ATI MENTAL HEALTH EXAM C

1. 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

2. 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 3. 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” 4. 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 5. 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 6. 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 7. 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” 8. 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 9. 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

ATI MENTAL HEALTH EXAM C

b. Platelets 90,000/mm3 c. Urine pH 5.6 d. RBC 4.7/mm3 10. 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” 11. 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 12. 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 13. 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

14. 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

15. 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 16. 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 17. 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

ATI MENTAL HEALTH EXAM C

18. 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 19. 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

20. 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 21. 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

22. 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 23. 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 24. 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 25. 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.”

ATI MENTAL HEALTH EXAM C

26. 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 27. 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 28. 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 29. 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 30. 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 31. 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 32. 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 33. 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?low ideal weight

d. Potassium 3.8 mEq/L

ATI MENTAL HEALTH EXAM C

34. 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.” 35. 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 36. 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 37. 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

38. 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 39. 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 40. 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 41. 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

ATI MENTAL HEALTH EXAM C

42. 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 43. 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.” 44. 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” 45. 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 46. 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 47. 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 48. 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. 49. 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. 50. 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

ATI MENTAL HEALTH EXAM C

c. sodium 132 mEq/L d. aspartate aminotransferase 40 units/L 51. 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 52. 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 53. 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 54. 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 55. 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 56. 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 57. 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 58. 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

ATI MENTAL HEALTH EXAM C

59. 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 60. 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 61. 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. 62. 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 63. 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 64. 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 65. 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 66. 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?

ATI MENTAL HEALTH EXAM C

67. 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

68. 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 69. 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. 70. 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