NR 326 / ATI Mental Health Final Quiz (aka Quiz 3) With Answers & Explanations Latest
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NR 326 / ATI Mental Health Final Quiz (aka Quiz 3) With Answers & Explanations
ATI Mental Health Final Quiz (aka Quiz 3)
1. A nurse is planning care for a client who has borderline personality disorder who self-mutilates. 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.
2. 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.
3. A nurse is caring for a client who reports that the television set in the room is really a two-way 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 nurse-client
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 nurse-
client relationship.
d. "Why do you think the TV is a two-way radio?"
,NR 326 / ATI Mental Health Final Quiz (aka Quiz 3) With Answers & Explanations
The nurse should avoid asking the client a "why" question, which promotes a defensive client
response.
4. 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 priority-setting 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.
5. 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.
6. 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
, NR 326 / ATI Mental Health Final Quiz (aka Quiz 3) With Answers & Explanations
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.
7. 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.
8. 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.
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