ATI mental health practice B

A nurse in an emergency department is caring for a femail adolescent who has a diagnosis of bulimia nervose and has a fainting episode during a ballet performance. Which of the following statements by the parent acknowledges the client's diagnosis?
A. "Sh

B. "She won't let me take the trash from her room. I'm concerned about what she has in there."
The client might be binge eating and attempting to hide food containers, which is a common behavior among clients who have bulimia nervosa. The parent's stateme

A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the following actions should the nurse take first?
A. Inform the client that t

A. Inform the client that this administration is confidential
According to evidence-based practice, the nurse should first inform the client about confidentiality during the orientation phase of the nurse-client relationship.

A nurse is teaching coping strategies to a client who is experiencing depression related to partner violence. Which of the following statements by the client indicates an understanding of the teaching?
A. "I will spend extra time at work to keep from feel

B. "I will talk about my feelings with a close friend."
Discussing feelings, such as fear and depression, with a support person is an effective coping strategy and can provide the client with emotional support and other resources.

A nurse is caring for a client who gave birth to a stillborn baby. Which of the following statements should the nurse make?
A. "you probably want to hold your baby"
B. "I'll stay with you just in case you want to talk."
C. "I know how you must be feeling.

B. "I'll stay with you just in case you want to talk."
This response demonstrates the therapeutic communication techniques of offering self and indicates the nurse's interest in the client and a desire to understand the client's feelings.

A charge nurse on a mental health unit is discussing client rights with a newly licensed nurse. Which of the following statements should the charge nurse make?
A. "Clients can't refuse to take medications if they are admitted involuntarily."
B. "You can n

C. "Clients who are admitted involuntarily maintain the right to give informed consent for procedures."
Clients who are admitted involuntarily maintain the right to give informed consent for treatment. They also have the right to give informed consent for

A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking orders. Which of the following therapeutic nursing interventions is the priority?
A. Encourage expression of feelings
B. Support

D. Reduce environmental stimuli
The greatest risk to the child and others is harm. Therefore, the nurse's priority intervention is to reduce environmental stimuli in an attempt to de-escalate the behavior and prevent injury.

A nurse in a community health center is teaching families of clients who have post-traumatic stress disorder (PTSD) about expected clinical manifestations. Which of the following manifestations should the nurse include?
A. Repeatedly talks about the traum

C. experiences feelings of isolation
The nurse should expect clients who have PTSD to feel estranged and detached from others.

A nurse is assessing a client for risk factors for the development of depression. The nurse should identify that which of the following factors places the client at an increased risk for depression?
A. The client is married
B. The client recently received

C. The client has COPD
The nurse should identify that clients who have a chronic medical illness are at an increased risk for the development of depression.

A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following laboratory findings should the nurse expect?
A. Increased creatine phosphokinase (CPK)
B. Increase low-density lipoproteins (LDL)
C. Decreased fasting blood glucose
D.

A. Increased creatine phosphokinase (CPK)
An increase in CPK, a muscle enzyme released when muscle tissue is damaged, occurs with cardiomyopathy.

A nurse is caring for an older adult client who is experiencing delirium. Which of the following interventions should the nurse include in the client's plan of care?
A. Offer the clients various choices for meal selection
B. Assign different nursing perso

C. Permit the client to perform daily rituals to decrease anxiety
The nurse should provide a client who has delirium with a plan of care that decreases agitation and anxiety by permitting the client to perform daily rituals.

A nurse at a providers office is interviewing an older adult client. Which of the following actions should the nurse plan to take?
Nurse's Notes
The client reports a history of anxiety; diagnosed with Alzheimer's disease 2 months ago. The client's partner

A. Use a screening tool to evaluate the client for depression
Depression can be underdiagnosed among older adult clients. The nurse should identify several risk factors for depression from the client's data, including having Alzheimer's disease, anxiety,

A nurse is talking with a group of parents who have recently experienced the death of a child. Which of the following actions should the nurse take?
A. Encourage the parents to avoid discussing the death with their other children to protect their feelings

C. Suggest forming a weekly support group for parents who have experienced the death of a child.
Support groups are a positive resource in the process of recovery for parents following the death of a child.

A nurse in a mental health clinic is caring for a client who has post-traumatic stress disorder (PTSD) after returning from military deployment. Which of the following is the priority action for the nurse to take?
A. Assist the client to identify personal

C. Stay with the client when flashbacks occur.
The greatest risk to this client is injury that can occur during a flashback; therefore, the priority intervention for the nurse is to remain with the client and offer reassurance and support when flashbacks

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 of the following adverse effects?
A. Blurred vision
B. Orthostatic hypot

D. Acute dystonia
The nurse should administer benztropine, an anticholinergic agent, to relieve acute dystonia, which is an extrapyramidal adverse effect of chlorpromazine.

A nurse in a mental health facility is caring for a client who has schizophrenia. Which of the following findings places the client at the greatest risk for self-directed injury or injuring others?
A. Inability to communicate with others
B. Feelings of ab

D. Command hallucinations
A client who has schizophrenia and is experiencing command hallucinations can hear voices telling them to hurt themselves or others. Therefore, a client who is experiencing command hallucinations is at the greatest risk for self-

A school nurse is assessing a school-age child who experienced the traumatic loss of a parent 8 months ago. Which of the following findings should the nurse identify as an indication that the child is experiencing post-traumatic stress disorder (PTSD)?
A.

D. Lack of interest in an upcoming holiday
The child who has PTSD will have negative moods and difficulty remembering aspects of the traumatic event. The child can also have a loss of interest or lack of participation in significant activities and events

A nurse is caring for a client who is in an abusive relationship and is assisting in the development of a safety plan. Which of the following actions is the first component of a safety plan?
A. Develop a code word that means "time to go."
B. Identify sign

B. Identify signs of escalation of violence.
It is important for the client to be able to identify signs of escalation of violence, which are the greatest risk to the client. Therefore, this is the first component of the safety plan because it increases a

A nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice?
A. Allowing a client to choose which unit activities to attend
B. Attempting alternative thera

D. Spending adequate time with a client who is verbally abusive
By spending adequate time with a client who is verbally abusive, the nurse is demonstrating the ethical principle of justice. When the nurse spends an appropriate amount of time with each cli

A nurse is planning discharge teaching for a client who has severe schizoaffective disorder. The nurse should identify that which of the following treatment options can offer interdisciplinary services for the client at home?
A. Community mental health ce

D. Assertive community treatment
Assertive community treatment provides comprehensive, community-based services to clients who have severe mental illness based upon individualized needs. Services are available in any setting, including the client's home,

A nurse is discussing a 12-step program with a client who has alcohol use disorder and is in an acute care facility undergoing detoxification. Which of the following information should the nurse include in the teaching?
A. The program will help the client

B. The client should obtain a sponsor before discharge for an increased chance of recovery.
The nurse should teach the client that peer support has been shown to increase program attendance and the chances of recovery. If the client does not have a sponso

A nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. Which of the following over-the-counter medications that the client reports taking should alert the nurse to a potential adverse reactions?
A. Lans

D. Phenylephrine
Clients who are taking tranylcypromine, an MAOI antidepressant, should not take phenylephrine and other over-the-counter medications for sinus congestion, colds, or allergies due to their actions on the sympathetic nervous system, which c

A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above their ideal body weight. Which of the following interventions should the nurse include in the plan?
A. Include a liquid supplement with meals.
B. Identify the client

B. Identify the client's trigger foods.
The nurse should identify the trigger foods that initiate the client's binge and assist the client to understand their thoughts and behavior that relate to the food.

A nurse in a mental health clinic is planning for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
A. Discuss outpatient resources with a client who has post-traumatic stress disorder.
B. Create a plan o

D. Stay with a client who has anorexia nervosa for 1 hr after mealtimes.
Staying with a client who has anorexia nervosa following mealtimes is within the range of function of an AP. APs are allowed to attend to the safety of clients who are stable, and th

A nurse on a mental health unit observes a client who has acute mania hit another client. Which of the following actions should the nurse take first?
A. Call the provider to obtain an immediate prescription for restraint.
B. Prepare to administer benzodia

C. Call for a team of staff members to help with the situation.
The greatest risk is injury to the client and others. Therefore, the first action the nurse should take is to call for assistance to prevent further injury to themselves or others.

A nurse is planning discharge teaching with a family member of a client who has diagnosis of depression. Which of the following information about relapse should the nurse include?
A. Additional acute episodes of depression are unlikely following inpatient

B. Early identification of changes, such as decreased social involvement, is important.
Decreased social involvement is a manifestation of depression, and early identification of findings can lead to early intervention.

A nurse in the emergency department is caring for four clients. Which of the following clients is the nurse required to report as a potential victim of abuse?
A. A school-age child who has bruises on the knees
B. An older adult client who is bedbound and

B. An older adult client who is bedbound and has a stage IV pressure ulcer
A stage IV pressure ulcer on an older adult client who is bedbound can indicate physical neglect and warrants mandatory reporting.

A nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and fear of gaining weight. The client states, "I'm so fat I can't even stand to look at myself." Which of the following therapeutic responses demonstrates the

B. "You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight."
The nurse is using the therapeutic technique of summarizing to review the key points of the discussion.

A nurse is caring for four clients in an emergency department. The nurse should identify that which of the following clients can give informed consent?
A. A 17-year-old client who lives with friends
B. A 50-year-old client who has a blood alcohol level of

C. A 35-year-old client who has major depressive disorder
A client who has major depressive disorder is capable of making health care decisions unless the client is determined to be legally incompetent.

A nurse is planning prevention strategies for partner violence in the community. Which of the following strategies should the nurse include as a method of secondary prevention?
A. Provide teaching about the use of positive coping mechanisms.
B. Establish

B. Establish screening programs to identify at-risk clients.
This is an example of secondary prevention. By establishing screening programs, the nurse can identify individuals who are at risk for partner violence in the community and can take the necessar

A nurse in a community health center is working with a group of clients who have post-traumatic stress disorder. Which of the following interventions should the nurse include to reduce anxiety among the group members?
A. Response prevention
B. Guided imag

B. Guided imagery
Guided imagery involves assisting the client to imagine a restful and safe place. This method is effective in reducing anxiety in clients who have post-traumatic stress disorder.

A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse plan to see first?
A. A client who has avoidant personality disorder and refuses to attend group therapy
B. A client who has bipolar disorder and

D. A client who is taking clozapine and reports a sore throat and chills
When using the urgent vs. nonurgent approach to client care, the nurse should determine to first see the client who is taking clozapine and reports a sore throat and chills. Clozapin

A nurse is facilitating a community meeting for acute care clients. One client is constantly talking and using the majority of the group's time. Which of the following interventions should the nurse implement?
A. Tell the client to talk less or risk being

B. Ask group members to discuss their feelings about this client's monopolizing behavior.
This intervention will validate other members' feelings toward the client who is dominating the meeting. It also should encourage group problem-solving.

A nurse is teaching the guardians of a client about their adolescent child's diagnosis of bulimia nervosa. Which of the following statements made by the guardians indicates an understanding of their client's illness?
A. "This disease will increase our chi

B. "It is important for our child to have regular dental checkups."
For a client who has bulimia nervosa, repeated vomiting erodes tooth enamel and predisposes the teeth to caries. Thus, the nurse should teach the guardians that regular dental checkups ar

A nurse is providing teaching to the partner of a client who is in a rehabilitation program for alcohol use disorder. The nurse should identify that which of the following statements by the client's partner indicates an understanding of the teaching?
A.

C. "I will not take charge of my partner's work responsibilities."
The nurse should identify that it is important for the individual who has the substance use disorder to take charge of personal responsibilities.

A nurse is planning care for a client who has generalized anxiety disorder. At which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques?
A. Panic
B. Moderate
C. Severe
D. Mild

D. Mild
The nurse should plan to teach the client relaxation techniques during the mild level of anxiety. This is when the client will be able to concentrate and process information.

A nurse on an acute mental health facility is receiving change-of-shift report for four clients. Which of the following client should the nurse assess first?
A. A client who does not recognize familiar people
B. A client who cannot verbalize their needs
C

D. A client who is experiencing delusions of persecution
The presence of delusions of persecution indicates that this client is at the greatest risk for injury due to the client's belief that a person in power is out to harm them. Therefore, the nurse sho

A nurse is preparing to discharge to home an older adult client who attempted suicide. The client lives alone and has difficulty performing ADLs. Which of the following referrals should the nurse initiate? SATA
A. Occupational therapy
B. Meal delivery ser

A. Occupational therapy
B. Meal delivery services
D. Physical therapy
E. Home health services
Occupational therapy is correct. An occupational therapist can assist the client to perform ADLs.
Meal delivery services is correct. Meal delivery services are n

A nurse observes a client on a mental health unit pushing on the locked unit door. Which of the following statements should the nurse make?
A. "It appears as though you would like to open the door."
B. "You will feel more comfortable after you've been her

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 relate

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?
A. Weight gain
B. Tinnitus
C. Tachycardia
D. Increased salvation

C. Tachycardia
The nurse should monitor the child for tachycardia, which is an adverse effect of methylphenidate.

A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect?
A. Sedation
B. Rhinorrhea
C. Bradycardia
D. Hypothermia

B. Rhinorrhea
The nurse should expect the client who is experiencing opioid withdrawal to have rhinorrhea and flu-like manifestations such as yawning, sneezing, and abdominal pain.

A nurse on a medical-surgical unit is assessing a client who sustained injuries 12 hr ago following a motor-vehicle crash. The client's admission blood alcohol level was 325 mg/dL. Which of the following findings should indicate to the nurse that the clie

B. Blood pressure 154/96 mm Hg
Physical manifestations of alcohol withdrawal occur in addition to psychological effects. A client who is experiencing alcohol withdrawal is expected to have hypertension, tachycardia, and fever greater than 38.3� C (101� F)

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 the teaching?
A. Fear of abandonment
B. Motor and verbal tics
C. Hostile beh

D. Language delay
The nurse should identify that language delays are a manifestation of autism spectrum disorder.

A nurse is reviewing laboratory results for a client who has schizophrenia and is taking clozapine. Which of the following values should the nurse identify as a contraindication for receiving clozapine
A. WBC count 2,500/mm^3
B. Hgb 11.5 mg/dL
C. Platelet

A. WBC count 2,500/mm^3
Clozapine can cause agranulocytosis, which can be fatal due to overwhelming infection. The nurse should identify a WBC count of less than 3,000/mm^3 as a possible manifestation of agranulocytosis and should withhold the medication

A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the nurse's suspicion of delirium?
A. Slow onset
B. Aphasia
C. C

D. Easily distracted
Extreme distractibility is a hallmark manifestation of delirium.

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?
A. Document the client's behavior every 8 hr.
B. Limi

C. Renew the prescription for the client every 4 hr.
The nurse should assess the client's behavior frequently during seclusion and should renew the prescription for seclusion for an adult client every 4 hr, for a maximum of 24 hr.

A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of a boundary issue?
A. An adolescent family member who questions parental authority
B. A family with three g

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 roles of family members.

A nurse is planning care for a client who is to undergo electroconvulsive therapy (ECT). Which of the following actions should the nurse include in the plan?
A. Administer phenytoin 30 min prior to the procedure.
B. Instruct the client to expect a headach

D. Monitor the client's cardiac rhythm during the procedure.
The seizure induced during ECT can stress the client's heart. Therefore, the nurse should plan to monitor the client's cardiac rhythm during ECT via an electrocardiogram.

A nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of acute mania. Which of the following findings should the client's partner report to the provider?
A. Obsessive attention to detail
B. Inability to sleep

B. Inability to sleep
During acute mania, the client is extremely active and does not sleep, which can lead to exhaustion. Therefore, the nurse should instruct the partner to report this finding.

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 it applies. Do

x mL= 1.5
Follow these steps for the Desired Over Have method of calculation:
Step 1: What is the unit of measurement the nurse should calculate? mL
Step 2: What is the dose the nurse should administer? Dose to administer = Desired 7.5 mg
Step 3: What is

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?
A. Orient the client to person, place, and time
B. Assist the client with deep-breathing exercises.
C. Calm the client by using therap

B. Assist the client with deep-breathing exercises
Relaxation techniques, such as deep, abdominal breathing exercises, help defuse manifestations of anxiety.

A nurse is preparing to participate in an interdisciplinary conference for a client who has bipolar disorder. Which of the following behaviors is the priority for the nurse to report to the treatment team?
A. Calling family members
B. Spending time alone

C. Giving away possessions
Giving away possessions indicates that this client is at greatest risk for suicide. Therefore, this is the priority finding for the nurse to report to the treatment team.

A nurse is planning care for a client who has made repeated physical threats toward others on the unit. Although the client does not want to leave the unit, the nurse requests the provider to transfer the client to a unit that is equipped to manage violen

A. Nonmaleficence
It is the responsibility of the nurse to do no harm to clients. The nurse is applying the ethical principle of nonmaleficence by requesting to transfer this client to a unit better able to manage their behavior and thereby prevent injury

A nurse is assessing a client who has major depressive disorder and has been receiving amitriptyline for 1 week. Which of the following outcomes should the nurse expect?
A. Rapid improvement in affect within 30 to 60 min after taking the medication
B. Gre

B. Greater risk of attempting suicide as affect and energy improve
The nurse should identify that an initial response to amitriptyline can develop in 1 week. For a client who has major depressive disorder with suicidal ideation, the energy to carry out a

A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan of care?
A. Encourage the client to participate in group therapy
B. Instructing the client

C. Offer the client high-calorie finger foods frequently
The nurse should frequently offer the client high-calorie foods that can be eaten while the client is on the go. Clients experiencing mania might be unable to sit down for meals and can experience w

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?
A. "I am going to order a wheelchair for when I'm unable to walk."
B.

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 client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression. The client who has depression reports to the nurse, "My roommate never sleeps and keeps me up, too." Which of the following actions should

A. Move the client who has bipolar disorder to a 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.

A nurse is teaching a group of newly licensed nurses about the use of mechanical restraints. Which of the following information should the nurse include in the teaching?
A. Complete documentation about the client's status every hour while they are in rest

C. Apply restraints when other means of managing the client's behavior have failed.
According to the Patient Self-Determination Act, clients have a right to be free from restraints or seclusion unless the safety of the client or others is at risk. De-esca

A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. "I will use the same plan of care a

C. "I will update the plan of care as a client's manifestations of depression change."
The nurse should update the plan of care as a client's status and needs change.

A nurse is caring for an older adult client who begins to cry and states, "I knew God would punish men and I deserve this horrible sickness!" Which of the following responses should the nurse make?
A. "Why do you think you deserve this punishment?"
B. "Do

C. "Let's talk about what is upsetting you."
The nurse is acknowledging the client's concerns and is showing a desire to understand what the client is thinking and feeling.

A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the following findings?
A. Amenorrhea
B. Lanugo
C. Cold extremities
D. Tooth erosion

D. Tooth erosion
A client who has bulimia nervosa is likely to have dental caries and tooth erosion caused by frequent exposure to gastric acid from vomiting.