ATI RN MENTAL HEALTH

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 When admitting a client to an inpatient mental health facility, a nurse notices that the client seems withdrawn and appears fearful.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 othersigns 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 hasschizophrenia 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 cau