NGN ATI RN MENTAL HEALTH PROCTORED EXAM 2019
ACTUAL EXAM QUESTIONS WITH DETAILED VERIFIED
ANSWERS AND RATIONALE /A+ GRADE ASSURED
A nurse is reviewing the medication administration record for a client who is
experiencing adverse effects of chlorpromazine. The nurse should administer
benztropine to relieve which ofthe following adverse effects?
• Blurred vision
• Orthostatic hypotension
• Dry mouth
• Acute dystonia - The nurse should administer benztropine, an
anticholinergic agent, torelieve acute dystonia, which is an
extrapyramidal adverse effect of chlorpromazine.
A nurse is planning discharge teaching with a family member of a client who has
diagnosis ofdepression. Which of thefollowing information about relapse should
the nurse include?
• Additional acute episodes of depression are unlikely following inpatient care.
• Early identification of changes, such as decreased social involvement, is
important.
• Medication compliance will prevent further need for inpatient hospitalization.
• It is helpful to regularly reinforce to the client that things will get better.
B. Early identification of changes, such as decreased social involvement, is
important.
Decreased social involvement is a manifestation of depression, and early
identification offindings can lead to early intervention.
A nurse is assessing a client who is experiencing opioid withdrawal. Which
of the followingmanifestations should the nurse expect?
• Sedation
• Rhinorrhea
• Bradycardia
• Hypothermia
Rhinorrhea - The nurse should expect the client who is experiencing opioid
withdrawal to haverhinorrhea and flu-like manifestations such as yawning,
sneezing, and abdominal pain.
,A nurse is assessing a family's dynamics during a counseling session. The
nurse shouldrecognize which of the following findings as an indication of a
boundary issue?
• An adolescent family member who questions parental authority
• A family with three generations in the same household
• Older children who are responsible for their younger siblings
• Two adults and their children from prior relationships in the same household
C. Older children who are responsible for their younger siblings
This is an example of enmeshed boundaries in which there are no distinctions
between the rolesof family members.
A nurse is assisting a client who has a terminal illness adjust to progressive loss of
independence. Which of the following statements by the client indicates
acceptance of her illness?
• "I am going to order a wheelchair for when I'm unable to walk."
• "I am going to stop paying my bills since I won't be around much longer."
• "I wish you would go take care of somebody who actually needs you."
• "I am sure I'm going to be able to continue to care for myself without help."
A. "I am going to order a wheelchair for when I'm unable to walk."
The client is recognizing the reality of continued loss of independence and is
anticipating the need for assistive devices, which indicates the behavioral
response of acceptance.
A nurse is caring for a child who is taking methylphenidate. The nurse should
monitor the child for which of the following findings as an adverse effects of
methylphenidate?
• Weight gain
• Tinnitus
• Tachycardia
• Increased salvation
C. Tachycardia - The nurse should monitor the child for tachycardia, which is an
adverse effect ofmethylphenidate.
A nurse is creating a plan of care for a client who has been placed in seclusion
after threatening to harm others or the unit. Which of the following
interventions should the nurse include in the plan?
, • Document the client's behavior every 8 hr.
• Limit the client's fluid intake to 50 mL/hr.
• Renew the prescription for the client every 4 hr.
• Toilet the client every 4 hr.
C. Renew the prescription for the client every 4 hr.
The nurse should assess the client's behavior frequently during seclusion and
should renew theprescription for seclusion for an adult client every 4 hr, for a
maximum of 24 hr.
A nurse observes a client on a mental health unit pushing on the locked unit
door. Which ofthe following statements should the nurse make?
• "It appears as though you would like to open the door."
• "You will feel more comfortable after you've been here for a while."
• "It is okay to not want to be here."
• "You really shouldn't be pushing on the door."
A. "It appears as though you would like to open the door."
This statement is an example of the therapeutic technique of making
observations. This technique encourages the client to notice the behavior so
that they can describe thoughts and feelings related to that behavior.
A nurse is education the parent of a child who has a new diagnosis of autism
spectrum disorder. Which of the following manifestations of this disorder
should the nurse include in theteaching?
• Fear of abandonment
• Motor and verbal tics
• Hostile behavior
• Language delay - The nurse should identify that language delays are a
manifestation of autismspectrum disorder.
A nurse is discussing a 12-step program with a client who has alcohol use
disorder and is in anacute care facility undergoing
detoxification. Which of the following information should the nurse include in the
teaching?
• The program will help the client accept responsibility for the disorder.
• The client should obtain a sponsor before discharge for an increased chance of
recovery.
• The client will need to identify individuals who have contributed to the disorder.
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