ATI RN Mental Health Online practice 2013 A
1. When admitting a client to an inpatient mental health facility, a nurse notices that the client seems withdrawn and appears fearful. To establish a trusting nurse-client re
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ATI RN Mental Health Online practice 2013 A
1. When admitting a client to an inpatient mental health facility, a nurse notices that the client seems withdrawn and appears fearful. To establish a trusting nurse-client relationship, the nurse should first
a. Introduce the client to other clients in the day room (working phase)
b. Inform the client that her admission will be confidential (orientation phase)
c. Assist the client in facilitating behavioral change (working phase)
d. Determine coping strategies that the client has used in the past (working phase)
2. A nurse is reviewing the potential adverse effects of lithium with a client who began the medication 2 weeks ago. For which of the following should the nurse instruct the client to monitor and report to the provider?
a. Hearing loss
b. Dry persistent cough
c. Bruising
d. Coarse hand tremor(indication toxicity )
3. A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. Which of the following therapeutic nursing interventions is the highest priority?
a. Encourage expression of feelings (acknowledge them)
b. Promote attendance at an assertiveness training group (how to be assertive rather than aggressive)
c. Assist the client to perform relaxation breathing (assist the child to calm down)
d. Use a therapeutic holding technique(the greatest risk to this child and others is harm? Therefore, the nurse’s priority intervention is to use a therapeutic holding technique to de-escalate the behavior and prevent injury)
4. A nurse in a mental health facility observes a client who is experiencing panic level of anxiety. Which of the following actions should the nurse take first?
a. Teach the client a relaxation technique (after the attack has subsided to prevent further escalations of anxiety)
b. Establish an exercise routine for the client (after the attack has subsided to prevent further escalations anxiety)
c. Assist the client to identify anxiety triggers
d. Accompany the client to a quiet room
5. A nurse is caring for a client who is taking chlorpromazine for schizophrenia. Which of the following assessment findings indicates that the client is experiencing extrapyramidal adverse effects?
a. Fever and sore throat (indicate agranulocytosis)
b. Urinary retention (Anticholinergic side effect)
c. Postural hypotension (cardiovascular side effect)
d. Lip smacking and tongue rolling(indicate long-term extrapyramidal side effects associated with typical antipsychotic medications)
6. A nurse is preparing to administer diazepam 7.5 mg IV bolus to a client for alcohol withdrawal. Available is diazepam injection 5 mg/ml. How many mL should the nurse administer? (round the answer to the nearest tenth. Use a leading zero if applicable. Do not use a trailing zero.)
1.5 mL
7. A nurse is assessing a client in the emergency department. The client appears agitated, his blood pressure is 152/94 mm Hg, his heart rate is 104/min, and his pupils are dilated. The nurse should suspect intoxication with which of the following substances?
a. Heroin (intoxication constricted pupils, decrease blood pressure)
b. Cocaine (intoxication cause tachycardia, elevated blood pressure, dilated pupils and agitation)
c. Benzodiazepines (decreased blood pressure)
d. Inhalants (central nervous system depression)
8. A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following characteristics of this disorder should the nurse include in the teaching?
a. Fear of abandonment (separation anxiety disorder)
b. Language delay(autism spectrum disorder)
c. Hostile behavior (oppositional defiant disorder)
d. Motor and verbal tics (Tourette’s disorder)
9. A nurse is leading a group therapy session when a client becomes agitated and yells, “Listening to all of you is making me worse!” which of the following is an appropriate response?
a. “You sound angry and frustrated. Tell us more about how you are feeling?” ( the nurse is making observations and exploring the client’s feelings to demonstrate caring)
b. “Maybe you would like to go to another group from now on.” (nurse’s response is showing disapproval of the client and can make all of the clients defensive)
c. “Let’s not talk about this now. We will talk more about this in our individual session.” (minimizing the client’s immediate concerns and feelings)
d. “Do any of the other group members feel this way?”(showing disapproval of the client and can make all of the clients defensive)
10. A home health nurse is assessing an older adult client who lives alone. Which of the following finding should indicate to the nurse that the client is experiencing delirium?
a. Sudden onset (suddenly over hours to days)
b. Euthymic mood ( clients who have delirium have rapid mood swings)
c. Flat affect (demonstrate expressions of feelings)
d. Slow speech (raid, inappropriate speech and language)
11. A nurse is caring for a client who has schizophrenia. The treatment plan is for the client to increase his autonomy from his parents. Prior to discharge, the nurse should plan to
a. Stress to the client that he need to be more independent (does not give him skills to gain autonomy. The nurse must assist the client to learn these skills)
b. Schedule a family conference (Allows the nurse to work with both the client and his family to make an action plan for increased autonomy. This is a positive step for the client prior to discharge)
c. Tell the client not to visit his family so often (The client needs emotional support from his family. Decreasing family visits could be obstructive to his emotional well-being and would not necessarily increase autonomy)
d. Arrange housing placement for the client in another town (The client needs emotional support from his family. Moving him to another city could isolate him from this support an d would not necessarily increase autonomy)
12. A nurse in a provider’s office is talking with a client who has diabetes mellitus and an HbA1c of 8.5%. The client states that she is under a lot of stress and that she doesn’t want to talk about her diabetes mellitus right now. Based on these comments, the nurse should note that the client is demonstrating which of the following defense mechanisms?
a. Suppression ( the client is suppressing her feelings about dealing with having a chronic illness when she consciously denies her current health status)
b. Conversion (the client demonstrates conversion if she unconsciously converted her anxiety into physical symptoms)
c. Displacement (the client demonstrates displacement if she transferred her feelings about her illness to another less threatening situation)
d. Reaction formation (The client demonstrates reaction formation if she demonstrated the opposite behavior of what she is really feeling)
13. A nurse is caring for a client who has schizophrenia in a mental health facility. Which of the following places the client at greatest risk for self-directed injury or injuring others?
a. Inability to communicate with others
b. Feelings of absence of self-worth
c. Lack of motivation to perform daily tasks
d. Command hallucinations (A client who has schizophrenia and is experiencing command hallucinations may be told to hurt himself or others. Therefore, a client who is experiencing command hallucinations is at greatest risk for self-directed injury or injuring others)
14. A nurse is performing an assessment on a 78-year-old client who has injuries consistent with suspected abuse. Which of the following statements indicates the greatest potential risk factor for abuse?
a. “My children manage my finances, but I still have to sign the checks.”
b. “My son enjoys a couple of drinks each night to unwind.”
c. “My daughter-in-law is expecting another baby soon.”
d. “I plan on living on y own with the help of home health services.”
15. A nurse is obtaining a health history during a client’s admission to a mental health facility. The client begins to talk on her cell phone. When the client finishes talking, she reports to the nurse “That was the president, I leave in the morning on my new mission.” Which of the following is an appropriate response?
a. “Do you want to leave so soon?”
b. “I do not think the president will need you on this mission.”
c. “How long have you been having conversations with the president?”
d. “I think you need to talk to your provider about the mission.”
16. A client recently diagnosed with bipolar disorder is placed in a room with a client who has severe depression reports to the nurse, “That man in my room never sleeps and he keeps me up, too.” Which of the following is an appropriate intervention for the nurse to take?
a. Move the client who has bipolar disorder to private room(clients who have bipolar disorder can disrupt the therapeutic milieu for other clients; therefore, the nurse should move this client to a private room)
b. Administer sleep medication to the client who has bipolar disorder (not an appropriate intervention)
c. Move the client who has severe depression to a private room (client who have severe depression are often at risk for self-harm and feel isolated; therefore, the nurse should not move this client to a private room)
d. Administer sleep medication to the client who has severe depression
17. The nurse is caring for a client who has anorexia nervosa. Which of the following criteria requires hospitalization?
a. Weight loss 10% of total body weight (weight loss over 30% of total body weight in six months)
b. Temperature of 35.6˚C (96.1˚F)(severe hypothermia (temperature lower than 96.8˚F) due to loss of subcutaneous tissue or dehydration requires hospitalization)
c. Serum potassium 3.8 mEq/L (WNL)
d. Heart rate 54/min (HR is less than 40/min)
18. A nurse is caring for a client whose child recently died in motor vehicle crash and states. “I just want to join him.” Which of the following is the nurse’s priority response?
a. “You may find it helpful to talk about your experience with a support person.”
b. “Would you like me to stay with you so you don’t feel alone?”
c. “Are you thinking about harming yourself?”
d. “What you have gone through must be very difficult.”
19. A nurse is caring for a client receiving imipramine for depression. For which of the following adverse effects should the nurse monitor?
a. Vertigo
b. Decreased appetite
c. Bradycardia
d. Urinary retention
20. A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following medications should the nurse administer?
a. Methadone
b. Disulfiram
c. Naltrexone
d. Chlordiazepoxide (Librium)
21. A nurse is preparing to discharge an older adult client, who attempted suicide, to his home where he lives alone. The client also has difficulty performing ADLs. Which of the following referrals should the nurse initiate? (Select all that apply.)
a. Occupational therapy
b. Meal delivery services
c. Speech therapy
d. Physical therapy
e. Home health services
22. A nurse is caring for a client who is deaf and is scheduled to have electroconvulsive therapy (ECT). The provider needs to explain the procedure to the client in order to obtain informed consent. Which of the following actions should the nurse take?
a. Request a professional interpreter to translate
b. Have a family member explain the information
c. Ask an assistive personnel (AP) to use sign language
d. Draw a diagram of the procedure
23. A nurse is caring for a client who has a history of substance use and was involuntarily admitted to mental health facility. When the nurse attempts to administer oral Lorazepam, the client refuses to take the medication and become physically aggressive. Which of the following actions should the nurse take?
a. Request a prescription for IV Lorazepam
b. Do not administer the Lorazepam
c. Request that another nurse attempt to administer the Lorazepam
d. Place the Lorazepam in the client’s food
24. During a client’s initial interview in a mental health inpatient setting, the nurse recognizes that the client maintains eye contact and leans toward him. The nurse should conclude that the client
a. Is beginning to trust the nurse
b. Is attempting to manipulate the nurse
c. Is physically attracted to the nurse
d. Needs to feel accepted by the nurse
25. A nurse is conducting a group therapy session for clients who have bipolar disorder. One of the clients begins bragging and dominating the conversation. Which of the following actions should the nurse take?
a. Tell the client to calm down or he will be dismissed from the session
b. Obtain an order form the provider to place the client in seclusion
c. Ignore the client’s behavior and continue the session
d. Interrupt the client and direct the discussion to another group member
26. A nurse is assessing a client in the emergency department who is brought in by a caregiver. The caregiver states the client fell recently. The nurse observes bruises on the client’s abdomen, back, and legs and suspects abuse. Which of the following action should the nurse take first?
a. Initiate a referral to social services for suspected abuse
b. Check the client for other signs and symptoms of abuse
c. Assist the client to identify signs of escalating abuse
d. Identify a family member who can provide support to the client
27. A nurse is providing teaching to a client who is to be discharge from an inpatient detoxification program and plans to attend Alcoholics Anonymous. Which of the following statements by the client indicates an understanding of the teaching?
a. “I will learn ways to decrease my alcohol use.” (AA promotes abstinence)
b. “I will use peer support to maintain my abstinence.”(encourage recovery )
c. “I will learn to take responsibility for my addiction.” (promotes responsibility for recovery)
d. “I will use a health care professional as my sponsor.”(provides individual with sponsors who are in recovery for substance use)
28. A nurse is caring for a client with dementia. Which of the following interventions is useful for orienting a client to reality?
a. Turn on the client’s television for entertainment throughout the day
b. Place a large wall calendar in the client’s room
c. Ask the family to bring the client’s rocking chair
d. Provide the client with current issues of his favorite magazines
29. A nurse is planning to teach a group of parents about healthy adolescent behavior. Which of the following information should the nurse include?
a. Displays an egocentric approach in problem-solving (preschooler)
b. Requires literal explanations (toddler)
c. Demonstrates mistrust of others (infant)
d. Exhibits a realistic self-concept
30. A nurse is caring for a client who has alcoholic Cardiomyopathy. Which of the following laboratory values should the nurse expect?
a. Increased creatine phosphokinase (CPK)( muscle enzyme released when muscle tissue is damaged, occur with Cardiomyopathy)
b. Increased low-density lipoproteins (LDL)
c. Decreased fasting blood sugar (FBS)
d. Decreased aspartate aminotransferase (AST)
31. A nurse is admitting a client who has depression to an inpatient mental health facility. The client states that he feels so bad that he is certain he will never be discharged. Which of the following is an appropriate response?
a. “The average client stay in our facility is only a few days.” (dismissive of the client’s concern)
b. “The nurses at this hospital are very skilled at caring for people who have depression.”(response focuses on the needs of the care provider rather than the client’s)
c. “You seem concerned about getting out of the hospital.”(response is making observations and encouraging the client to talk further about concerns)
d. “Care at the hospital will help you to feel better about yourself.”(false reassurance for the client)
32. During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in her bed. The client reports that a bomb was placed in her room by a family member during visiting hours. Which of the following is an appropriate action by the nurse?
a. Ask the client to identify the bomb in the room (inappropriate action because the nurse is responding as if the hallucination is real)
b. Initiate disaster protocols per facility policies and procedures (without evidence of a disaster on a mental health unit)
c. Assess the client for evidence of a perceptual disturbance(assess the situation to determine if the client is hallucinating or misperceiving external stimuli (experiencing illusions)
d. Convince the client that there is no bomb in the client’s room (negates her experience)
33. A nurse is caring for a client who has schizophrenia and is prescribed risperidone. Which of the following laboratory tests should the nurse monitor?
a. BUN
b. Hemoglobin
c. Platelet count
d. Blood glucose (risperidone can cause diabetes mellitus to develop; therefore, the nurse should plan to monitor the client’s blood glucose level when taking this medication
34. A nurse is admitting an adolescent client who has anorexia nervosa. Which of the following clinical finding should the nurse expect?
a. Tooth erosion (bulimia from self-induced vomiting)
b. Amenorrhea (caused by low weight)
c. Russell’s sign (calluses on knuckles can occur due to self-inducing vomiting)
d. Parotid gland swelling (increased serum amylase levels)
35. A nurse is caring for a client who is scheduled to undergo electroconvulsive therapy (ECT). The provider has explained the procedure to the client. Which of the following statement s made by the client indicates a need for further teaching?
a. “Following the procedure, I can expect to have short-term memory loss.”
b. “I can expect to have two treatments a week for the next 4 to 6 weeks.”
c. “During the procedure, I will have a cardiac monitor in place.”
d. “This procedure can increase my risk for developing Parkinson’s disease.”
36. A nurse working in a clinic is assessing a client whose partner died 4 months ago. Which of the following statements indicates the client is at risk for complicated grief?
a. “I wish I had been nicer and more generous with my wife before she died.”(expressing guilt which is expected during bereavement)
b. “I told my wife to go to the doctor, but she wouldn’t listen to me.” (expressing anger)
c. “I feel so empty without my wife; it’s hard to get up every morning.”( risk for complicated grief)
d. “I think about my wife all the time when I go on outings with my family.”(expressing preoccupation with the image of the decreased)
37. A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom of this disorder?
a. Flat affect(absence of emotion, negative symptom)
b. Flight of ideas (thought disorder. Positive symptom)
c. Agitated behavior( bizarre behavior, positive symptom)
d. Hallucinations (alteration in perception, positive symptom)
38. A nurse is facilitating a bereavement support group and observes that one member remains silent, even after attending several sessions. Which of the following strategies should the nurse use to encourage the member’s participation?
a. Remind the group that everyone should have a chance to participate (effective with group members who monopolize the discussion)
b. Ask the group to share observations of other group members (effective with group member who monopolize the discussion. Allowing the group to address the silence of one member might cause the member to withdraw and stop attending sessions)
c. Divide the group into pairs to discuss a topic, then summarize the discussion to the group(draw a silent member into group participation)
d. Focus on other group members and emphasize their helpfulness (effective with group members who demonstrate demoralizing or negative behavior)
39. A nurse is planning discharge teaching with a family member of a client who has a new diagnosis of depression. Which of the following information about relapse should the nurse included?
a. Additional acute episode of depression are unlikely following inpatient care
b. Early identification of changes such as decreased social involvement is important
c. Medication compliance will prevent further need for inpatient hospitalization
d. It is helpful to regularly reinforce to the client that things will get better
40. A nurse is obtaining a history and physical on a client who presents to the emergency department of a mental health facility. The nurse recognizes which of the following assessment findings as being consistent with posttraumatic stress disorder (PTSD)? (Select all that apply.)
a. Distressing dream(persistently reexperince the event the triggers PTSD in the form of distressing dreams)
b. Delusions (false fixed belief that are difficult to eradicate)
c. Difficulty concentrating (persistent increased arousal)
d. Compulsions (compelled to repeatedly perform to reduce anxiety)
e. Exaggerated startle response(persistent increased arousal)
41. A nurse is preparing to participate in an interdisciplinary conference for a client who has bipolar disorder. Which of the following behaviors is the highest priority for the nurse to report to the treatment team?
a. Calling family members (client has support)
b. Spending time alone (withdrawn from others)
c. Giving away possession (risk for suicide)
d. Excessive crying (showing signs of depression)
42. A nurse is developing a plan of care for a client who exhibits anger, aggression, and violent behavior on the unit. The priority nursing intervention is to
a. Implement the use of seclusion and restraints
b. Defuse the situation using therapeutic communication
c. Administer prescribed tranquilizing medications
d. Create a large, personal space (greatest risk is injury to the client, staff, and other, and client to ensure safety for the nurse and client)
43. While observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors is consistent with this condition?
a. The client need excessive external input to make everyday decisions
b. The client demonstrates a dedication to his job that excludes time for leisure activities (OCD)
c. The client adheres to a rigid set of rules (OCD)
d. The client has difficulty starting new relationships unless he feels accepted (avoidant personality disorder are unwilling to get involved socially unless one is accepted)
44. A nurse is providing teaching to a client who has a new prescription for haloperidol. Which of the following side effects should the nurse instruct the client to report to the provider?
a. Blurred vision
b. Photosensitivity
c. Shuffling gait (Pseudoparkinsonism, 5 hr to 30 days after beginning treatment)
d. Dry mouth
45. A nurse working in an outpatient clinic is assessing a university student who says he feels restless and irritable before taking an exam. The nurse should assess the clinical findings as which of the following?
a. Mild anxiety ( restlessness, irritability, nail biting, and fidgeting)
b. Moderate anxiety (tension, palpitation, increased heart rate, and diaphoresis)
c. Severe anxiety (difficulty sleeping, light headedness, nausea, tremors, and a sense of impending doom)
d. Panic (hyperactivity, severe tremors, and uncoordinated impulsive behavior)
46. A nurse is caring for a client who has borderline personality disorder. Which of the following is the priority goal when planning care for this client?
a. The client will take prescribed medications as scheduled
b. The client will express feelings of frustration
c. The client will refrain from self-mutilation
d. The client will participate in group therapy
47. A nurse is developing a discharge plan for a client who has a history of gambling dependency and included participation in a support group. The nurse should tell the client that which of the following is the purpose of attending a support group?
a. Establish a therapeutic relationship
b. Provide assurance that others have a similar problem
c. Learn about medication management
d. Develop an understanding of unconscious thoughts.
48. A nurse is communicating with a client in an inpatient mental health facility. Which of the following demonstrates the use of active listening?
a. Offering self (demonstrate genuine interest in the client)
b. Use of silence (demonstrate willingness to wait for the client’s response)
c. Attention to body language
d. Reflection of feelings (encourage the client to acknowledge his feeling)
49. A nurse is providing care for a client who has bipolar disorder and is experiencing acute mania. The client’s morning lithium level is 1.5 mEq/L. Which of the following additional laboratory data has the highest priority? Vs: temp: 37.3˚C (99.2˚F), pulse 88/min, respirations 18/min, BP 138/88 mm hg. History and physical: Client has been hospitalized for manic episodes 3 times in the past 2 years. Reports inability to sleep. Report nausea, vomiting, and thirst. Family reports client has lost 5 lb in last week. Prescription: Lithium carbonate 600 mg PO three times a day, Risperidone 3 mg PO daily.
a. Serum erythrocyte sedimentation rate 18mm/hr
b. Hemoglobin 15 g/dl
c. Serum T₄5 mcg/dl
d. Serum sodium 125 mEq/L (low sodium level)
50. A client is experiencing a situational crisis. Which of the following findings should the nurse expect?
a. The client recently lost a grandparent in a motor vehicle crash
b. The client’s town was hit by a tornado (adventitious crisis when an external disaster occurs)
c. The client’s youngest son leaves for college (maturational crisis during a natural life event)
d. The client is ambivalent about her upcoming retirement (maturational crisis)
51. A nurse is caring for four clients in an inpatient mental health facility. Which of the following clients can give informed consent?
a. A 17-year-old who lives with friends (minor)
b. A 50-year-old who has a blood alcohol level of 0.08 (intoxicated)
c. A 35-year-old who has major depressive disorder
d. A 65-year-old who just received a dose of morphine (functionally incompetent due to the effect on the CNS)
52. A nurse is conducting a counseling session with a client who has depression. Which of the following statements by the client indicates the client is demonstrating transference?
a. “Thank you for taking my side in group today.”
b. “I feel like you talk to me like my sister does. “
c. “You are helping me learn a lot about myself in counseling.”
d. “I’m not looking forward to the end of our sessions.”
53. A nurse is caring for a client receiving tranylcypromine. Which of the following is an appropriate menu choice for the nurse to suggest?
a. Roasted chicken
b. Avocado salad
c. Bologna sandwich
d. Cheddar cheese
54. A nurse is interviewing an older adult client in an outpatient mental health clinic. Which of the following strategies should the nurse use?
a. Ask questions in a similar manner as when interviewing a younger client
b. Dim lighting to minimize stimuli
c. Remain as close to the client as possible when communicating
d. Conduct the interview in a private area
55. A client who has paranoid schizophrenia is attending a treatment planning conference with a family member. During the discussion of the medication adherence portion of the plan, the nurse notices that he family member seems distracted. Which of the following is an appropriate action by the nurse?
a. Call the family member to the side to inquire if he has question or concerns about the treatment plan
b. Advise the family member that this treatment plan has been developed specifically for the client to follow
c. Ask the family member if she has any thoughts or questions about this portion of the treatment plan
d. Document that the family member does not support the medication treatment plan
56. A nurse is meeting with a client being discharged from a substance use disorder treatment program. Which of the following client statements indicates the client is planning to make a lifestyle change?
a. “I will volunteer to be the designated driver when my friends are drinking so I know I will not drink.”
b. “I will change my route going home from work so I don’t pass my favorite bar.”
c. “I will need to attend AA meetings regularly for the next three months.”
d. “I will tell my family to go to Alanon meetings so they can make sure I do not drink.”
57. A nurse is caring for a client who has schizophrenia and is threatening to harm others on the unit. The provider prescribes haloperidol and seclusion. Which of the following should be included in the plan of care?
a. Offer the client food every hour
b. Limit the client’s fluid intake
c. Document the client’s behavior every 8 hr
d. Obtain baseline serum sodium level
58. A nurse is admitting a client to an inpatient unit who is in the acute stages of schizophrenia. The nurse observes the following findings: restlessness, pacing with clenched fists, eyes darting to one side, and muttering. Which of the following interventions should the nurse initiate?
a. Encourage the client to express feeling verbally
b. Involve the client in activities on the unit
c. Stay with the client in a quiet setting
d. Tell the client that she needs to calm down
59. A nurse is caring for a client in mental health facility who has recently started a new prescription for valproic acid. For which of the following should the nurse monitor to determine effectiveness of the medication?
a. The client has decreased preoccupation with thought of food
b. The client states that her craving for alcohol has decreased
c. The client has decreased episodes of pressured speech
d. The client is no longer experiencing agnosia
60. A nurse is planning a teaching session regarding the code of ethics for registered nurses. Which of the following should the nurse include in the teaching?
a. Client confidentiality applies until the client dies
b. Privileged communication protects nurse-nurse communication
c. The duty to protect third parties requires a nurse to testify about a client
d. The right to treatment ensures individualized care
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