia. The client tells the nurse, “My heart
exploded and my blood is draining out” The nurse should interpret this statement as which of
the following manifestations?
A. concrete thinking
B. a visual hallucination
C. a somatic delusion
D. paranoia
Answer: C. a somatic delusion
A nurse is interviewing a client who has schizophrenia. The client states, “aliens are going to
abduct me at midnight tonight” Which of the following responses should the nurse make?
A. why are the aliens going to abduct you?
B. you are safe from aliens here
C. believing that aliens will abduct you must be scary
D. have you ever been abducted by aliens before?
Answer: C. believing that aliens will abduct you must be scary
A nurse is caring for a client who has generalized anxiety disorder and a history of substance
abuse use disorder. Which of the following medications would the nurse expect the provider
to prescribe?
A. Chlordiazepoxide

B. Clonazepam
C. Busprione
D. Alprazolam
Answer: C. Busprione
A nurse in an ED is creating a plan of care for a client who reports experiencing intimate
partner violence.
Which of the following interventions should the nurse include as the priority?
A. teach the client stress reduction techniques
B. help the client devise a safety plan
C. refer the client to a support group
D. follow the facilities protocol for reporting the abuse
Answer: D. follow the facilities protocol for reporting the abuse
A nurse in a mental health facility is caring for a client who is being aggressive toward other
clients. Which of the following actions is the priority for the nurse to take?
A. Assist the client to explore techniques to reduce stress
B. Ask the client if he intends to harm others,
C. role model healthy ways to express anger
D. suggest the client make a list of things that make him angry.
Answer: B. Ask the client if he intends to harm others,
A nurse in the ED is caring for a client who has serotonin syndrome. The nurse should assess
the client for which of the following manifestations?
A. Hyperpyrexia
B. Priapism
C. Parathesisa
D. bradycardia
Answer: A. Hyperpyrexia
ATI Mental Health Final Quiz (aka Quiz 3)
VERSION 14

A nurse is planning care for a client who has borderline personality disorder who selfmutilates. Which of the following test approaches should the nurse plan to take?
A. Restrict participation in group therapy sessions.
The nurse should encourage the client who has borderline personality disorder to participate
in group therapy sessions to encourage appropriate interaction with other clients.
B. Establish consequences for self-mutilation.
The nurse should respond to self-mutilation with a neutral affect and encourage the client to
write down feelings that occurred leading up to the incident.
C. Maintain close observation of the client.
Clients who have borderline personality disorder are at risk for self-harm during times of
increased anxiety. Maintaining close observation reduces the client's risk of injury.
D. Provide an unstructured environment.
Providing an unstructured environment for a client who has borderline personality disorder is
not an effective treatment approach because it does not provide a safe environment to protect
the client from impulsive and self-injurious behavior.
Answer: C. Maintain close observation of the client.
Clients who have borderline personality disorder are at risk for self-harm during times of
increased anxiety. Maintaining close observation reduces the client's risk of injury.
A nurse is assessing a client who has Stage 4 Alzheimer's disease. Which of the following
findings should the nurse expect?
A. The client requires assistance with eating.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to still have the
ability to eat without assistance. Clients who have Alzheimer’s disease maintain this ability
until Stage 7.
B. The client independently manages personal finances.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to have difficulty
performing complex tasks, such as managing personal finances.
C. The client has bladder incontinence.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to be able to use the
toilet independently. Clients who have Alzheimer’s disease maintain continence until Stage 6.
D. The client is able to identify the names of family members.

The nurse should expect the client who has Stage 4 Alzheimer’s disease to recognize and
identify family members. Clients who have Alzheimer’s disease maintain this ability until
Stage 6.
Answer: D. The client is able to identify the names of family members.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to recognize and
identify family members. Clients who have Alzheimer’s disease maintain this ability until
Stage 6.
A nurse is caring for a client who reports that the television set in the room is really a twoway radio and states, "voices are coming from the TV and everything we say in the room is
being recorded." Which of the following responses should the nurse make?
A. "What we say is not being recorded."
The nurse should avoid negating the client’s beliefs about the delusion. This response can
promote a defensive client response and interfere with the development of trust in the nurseclient relationship.
B. "Let's ignore the voices and talk about something else."
The nurse should ask the client directly about what the voices are saying to determine if there
is a safety risk. The nurse should also avoid validating that the voices are real, which
promotes the client’s beliefs about the delusion.
C. "That must be very frightening."
The nurse should respond to the client’s delusion in a calm and empathetic manner. By
acknowledging to the client that the delusion must be frightening, the nurse promotes the
nurseclient relationship.
D. "Why do you think the TV is a two-way radio?"
The nurse should avoid asking the client a "why" question, which promotes a defensive client
response.
Answer: C. "That must be very frightening."
The nurse should respond to the client’s delusion in a calm and empathetic manner. By
acknowledging to the client that the delusion must be frightening, the nurse promotes the
nurseclient relationship.
A nurse is planning care for a newly admitted client who has bipolar disorder and is
experiencing acute mania. Which of the following client goals should the nurse identify as
the priority?

A. Practicing problem-solving skills
The nurse should encourage the client to practice problem-solving skills during the
continuation phase of treatment; however, there is another intervention that is the priority
during the acute phase of bipolar disorder.
B. Understanding of medication regimen
The nurse should ensure that the client understands the medication regimen during the
continuation phase of treatment; however, there is another intervention that is the priority
during the acute phase of bipolar disorder.
C. Identifying indications of relapse
The nurse should teach the client to recognize indications of relapse during the continuation
phase of treatment; however, there is another intervention that is the priority during the acute
phase of bipolar disorder.
D. Maintaining adequate hydration
The nurse should identify that the priority goal is to prevent physical exhaustion, maintain
health, and meet nutritional and rest needs during the acute phase of the client’s manic
episode. The nurse should consider Maslow’s hierarchy of needs, which includes five levels
of priority when planning care for this client. The first level consists of physiological needs;
the second level consists of safety and security needs; the third level consists of love and
belonging needs; the fourth level consists of personal achievement and self-esteem needs; and
the fifth level consists of achieving full potential and the ability to problem solve and cope
with life situations. When applying Maslow’s hierarchy of needs prioritysetting framework
the nurse should review physiological needs first. The nurse should then address the client’s
needs by following the remaining four hierarchical levels. It is important, however, for the
nurse to consider all contributing client factors, as higher levels of the pyramid can compete
with those at the lower levels, depending on the specific client situation. The fourth level of
Maslow’s hierarchy of needs includes usefulness, self-worth, and self-confidence in fulfilling
self-esteem needs.
Answer: D. Maintaining adequate hydration
The nurse should identify that the priority goal is to prevent physical exhaustion, maintain
health, and meet nutritional and rest needs during the acute phase of the client’s manic
episode. The nurse should consider Maslow’s hierarchy of needs, which includes five levels
of priority when planning care for this client. The first level consists of physiological needs;
the second level consists of safety and security needs; the third level consists of love and
belonging needs; the fourth level consists of personal achievement and self-esteem needs; and

the fifth level consists of achieving full potential and the ability to problem solve and cope
with life situations. When applying Maslow’s hierarchy of needs prioritysetting framework
the nurse should review physiological needs first. The nurse should then address the client’s
needs by following the remaining four hierarchical levels. It is important, however, for the
nurse to consider all contributing client factors, as higher levels of the pyramid can compete
with those at the lower levels, depending on the specific client situation. The fourth level of
Maslow’s hierarchy of needs includes usefulness, self-worth, and self-confidence in fulfilling
self-esteem needs.
A nurse is preparing to administer benzodiazepine to a client with Generalized Anxiety
Disorder. The nurse should tell the client to expect with of the following adverse reactions?
A. Tinnitus
Tinnitus is not an adverse effect of benzodiazepines.
B. Bradycardia
Tachycardia, rather than bradycardia, is a potential adverse effect of benzodiazepines.
C. Halitosis
Halitosis is not an adverse effect of benzodiazepines.
D. Sedation
The nurse should tell the client to expect sedation as an adverse effect of benzodiazepines
because of the CNS depression effects.
Answer: D. Sedation
The nurse should tell the client to expect sedation as an adverse effect of benzodiazepines
because of the CNS depression effects.
A nurse in a mental health unit is planning care for a client who is receiving treatment for
self-inflicted injuries. The nurse should identify which of the following interventions as the
priority when planning care for this client?
A. Promoting and maintaining client safety
The nurse should recognize that the client who has self-inflicted injuries is at risk for further
self-harm or suicide; therefore, the client’s safety is the priority. The nurse should apply the
safety and risk reduction priority-setting framework when planning care for this client. This
framework assigns priority to the factor or situation posing the greatest safety risk to the
client. When there are several risks to client safety, the one posing the greatest threat is the

highest priority. The nurse should use Maslow’s hierarchy of needs, the ABC priority-setting
framework, or nursing knowledge to identify which risk poses the greatest threat to the client.
B. Discussing reasons for the client's behavior
The nurse should communicate with the client to discuss reasons for the client’s behavior;
however, there is another action that is the priority.
C. Assisting the client to recognize feelings
The nurse should assist the client to recognize feelings; however, there is another action that
is the priority.
D. Teaching the client alternative coping strategies
The nurse should teach the client alternative coping strategies; however, there is another
action that is the priority.
Answer: A. Promoting and maintaining client safety
The nurse should recognize that the client who has self-inflicted injuries is at risk for further
self-harm or suicide; therefore, the client’s safety is the priority. The nurse should apply the
safety and risk reduction priority-setting framework when planning care for this client. This
framework assigns priority to the factor or situation posing the greatest safety risk to the
client. When there are several risks to client safety, the one posing the greatest threat is the
highest priority. The nurse should use Maslow’s hierarchy of needs, the ABC priority-setting
framework, or nursing knowledge to identify which risk poses the greatest threat to the client.
A nurse is providing teaching to a client who has a new prescription for disulfiram for
management of alcohol dependence. Which of the following dietary choices should the nurse
instruct the client to avoid?
A. Peppermint candy
It is not necessary for the client to avoid peppermint while taking disulfiram.
B. Pure vanilla extract
The nurse should instruct the client to avoid alcohol and alcohol-containing substances, such
as pure vanilla extract, while taking disulfiram. The ingestion of alcohol while taking this
medication causes a disulfiram-alcohol reaction, which is manifested by hyperventilation,
dizziness, vomiting, and hypotension.
C. Salt
Though certain medications require a reduction in sodium intake, it is not necessary for the
client to avoid salt while taking disulfiram.
D. Chocolate

Though certain medications require a reduction in caffeine-containing substances such as
chocolate, it is not necessary for the client to avoid chocolate while taking disulfiram.
Answer: B. Pure vanilla extract
The nurse should instruct the client to avoid alcohol and alcohol-containing substances, such
as pure vanilla extract, while taking disulfiram. The ingestion of alcohol while taking this
medication causes a disulfiram-alcohol reaction, which is manifested by hyperventilation,
dizziness, vomiting, and hypotension.
A nurse is planning care for a client with a physical dependence of Alprazolam and must
discontinue the medication. Which of the following should the nurse include in the plan?
A. Taper the medication gradually over several weeks.
The nurse should plan to taper the dosage of alprazolam gradually over several weeks,
possibly months. This gradual reduction in dosage reduces the manifestations of withdrawal.
B. Encourage participation in stimulating physical activity.
The nurse should provide the client with a calm, low-stimulation environment to decrease the
anxiety and physical manifestations that can result from alprazolam withdrawal.
C. Monitor the client for a return of anxiety for up to 72 hr following discontinuation of the
medication. The nurse should plan to monitor the client for at least 3 weeks following
discontinuation of the medication for a return of anxiety manifestations.
D. Implement restraints and seclusion as needed.
It is not necessary to restrain or seclude the client during withdrawal from alprazolam.
Restraints are considered restrictive, and the nurse should work to promote the least
restrictive environment.
Answer: A. Taper the medication gradually over several weeks.
The nurse should plan to taper the dosage of alprazolam gradually over several weeks,
possibly months. This gradual reduction in dosage reduces the manifestations of withdrawal.
A nurse is caring for a newly admitted client who is receiving treatment for alcohol use
disorder. the client tells the nurse “I have not had a drink for 6 hours.” Which findings should
the nurse expect during alcohol withdrawals.
A. Low body temperature
The nurse should expect the client who is experiencing alcohol withdrawal to have an
elevated temperature.
B. Insomnia

The nurse should expect the client who is experiencing alcohol withdrawal to have insomnia
and restlessness.
C. Muscle flaccidity
The nurse should expect the client who is experiencing alcohol withdrawal to have muscle
tremors.
D. Bradycardia
The nurse should expect the client who is experiencing alcohol withdrawal to have
tachycardia.
Answer: B. Insomnia
The nurse should expect the client who is experiencing alcohol withdrawal to have insomnia
and restlessness.
A nurse is caring for a client who is receiving treatment for alcohol detoxification. Which of
the following medications should the nurse expect to administer during this phase of the
client's care?
A. Buprenorphine
The nurse should expect to administer buprenorphine to a client during opiate detoxification.
B. Diazepam
The nurse should expect to administer diazepam to a client during alcohol detoxification.
Anti- anxiety agents, such as chlordiazepoxide and diazepam, are long-acting CNS
depressants that are used to minimize the manifestations of alcohol withdrawal.
C. Varenicline
The nurse should expect to administer varenicline to a client who has nicotine use disorder.
D. Rimonabant
The nurse should expect to administer rimonabant to a client who has nicotine use disorder.
Answer: B. Diazepam
The nurse should expect to administer diazepam to a client during alcohol detoxification.
Anti- anxiety agents, such as chlordiazepoxide and diazepam, are long-acting CNS
depressants that are used to minimize the manifestations of alcohol withdrawal.
A nurse is speaking to a community group about the diagnosis and treatment of clients who
have Alzheimer's. The nurse should conclude that the members of the group need further
teaching when she identifies the following as manifestations of Alzheimer Disease.
A. Impaired judgment

The nurse should identify impaired judgment as a common manifestation associated with
Alzheimer Disease.
B. Sudden confusion
The nurse should clarify that the client who has Alzheimer’s disease is expected to exhibit
confusion that develops slowly over a period of months. Clients who have delirium exhibit
sudden confusion.
C. Personality change
The nurse should identify that clients who have Alzheimer’s disease are expected to exhibit
changes in personality as the disease progresses.
D. Remote memory loss
The nurse should identify recent and remote memory loss as common manifestations
associated with Alzheimer’s disease.
Answer: B. Sudden confusion
The nurse should clarify that the client who has Alzheimer’s disease is expected to exhibit
confusion that develops slowly over a period of months. Clients who have delirium exhibit
sudden confusion.
A nurse is providing teaching to a client with Generalized Anxiety Disorder and a new
prescription for Buspirone. The nurse should inform the client that which of the following
manifestations is a common adverse effect of this medication?
A. Confusion
Confusion is not an adverse effect of buspirone, though the client might experience decreased
concentration and headache.
B. Bradycardia
Tachycardia and palpitations, not bradycardia, are possible adverse effects of buspirone.
C. Dizziness
The nurse should inform the client that dizziness is a common adverse effect of buspirone.
The nurse should instruct the client to avoid driving and operating heavy machinery until the
presence of adverse effects is determined.
D. Insomnia
Drowsiness, not insomnia, is an adverse effect of buspirone.
Answer: C. Dizziness

The nurse should inform the client that dizziness is a common adverse effect of buspirone.
The nurse should instruct the client to avoid driving and operating heavy machinery until the
presence of adverse effects is determined.
A nurse is reviewing the medications of a client who has bipolar disorder and a new
prescription for lithium. The nurse should identify that it is safe to administer which of the
following medications while the client is taking lithium?
A. Ibuprofen
Ibuprofen is not safe to administer to a client who is taking lithium because it can cause
increased kidney absorption of lithium, which can lead to lithium toxicity.
B. Haloperidol
Haloperidol is not safe to administer to a client who is taking lithium because the
combination of these medications increases the client’s risk for extrapyramidal adverse
effects and tardive dyskinesia.
C. Valproic acid
Valproic acid and lithium are both indicated for the treatment of bipolar disorder. It is safe for
the nurse to administer both of these medications to the client.
D. Hydrochlorothiazide
Hydrochlorothiazide is not safe to administer to a client who is taking lithium because it
promotes sodium loss, which can lead to lithium toxicity.
Answer: C. Valproic acid
Valproic acid and lithium are both indicated for the treatment of bipolar disorder. It is safe for
the nurse to administer both of these medications to the client.
A nurse in the emergency department is caring for a toddler with a fractured arm. which of
the following finding should the nurse suspect as possible abuse?
A. The parent provides a history that is inconsistent with the child's injury.
The nurse should suspect possible abuse when the child’s injury conflicts with the history of
the injury that is reported by his parent.
B. The child is brought to the emergency department immediately following the injury.
The nurse should suspect possible abuse when there is a delay in seeking medical care
following an injury.
C. The parent requests to remain present with the child throughout treatment of the injury.

The nurse should suspect possible abuse when the parent leaves the treatment area or facility
after bringing the child in for treatment of an injury.
D. The child clings to the parent when the nurse begins to assess the injury.
The nurse should suspect possible abuse if the child displays fear of the parent.
Answer: A. The parent provides a history that is inconsistent with the child's injury.
The nurse should suspect possible abuse when the child’s injury conflicts with the history of
the injury that is reported by his parent.
A nurse is evaluating a care plan for a client who has an Antisocial Personality Disorder.
Which of the following client actions indicates he is making progress in treatments? (Select
All That Apply)
A. Assisting another client who has depression to fill out a menu.
Clients who have antisocial personality disorder tend to lack empathy for others and often
display an inability to connect with others. Assisting another client indicates the client’s
willingness to help and connect with others and demonstrates to the nurse his progress with
treatment.
B. Nominating himself to chair the client government meeting.
Clients who have antisocial personality disorder tend to see themselves as superior to others.
Providing a self-nomination for chairperson status places him in a position of power over
others; therefore, this behavior does not indicate progress with the treatment.
C. Requesting a weekend pass to go home.
Clients who have antisocial personality disorder tend to disregard rules and have a lack of
respect for authority. Requesting a weekend pass indicates the client’s willingness to follow
unit rules and demonstrates to the nurse his progress with the treatment.
D. Serving as the judge for a unit talent show.
Clients who have antisocial personality disorder tend to see themselves as superior to others.
Serving as a judge places the client in a position of power over others; therefore, this
behavior does not indicate progress with the treatment.
E. Informing the nurse that the staff provides excellent care to clients.
Clients who have antisocial personality disorder often use flattery as a form of manipulation
to promote personal gain; therefore, providing a compliment to the nursing staff does not
indicate progress with the treatment.
Answer: A. Assisting another client who has depression to fill out a menu.

Clients who have antisocial personality disorder tend to lack empathy for others and often
display an inability to connect with others. Assisting another client indicates the client’s
willingness to help and connect with others and demonstrates to the nurse his progress with
treatment.
C. Requesting a weekend pass to go home.
Clients who have antisocial personality disorder tend to disregard rules and have a lack of
respect for authority. Requesting a weekend pass indicates the client’s willingness to follow
unit rules and demonstrates to the nurse his progress with the treatment.
A nurse is providing teaching to a client who is to start taking valproic acid. Which of the
following instructions should the nurse include?
A. "You should expect the provider to gradually decrease your dosage of valproic acid."
The nurse should inform the client that the provider will initially prescribe a small dose, and
then gradually increase the dose until a maintenance dosage is achieved.
B. "You should take aspirin for pain you have while taking valproic acid."
The nurse should instruct the client to avoid aspirin while taking valproic acid because of the
increased risk of spontaneous bleeding.
C. "You should undergo thyroid function tests every 6 months while taking valproic acid."
The nurse should identify that hypothyroidism is an adverse effect of lithium rather than
valproic acid.
D. "You should have your liver function levels monitored regularly while taking valproic
acid"
The nurse should inform the client of the need to regularly monitor liver function levels due
to the risk for hepatotoxicity while taking valproic acid. It is recommended to obtain baseline
levels and then repeat every 2 months during the first 6 months of therapy.
Answer: D. "You should have your liver function levels monitored regularly while taking
valproic acid"
The nurse should inform the client of the need to regularly monitor liver function levels due
to the risk for hepatotoxicity while taking valproic acid. It is recommended to obtain baseline
levels and then repeat every 2 months during the first 6 months of therapy.
A nurse is teaching a client who has Agoraphobia about Systematic Desensitization. Which of
the following comments should the nurse include in the teaching?
A. "You will watch from a secure location as your therapist goes to public spaces."

The nurse should recognize that encouraging the client to watch as the therapist acts as a role
model in anxiety-provoking situations is an example of modeling, not systematic
desensitization.
B. "You will start your therapy by staying in a public space until your anxiety decreases."
The nurse should recognize that sudden exposure of the client to the undesirable stimulus is
an example of flooding, not systematic desensitization.
C. "You will be instructed to say 'Stop!' out loud when you become anxious in public spaces."
The nurse should recognize that saying "Stop!" to interrupt a negative thought is an example
of thought stopping, not systematic desensitization.
D. "You will slowly be exposed to increasing levels of public spaces."
The nurse should inform the client that, using systematic desensitization, she will be
gradually exposed to the feared situation under controlled conditions until she learns to
overcome the anxious response.
Answer: D. "You will slowly be exposed to increasing levels of public spaces."
The nurse should inform the client that, using systematic desensitization, she will be
gradually exposed to the feared situation under controlled conditions until she learns to
overcome the anxious response.
A nurse is planning a staff education session about the administration of antidepressant
medications to older adult clients. Which of the following information should the nurse
include in the teaching?
A. Older adult clients require a lower initial dose of antidepressant medication than adult
clients. The nurse should recognize that older adult clients are recommended to start at half
the adult dose for antidepressant medications. This is due to altered rates of absorption and
the increased risk for adverse effects.
B. Older adult clients should not receive antidepressant medication.
The nurse should identify that antidepressant medications are commonly prescribed for older
adult clients; however, adjustments are needed due to the clients' altered rates of absorption.
C. Older adult clients achieve the therapeutic effects of antidepressant medications more
quickly than adult clients. The nurse should identify that older adult clients have a decreased
rate of absorption, distribution, and metabolism, resulting in a delay in achieving therapeutic
effects. It can take about 1 month of treatment for the older adult client to achieve therapeutic
effects.

D. Older adult clients have a decreased risk for adverse effects from antidepressant
medication.
The nurse should identify that older adult clients have an increased risk for adverse effects
due to a decreased rate of excretion.
Answer: A. Older adult clients require a lower initial dose of antidepressant medication than
adult clients. The nurse should recognize that older adult clients are recommended to start at
half the adult dose for antidepressant medications. This is due to altered rates of absorption
and the increased risk for adverse effects.
A nurse in an acute mental health facility is reviewing the medication records for a group of
clients. The nurse should expect a prescription for memantine for a client who has which of
the following diagnoses?
A. Postpartum depression
The nurse should recognize that memantine, an N-methyl-D-aspartate (NMDA) receptor
agonist, is not indicated for the treatment of depression.
B. Schizophrenia
The nurse should recognize that memantine, an NMDA receptor agonist, is not indicated for
the treatment of schizophrenia.
C. Obesity
The nurse should recognize that memantine, an NMDA receptor agonist, is not indicated for
the treatment of obesity.
D. Severe Alzheimer's disease
The nurse should expect a prescription for memantine for a client who has moderate to severe
Alzheimer’s disease. Memantine, an NMDA receptor agonist, is shown to slow the
progression of manifestations and to improve cognitive function.
Answer: D. Severe Alzheimer's disease
The nurse should expect a prescription for memantine for a client who has moderate to severe
Alzheimer’s disease. Memantine, an NMDA receptor agonist, is shown to slow the
progression of manifestations and to improve cognitive function.
A nurse is assessing a client who has Binge-Eating Disorder. Which of the following findings
should the nurse expect?
A. Amenorrhea

Clients who have binge-eating disorder often have an increased BMI; therefore, amenorrhea
resulting from a low body weight is not expected.
B. Abdominal pain
The nurse should expect the client who has binge-eating disorder to report problems with
abdominal pain. This is due to the gastrointestinal dilation that occurs as a result of eating
excessive volumes of food.
C. Restricted caloric intake
Clients who have binge-eating disorder often have an increased BMI resulting from eating
excessive volumes of food.
D. Frequent use of laxatives
Clients who have binge-eating disorder have repeated episodes of binging without the use of
compensatory behaviors, such as the use of laxatives.
Answer: B. Abdominal pain
The nurse should expect the client who has binge-eating disorder to report problems with
abdominal pain. This is due to the gastrointestinal dilation that occurs as a result of eating
excessive volumes of food.
A nurse on an acute care unit is providing postoperative care for an elderly patient who
developed Delirium. Which of the following actions should the nurse take?
A. Request a prescription for an antianxiety medication.
The nurse should request a prescription for an antianxiety medication for a client who
develops delirium. Administration of a PRN antianxiety medication can decrease her anxiety
and agitation.
B. Provide the client with a stimulating activity prior to bedtime.
The nurse should maintain a low-stimulation environment for the client to decrease
disorientation due to overstimulation.
C. Keep the lights in the client's room dim at night.
The nurse should keep the client’s room well-lit. Adequate lighting can help her to remain
oriented to place upon waking at night and will provide for safety if she becomes ambulatory.
D. Encourage the client to make decisions about her daily routine.
The nurse should provide the client with a consistent routine and limit her need to make
decisions. These actions will decrease disorientation and anxiety.
Answer: A. Request a prescription for an antianxiety medication.

The nurse should request a prescription for an antianxiety medication for a client who
develops delirium. Administration of a PRN antianxiety medication can decrease her anxiety
and agitation.
A nurse assessing a client who has Conduct Disorder. Which of the following findings should
the nurse expect?
A. Fearfulness of authority figures
Clients who have conduct disorder exhibit a lack of respect for authority figures and might
attempt to initiate a fight with or intimidate others.
B. Flat affect
Clients who have conduct disorder are easily angered and do not have a flat affect.
C. Preoccupation with enforcing rules
Clients who have conduct disorder exhibit a lack of respect for rules.
D. Aggressive behavior toward others
The nurse should expect the client who has conduct disorder to exhibit aggression toward
others and impulsively violate others' rights.
Answer: D. Aggressive behavior toward others
The nurse should expect the client who has conduct disorder to exhibit aggression toward
others and impulsively violate others' rights.
A nurse in an acute care facility is leading a staff discussion about the legal implications of
involuntary admissions. Which of the following should the nurse include?
A. A client who is involuntarily admitted must take prescribed medications.
Clients who are involuntarily admitted retain the legal right to refuse medications.
B. An involuntary admission of a client is limited to 2 weeks.
Clients who are involuntarily admitted might be required to remain in the facility for up to 60
days. After this time a legal review of the case is required to determine if continued
involuntary treatment is required.
C. A client who is involuntarily admitted can leave the facility against medical advice.
Clients who are involuntarily admitted retain certain rights; however, they are unable to leave
the health care facility against medical advice. If a client who is involuntarily admitted feels
that the admission is unjustified, the client can file a legal petition requesting a review of the
admission.
D. An involuntary admission is justified if the client is a danger to others.

A client who is a danger to others or to himself qualifies for an involuntary admission. The
inability to meet basic needs due to the need for mental health treatment is also a justification
for an involuntary admission.
Answer: D. An involuntary admission is justified if the client is a danger to others.
A client who is a danger to others or to himself qualifies for an involuntary admission. The
inability to meet basic needs due to the need for mental health treatment is also a justification
for an involuntary admission.
A nurse is caring for a client who has Schizophrenia. The nurse notices that the client is
pacing up and down the hall very rapidly and muttering in an angry manner. Which of the
following actions should the nurse take first?
A. Apply mechanical restraints to the client.
The nurse might have to place the client in restraints to prevent harm to others and allow the
client to calm down; however, the nurse should use a less restrictive intervention first.
B. Administer PRN haloperidol IM to the client.
The nurse might have to administer PRN haloperidol to calm the client; however, the nurse
should use a less restrictive intervention first.
C. Approach the client in a nonthreatening manner.
The first action the nurse should take is to approach the client calmly, in a nonthreatening
manner, to create a nonthreatening environment. The nurse should apply the least restrictive
priority-setting framework when caring for this client. This framework assigns priority to
nursing interventions that are least restrictive to the client, as long as those interventions do
not jeopardize client safety. Least restrictive interventions promote client safety without using
restraints. The nurse should only use physical or chemical restraints when the safety of the
client, staff, or others is at risk.
D. Place the client in seclusion.
The nurse might have to place the client in seclusion to prevent harm to others and allow the
client to calm down; however, the nurse should use a less restrictive intervention first.
Answer: C. Approach the client in a nonthreatening manner.
The first action the nurse should take is to approach the client calmly, in a nonthreatening
manner, to create a nonthreatening environment. The nurse should apply the least restrictive
priority-setting framework when caring for this client. This framework assigns priority to
nursing interventions that are least restrictive to the client, as long as those interventions do
not jeopardize client safety. Least restrictive interventions promote client safety without using

restraints. The nurse should only use physical or chemical restraints when the safety of the
client, staff, or others is at risk.
A nurse is reviewing the medical record of a client who has a new prescription for a
benzodiazepine. For which of the following findings should the nurse question the provider's
prescriptions?
A. A skeletal muscle injury
Benzodiazepines have muscle relaxant properties and can relieve muscle spasms; therefore, a
skeletal muscle injury is not a contraindication for receiving benzodiazepines.
B. History of status epilepticus
Benzodiazepines can raise the seizure threshold and prevent seizures; therefore, a history of
status epilepticus is not a contraindication for receiving benzodiazepines.
C. Hypotension
The nurse should question the provider’s prescription for a benzodiazepine for a client who
has hypotension. Benzodiazepines can cause severe hypotension and increase the client’s risk
for cardiac arrest.
D. Insomnia
Benzodiazepines induce sleep for clients who have a sleep disorder; therefore, insomnia is
not a contraindication for receiving benzodiazepines.
Answer: C. Hypotension
The nurse should question the provider’s prescription for a benzodiazepine for a client who
has hypotension. Benzodiazepines can cause severe hypotension and increase the client’s risk
for cardiac arrest.
A nurse is providing teaching to the parents of a school-age child who has attention deficit
hyperactivity disorder (ADHD). Which of the following instructions should the nurse include
in the teaching?
A. "Ignore your child's attention-seeking behaviors that are not dangerous."
The nurse should instruct the parents about the use of planned ignoring. This technique
ignores attention-seeking behaviors that are not dangerous to the child or others. If the child
learns that the behavior will not elicit the desired response, then the behavior should decrease.
B. "Administer ADHD medications within 30 minutes of your child's bedtime."
The nurse should instruct the parents to administer medications in the morning to decrease
insomnia, which is a common adverse effect of ADHD medications.

C. "Continue with an activity as planned even if your child becomes frustrated."
The nurse should instruct the parents about the use of restructuring. This technique adjusts or
changes an activity based on the child’s level of frustration.
D. "Expect your child to gain weight after starting ADHD medications."
The nurse should instruct the parents that a decreased appetite and weight loss are common
adverse effects of ADHD medications.
Answer: A. "Ignore your child's attention-seeking behaviors that are not dangerous."
The nurse should instruct the parents about the use of planned ignoring. This technique
ignores attention-seeking behaviors that are not dangerous to the child or others. If the child
learns that the behavior will not elicit the desired response, then the behavior should decrease.
The nurse is interviewing a client who has Anorexia Nervosa. Which if the following findings
should the nurse expect?
A. Poor personal hygiene habits
The nurse should not expect the client who has anorexia nervosa to have poor personal
hygiene habits. Clients who have anorexia nervosa often exhibit compulsive behaviors, such
as frequent hand washing, and are preoccupied with their appearance.
B. Strenuous exercise regimen
The nurse should expect the client who has anorexia nervosa to report a strenuous exercise
regimen. The client might participate in excessive physical activity due to the perceived need
to burn calories and lose weight.
C. Grandiose behaviors
The nurse should expect clients who have anorexia nervosa to have poor self-esteem and
negative feelings about themselves.
D. Intense fear of death
The nurse should expect the client who has anorexia nervosa to have an intense fear of
gaining weight. Clients who have anorexia nervosa exhibit behaviors that have negative
health consequences in order to prevent weight gain.
Answer: B. Strenuous exercise regimen
The nurse should expect the client who has anorexia nervosa to report a strenuous exercise
regimen. The client might participate in excessive physical activity due to the perceived need
to burn calories and lose weight.

A nurse is caring for a client who has depression, the clients states, "I am too tired and
depressed to attend group therapy today." Which of the following responses should the nurse
make?
A. "Attending group therapy, even if you're tired, is an important part of your treatment."
The nurse provides a therapeutic response by giving the client information to make an
informed decision. Group therapy is beneficial to the client who has depression by promoting
peer support and reducing social isolation.
B. "That's okay if you're too tired to attend group therapy today, but you will have to go
tomorrow."
The nurse should recognize that a lack of energy is expected for a client who has depression.
There is no indication that the client will have more energy for group therapy in the future.
The nurse should also respect the client’s autonomy and avoid giving a directive about
required participation.
C. "It is normal to feel tired when you're feeling depressed. The others in group therapy also
feel this way." The nurse should avoid minimizing the client’s feelings by making a
generalization about her status in relation to others.
D. "I agree with your decision to wait for participation in group therapy until you begin to
feel better."
The nurse should avoid giving approval to the client’s decision, which promotes the need for
her to please the nurse. The nurse should also encourage her to participate in group therapy to
promote improvement of her depression.
Answer: A. "Attending group therapy, even if you're tired, is an important part of your
treatment."
The nurse provides a therapeutic response by giving the client information to make an
informed decision. Group therapy is beneficial to the client who has depression by promoting
peer support and reducing social isolation.
A nurse is performing an admission assessment for a client who has restricting type Anorexia
Nervosa. The nurse should expect which of the following findings? A. Decreased caloric
intake
The nurse should expect the client who has restricting type anorexia nervosa to have a
restricted and decreased caloric intake due to the client’s intense fear of weight gain.
B. Recurrent binging

Recurrent binging is an expected finding of binge-eating/purging type anorexia nervosa.
Clients who have restricting type anorexia nervosa are not expected to exhibit bulimic
manifestations, such as binge eating.
C. Compensatory vomiting
Compensatory vomiting is an expected finding of binge-eating/purging type anorexia
nervosa. Clients who have restricting type anorexia nervosa are not expected to exhibit
bulimic manifestations, such as compensatory vomiting.
D. Loss of appetite
Loss of appetite is not an expected finding of a client who has anorexia nervosa. Clients who
have restrictive type anorexia nervosa maintain an appetite; however, they have inadequate
intake due to fear of gaining weight.
Answer: A. Decreased caloric intake
The nurse should expect the client who has restricting type anorexia nervosa to have a
restricted and decreased caloric intake due to the client’s intense fear of weight gain.
A nurse in a substance abuse treatment facility is reviewing the medication records for a
group of clients. The nurse should expect to administer Methadone for a client who has a
substance use disorder for which of the following addictions?
A. Amphetamines
The nurse should recognize that the administration of methadone is not indicated for the
treatment of amphetamine use disorder.
B. Opiates
The nurse should recognize that the administration of methadone is indicated for the
treatment of opiate use disorder. Opiates include opium, morphine, codeine, methadone, and
heroin. Methadone is given as a substitute to prevent cravings and severe manifestations of
opiate withdrawal.
C. Barbiturates
The nurse should recognize that the administration of methadone is not indicated for the
treatment of barbiturate use disorder.
D. Hallucinogenics
The nurse should recognize that the administration of methadone is not indicated for the
treatment of hallucinogen use disorder.
Answer: B. Opiates

The nurse should recognize that the administration of methadone is indicated for the
treatment of opiate use disorder. Opiates include opium, morphine, codeine, methadone, and
heroin. Methadone is given as a substitute to prevent cravings and severe manifestations of
opiate withdrawal.
A nurse is caring for a client who has just received a terminal diagnosis of cancer. Which of
the following initial reactions should the nurse expect?
A. Bargaining
The nurse should expect the client to exhibit bargaining during the grief process; however,
there is another response that is expected first.
B. Depression
The nurse should expect the client to exhibit depression during the grief process; however,
there is another response that is expected first.
C. Denial
The nurse should expect the client to initially deny the reality of the diagnosis. This is a
protective reaction that serves to protect the client from psychological pain.
D. Anger
The nurse should expect the client to exhibit anger during the grief process; however, there is
another response that is expected first.
Answer: C. Denial
The nurse should expect the client to initially deny the reality of the diagnosis. This is a
protective reaction that serves to protect the client from psychological pain.
A nurse is caring for a client with Alzheimer Disease and becomes agitated while refusing
morning hygiene care. Which of the following actions should the nurse take?
A. Talk to the client from two arm-lengths away.
The nurse should talk calmly and quietly to the client to decrease her agitation. The nurse
should remain one to two arm-lengths away to provide her with a sense of personal space and
maintain safety if she becomes aggressive.
B. Obtain assistance to restrain the client for safety.
The nurse should identify that the client’s refusal of care is not a justification for restraints.
The nurse should apply restraints only if her behavior becomes a threat to her safety or the
safety of others.
C. Firmly state to the client that morning care will be performed.

The nurse should recognize that the client has a right to refuse care. Telling her that care will
be performed, despite refusal, can increase her anxiety and agitation.
D. Call the provider to request a prescription for an antipsychotic medication.
The nurse should recognize that antipsychotic medications are used only with extreme
caution due to the increased risk of death for clients who have Alzheimer’s disease.
Antipsychotic medications are not indicated for the treatment of agitation.
Answer: A. Talk to the client from two arm-lengths away.
The nurse should talk calmly and quietly to the client to decrease her agitation. The nurse
should remain one to two arm-lengths away to provide her with a sense of personal space and
maintain safety if she becomes aggressive.
A nurse is assessing a client who takes Phenelzine for the treatment of Depression. Which of
the following finding should the nurse report to the provider?
A. Elevated blood pressure
The nurse should identify that the greatest risk to the client is an elevated blood pressure,
which increases his risk for a hypertensive crisis that can result from taking an MAOI, such
as phenelzine. The nurse should apply the safety and risk reduction priority-setting
framework when assessing this client.
This framework assigns priority to the factor or situation posing the greatest safety risk to the
client. When there are several risks to client safety, the one posing the greatest threat is the
highest priority. The nurse should use Maslow’s hierarchy of needs, the ABC priority-setting
framework, or nursing knowledge to identify which risk poses the greatest threat to the client.
B. Weight gain
The nurse should identify weight gain as a common adverse effect of an MAOI, such as
phenelzine. The nurse should report the adverse effect to the provider; however, there is
another finding that is a greater risk to the client than weight gain.
C. Muscle twitching
The nurse should identify muscle twitching as a common adverse effect of an MAOI, such as
phenelzine. The nurse should report the adverse effect to the provider; however, there is
another finding that is a greater risk to the client than muscle twitching.
D. 2+ peripheral edema
The nurse should identify peripheral edema as a common adverse effect of an MAOI, such as
phenelzine. The nurse should report the adverse effect to the provider; however, there is
another finding that is a greater risk to the client than peripheral edema.

Answer: A. Elevated blood pressure
The nurse should identify that the greatest risk to the client is an elevated blood pressure,
which increases his risk for a hypertensive crisis that can result from taking an MAOI, such
as phenelzine. The nurse should apply the safety and risk reduction priority-setting
framework when assessing this client.
This framework assigns priority to the factor or situation posing the greatest safety risk to the
client. When there are several risks to client safety, the one posing the greatest threat is the
highest priority. The nurse should use Maslow’s hierarchy of needs, the ABC priority-setting
framework, or nursing knowledge to identify which risk poses the greatest threat to the client.
A nurse is assessing a client who experienced a sexual assault 6 months ago. Which of the
following findings should the nurse report to the provider as an indication of rape-trauma
syndrome?
A. Flat affect
The nurse should expect the client who has rape-trauma syndrome to experience mood
swings and intense emotions.
B. Refusal to accept help from others
The nurse should expect the client who has rape-trauma syndrome to exhibit dependence
toward others.
C. Report of intense guilt
The nurse should expect the client who has rape-trauma syndrome to experience guilt about
the sexual assault. These feelings of guilt can delay the healing process and produce a
sustained and maladaptive response.
D. Denial of the sexual assault
The nurse should expect a client to have denial immediately following a sexual assault;
however, this is not a characteristic of rape-trauma syndrome.
Answer: C. Report of intense guilt
The nurse should expect the client who has rape-trauma syndrome to experience guilt about
the sexual assault. These feelings of guilt can delay the healing process and produce a
sustained and maladaptive response.
A nurse in interviewing an older adult client about possible anger abuse by her caregiver.
Which of the following techniques should the nurse use?
A. Avoid directly asking the client if she has been abused.

The nurse should ask the client directly about possible abuse to identify the client’s physical,
emotional, and safety needs.
B. Use a confrontational approach.
The nurse should avoid a confrontational approach, which can raise the client’s defensive
barriers and potentially block further communication.
C. Maintain a nonjudgmental tone.
The nurse should use a nonjudgmental tone to promote trust and communication.
D. Avoid being in the room alone with the client.
The nurse should conduct the interview in private to provide a calm and safe environment.
Answer: C. Maintain a nonjudgmental tone.
The nurse should use a nonjudgmental tone to promote trust and communication.
A nurse is providing teaching for a family of a client who has Alzheimer Disease about
Donepezil. Which of the following statements should the nurse include in the teaching?
A. "Donepezil can improve cognitive functioning during the earlier stages of the disease."
The nurse should inform the family that donepezil is used to treat the manifestations of mild
to severe Alzheimer’s disease. Although donepezil does not prevent the progression of
Alzheimer’s disease, it is intended to prolong the client's ability to function in the early stages
of the disease.
B. "Donepezil cures the disease process if it is started upon first recognition of dementia."
The nurse should inform the family that donepezil is used to treat the manifestations of mild
to severe Alzheimer’s disease; however, donepezil does not prevent the progression of
Alzheimer’s disease.
C. "Donepezil provides long-term reversal of memory loss in the last phase of the disease."
The nurse should inform the family that donepezil is used to treat the manifestations of mild
to severe Alzheimer’s disease. Though donepezil can provide mild improvements in memory,
it does not reverse memory loss. Improvements in the client’s memory are usually short-term.
D. "Donepezil accelerates the breakdown of acetylcholine within the client's brain."
The nurse should inform the family that donepezil is used to treat the manifestations of mild
to severe Alzheimer’s disease. Donepezil works by preventing the breakdown of
acetylcholine within the client’s brain, increasing its availability at cholinergic synapses.
Answer: A. "Donepezil can improve cognitive functioning during the earlier stages of the
disease."

The nurse should inform the family that donepezil is used to treat the manifestations of mild
to severe Alzheimer’s disease. Although donepezil does not prevent the progression of
Alzheimer’s disease, it is intended to prolong the client's ability to function in the early stages
of the disease.
A nurse is obtaining a client's medical history prior to scheduling them for ECT. Which of the
following findings should the nurse identify as a potential complication for the procedure?
A Severe depression
A client can receive ECT for treatment of severe depression.
B. Cardiac arrhythmia
A client who has cardiac arrhythmias needs further evaluation. The nurse should identify that
the greatest risk for death due to ECT is related to cardiac complications.
C. Bipolar disorder
A client can receive ECT for treatment of bipolar disorder.
D. Parkinson's disease
A client can receive ECT for treatment of Parkinson's disease.
Answer: B. Cardiac arrhythmia
A client who has cardiac arrhythmias needs further evaluation. The nurse should identify that
the greatest risk for death due to ECT is related to cardiac complications.
A nurse is planning care for a client who had Bipolar Disorder and is experiencing a Manic
Episode. Which of the following interventions should the nurse include in a plan of care?
A. Discourage the client from taking naps during the day.
The nurse should encourage the client to take naps and frequent rest periods during the day to
avoid physical exhaustion due to mania.
B. Allow the client to choose which clothing to wear each day.
The nurse should closely supervise the client’s choice of clothing to maintain her dignity and
promote positive self-esteem during a manic episode.
C. Encourage the client to participate in group therapy.
The nurse should encourage one-on-one therapy during the manic phase. Group therapy can
cause anxiety and agitation in the client.
D. Provide the client frequently with high-calorie finger-foods.
The nurse should provide the client with frequent, high-calorie snacks and meals during a
manic episode to provide the calorie replacement needed due to excessive physical energy

and activity. Providing finger-foods increases the client’s intake by making it easier to eat
when mania makes it difficult for her to sit down and concentrate on a meal.
Answer: D. Provide the client frequently with high-calorie finger-foods.
The nurse should provide the client with frequent, high-calorie snacks and meals during a
manic episode to provide the calorie replacement needed due to excessive physical energy
and activity. Providing finger-foods increases the client’s intake by making it easier to eat
when mania makes it difficult for her to sit down and concentrate on a meal.
A nurse in an acute mental health facility is caring for a client who is experiencing an Acute
Manic Episode.
Which of the following actions is the nurse's priority?
A. Maintain the client's contact with her family.
The nurse should assist all acute care clients in maintaining contact with family during
treatment; however, there is another action that is the priority.
B. Discourage the client's use of vulgar language.
The nurse should discourage behaviors that disrupt the therapeutic milieu; however, there is
another action that is the priority.
C. Protect the client from impulsive behavior.
The nurse should protect the client who is manic from impulsive behavior that puts the client
at risk for self-harm. The nurse should apply the safety and risk reduction priority-setting
framework. This framework assigns priority to the factor or situation posing the greatest
safety risk to the client. When there are several risks to client safety, the one posing the
greatest threat is the highest priority. The nurse should use Maslow’s hierarchy of needs, the
ABC priority-setting framework, or nursing knowledge to identify which risk poses the
greatest threat to the client.
D. Redirect excessive energy to creative tasks.
The nurse should redirect the client’s energy into a calming and constructive activity;
however, there is another action that is the priority.
Answer: C. Protect the client from impulsive behavior.
The nurse should protect the client who is manic from impulsive behavior that puts the client
at risk for self-harm. The nurse should apply the safety and risk reduction priority-setting
framework. This framework assigns priority to the factor or situation posing the greatest
safety risk to the client. When there are several risks to client safety, the one posing the
greatest threat is the highest priority. The nurse should use Maslow’s hierarchy of needs, the

ABC priority-setting framework, or nursing knowledge to identify which risk poses the
greatest threat to the client.
A nurse in an acute mental health facility is planning care for a client who has obsessivecompulsive disorder (OCD). Which of the following actions should the nurse include in the
plan?
A. Encourage the client to focus on personal hygiene.
Clients who have OCD are often obsessive about personal hygiene and might perform
ritualistic behaviors related to handwashing and grooming. The nurse should plan
interventions to limit and control these obsessive thoughts.
B. Limit the hours the client sleeps each day.
Clients who have OCD often have difficulty sleeping due to obsessive thoughts and ritualistic
behaviors. The nurse should plan interventions to promote sleep.
C. Instruct the client to practice thought stopping.
The nurse should teach the client who has OCD to use thought stopping. By saying "stop" out
loud, the client can learn to interrupt obsessive thoughts.
D. Make negative statements about the client's behavior.
Clients who have OCD often feel shame and humiliation about their obsessive thoughts and
ritualistic behavior. The nurse should plan interventions to decrease feelings of shame and
increase feelings of selfworth.
Answer: C. Instruct the client to practice thought stopping.
The nurse should teach the client who has OCD to use thought stopping. By saying "stop" out
loud, the client can learn to interrupt obsessive thoughts.
A nurse is caring for a client who has alcohol use disorder.Following alcohol withdrawal,
which of the following medications should the nurse expect to administer to the client during
maintenance?
A. Methadone
The nurse should expect to administer methadone to the client who has opioid withdrawal.
B. Disulfiram
The nurse should expect to administer disulfiram as a deterrent to prevent future use of
alcohol. The nurse must ensure that the client has not had any alcohol intake for at least 12 hr
prior to administration.
C. Chlordiazepoxide

The nurse should expect to administer chlordiazepoxide during alcohol withdrawal.
Chloridiazepoxide is not a medication used to help with maintenance.
D. Naloxone
The nurse should expect to administer naloxone to the client who is experiencing a narcotic
overdose.
Answer: B. Disulfiram
The nurse should expect to administer disulfiram as a deterrent to prevent future use of
alcohol. The nurse must ensure that the client has not had any alcohol intake for at least 12 hr
prior to administration.
A nurse is caring for a client who attends family counseling with his partner and their
children. The client tells the nurse he isn't going to attend any further sessions and states, "I
don't have time for all this talking." Which of the following responses should the nurse make?
A. "It must be difficult for you to talk about family problems."
The nurse’s response indicates empathy for the client’s feelings and is an example of the
therapeutic communication technique of verbalizing what the client implied. With this
technique, the nurse helps him focus on the actual reason for not wanting to continue family
therapy.
B. "You should continue attending the family counseling sessions until the therapist tells you
to stop." The nurse’s response is an example of the nurse giving advice, which is
nontherapeutic and a possible block to further communication.
C. "If you continue to go to family counseling, I'm sure you'll be able to resolve your family
problems soon." The nurse’s response is an example of false reassurance. The client’s
continued participation is not an indication that problems will be resolved.
D. "I think you need to continue family therapy if your partner and children want to receive
further counseling." The nurse’s response is an example of the nurse giving advice, which is
nontherapeutic and a possible block to further communication.
Answer: A. "It must be difficult for you to talk about family problems."
The nurse’s response indicates empathy for the client’s feelings and is an example of the
therapeutic communication technique of verbalizing what the client implied. With this
technique, the nurse helps him focus on the actual reason for not wanting to continue family
therapy.

A nurse in an acute substance is assessing a client who received treatment in the Emergency
Department for a Heroin Overdose. Which of the following findings should the nurse
anticipate during Heroin Withdrawal?
A. Excessive sleeping
The nurse should expect the client to have insomnia during heroin withdrawal.
B. Muscle aches
The nurse should expect the client to have muscle aches during heroin withdrawal. The nurse
should expect this and other manifestations of withdrawal to begin within 6 to 8 hr following
the last dose of heroin.
C. Pupillary constriction
The nurse should expect the client to have pupillary dilation during heroin withdrawal.
D. Absent bowel sounds
The nurse should expect the client to have diarrhea during heroin withdrawal.
Answer: B. Muscle aches
The nurse should expect the client to have muscle aches during heroin withdrawal. The nurse
should expect this and other manifestations of withdrawal to begin within 6 to 8 hr following
the last dose of heroin.
A nurse in an emergency room is assessing a client who has cocaine intoxication. Which of
the following findings should the nurse expect?
A. Low blood pressure
The nurse should expect a client who has cocaine intoxication to have an elevated blood
pressure.
B. Dilated pupils
Dilated pupils are associated with the use of cocaine.
C. Conjunctival redness
The nurse should expect a client who has cannabis intoxication to have conjunctival redness.
D. Decreased body temperature
The nurse should expect a client who has cocaine intoxication to have an elevated body
temperature.
Answer: B. Dilated pupils
Dilated pupils are associated with the use of cocaine.

A nurse is admitting a client who has antisocial personality disorder to an acute care unit. The
client is admitted under court order following the theft and destruction of a car. Which of the
following behaviors should the nurse expect the client to display?
A. Relief about finally receiving care for a problem for which he was previously afraid to ask
for help
A client who has antisocial personality disorder exhibits a pattern of irresponsible behavior
that lacks morals and ethics and brings the client into conflict with society. The client views
this behavior as justified and does not perceive the need for help.
B. Anger with the nursing staff for hospitalizing him against his will.
A client who has antisocial personality disorder exhibits a low frustration level and can
quickly become angry and aggressive when the situation goes against his will or desires.
C. Withdrawal from others due to shame over his recent actions
Clients with antisocial behavior do not view their own behavior objectively and rarely
experience any anxiety or guilt over their actions.
D. Remorse for stealing and destroying the car
Clients who have antisocial behavior usually display a sense of entitlement and rarely express
any remorse for their illegal or unethical actions.
Answer: B. Anger with the nursing staff for hospitalizing him against his will.
A client who has antisocial personality disorder exhibits a low frustration level and can
quickly become angry and aggressive when the situation goes against his will or desires.
A nurse is developing a plan of care with a client who has Anorexia Nervosa. The nurse
should identify that which of the following actions is contraindicated for this client?
A. Explaining that tube feedings are necessary if the client refuses oral intake
The nurse should inform the client that he might require tube feedings to provide adequate
nutritional intake if oral intake is inadequate. This intervention is not intended to be punitive
but to ensure the client’s safety.
B. Weighing the client each day prior to any oral intake
The nurse should weigh the client each day prior to any oral intake to obtain accurate data
and to monitor his progress toward weight gain goals.
C. Permitting the client to spend some quiet time alone after each meal
The nurse should directly observe the client for a minimum of 1 hr following meals. This
intervention prevents the client from purging or discarding hidden food. Therefore, permitting
the client to have alone time following meals is contraindicated for his plan of care.

D. Refraining from commenting about the client's eating during meal times
The nurse should encourage conversation during meals to promote a pleasurable eating
environment; however, the nurse should avoid the topics of eating and food, which can
increase the client’s level of anxiety.
Answer: C. Permitting the client to spend some quiet time alone after each meal
The nurse should directly observe the client for a minimum of 1 hr following meals. This
intervention prevents the client from purging or discarding hidden food. Therefore, permitting
the client to have alone time following meals is contraindicated for his plan of care.
A nurse in the Emergency Department is assessing a client who has Heroin Intoxication.
Which of the following findings should the nurse expect?
A. Seizure activity
Heroin is an opioid, which can result in impaired coordination rather than seizure activity.
B. Respiratory depression
Heroin is an opioid; therefore, the nurse should expect the client who has heroin intoxication
to exhibit respiratory depression.
C. Hypersensitivity to pain
Heroin is an opioid, which can result in pain reduction rather than a hypersensitivity to pain.
D. Increased mental alertness
Heroin is an opioid, which can result in drowsiness and sedation rather than increased mental
alertness.
Answer: B. Respiratory depression
Heroin is an opioid; therefore, the nurse should expect the client who has heroin intoxication
to exhibit respiratory depression.
A nurse is caring for a client who has Alzheimer Disease and a new prescription for
Donepezil. Which of the following actions should the nurse take?
A. Monitor the client's liver function while taking this medication.
The nurse should monitor the liver function for a client who is taking the cholinesterase
inhibitor tacrine; however, donepezil is a medication in this category that is not hepatotoxic.
B. Increase the dosage of this medication every 72 hr.
The nurse should expect the provider to gradually increase the client’s dosage until a
therapeutic effect is achieved; however, an increase is not expected until the client has been
taking the medication for 4 to 6 weeks.

C. Offer the client a PRN NSAID while taking this medication.
The nurse should inform the client of the risk for gastrointestinal bleeding while taking this
medication.
Taking donepezil concurrently with an NSAID increases this risk.
D. Administer the medication at bedtime.
Donepezil is used to treat the manifestations of mild to moderate Alzheimer’s disease. The
nurse should administer this medication at bedtime to reduce the risk for injury due to
bradycardia and syncope.
Answer: D. Administer the medication at bedtime.
Donepezil is used to treat the manifestations of mild to moderate Alzheimer’s disease. The
nurse should administer this medication at bedtime to reduce the risk for injury due to
bradycardia and syncope.
A nurse is caring for a client who has major depressive disorder and is severely withdrawn.
Which of the following techniques should the nurse use to facilitate communication with the
client?
A. Continue to talk if the client does not provide an immediate verbal response.
The nurse should allow the client additional time to respond. Clients who are severely
withdrawn might take longer to comprehend what is being said and formulate a response.
B. Use platitudes when talking with the client.
The nurse should avoid the use of platitudes because this technique minimizes the client’s
feelings and promotes feelings of worthlessness in clients who are severely withdrawn.
C. Ask the client direct questions.
The nurse should avoid asking direct questions to a client who is severely withdrawn because
this technique can raise his level of anxiety.
D. Speak to the client using simple and concrete terminology.
The nurse should use simple and concrete terminology when communicating with this client.
The client who is severely withdrawn has impaired comprehension and difficulty
concentrating; therefore, this technique facilitates communication.
Answer: D. Speak to the client using simple and concrete terminology.
The nurse should use simple and concrete terminology when communicating with this client.
The client who is severely withdrawn has impaired comprehension and difficulty
concentrating; therefore, this technique facilitates communication.

A nurse is caring for a client who has Wernicke-Korsakoff Syndrome due to Alcohol Use
Disorder. Which of the following findings should the nurse expect?
A. Increased arousal
The nurse should expect the client who has Wernicke-Korsakoff syndrome to exhibit
somnolence and stupor rather than increased arousal.
B. Arrhythmias
The nurse should expect the client who has cardiomyopathy due to alcohol use to have
arrhythmias. Cardiac manifestations are not expected findings of Wernicke-Korsakoff
syndrome.
C. Confusion
The nurse should expect the client who has Wernicke-Korsakoff syndrome to exhibit
neurological and cognitive manifestations due to thiamine deficiency. Confusion, stupor,
diplopia, and memory loss are expected findings of this disorder.
D. Esophageal pain
The nurse should expect the client who has esophagitis due to alcohol use to have esophageal
pain. Gastrointestinal manifestations are not expected findings with Wernicke-Korsakoff
syndrome.
Answer: C. Confusion
The nurse should expect the client who has Wernicke-Korsakoff syndrome to exhibit
neurological and cognitive manifestations due to thiamine deficiency. Confusion, stupor,
diplopia, and memory loss are expected findings of this disorder.