ATI MENTAL HEALTH 2023/MENTAL HEALTH ATI PROCTORED EXAM 2023-2024 REAL EXAM 70 QUESTINS AND CORRECT ANSWERS|AGRADE

1. 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?

– Response prevention

– Guided imagery *

– Aversion therapy

– Light therapy

2. 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 the nurse take?

– Move the client who has bipolar disorder to a private room *

– Administer sleep medication to the client who has bipolar disorder

– Move the client who has severe depression to a private room

– Administer sleep medication to the client who has severe depression

3. 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 2500/mm3 *

B. Hbg 11.5 mg/dL

C. Platelets 150,000/mm3

D. RBC 3.5 million/mm3

4. 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?

– 17 yr old who lives with friends

– 50 yr old who has a blood alcohol level of 80 mg/dL

– 65 yr old who just received a dose of morphine

– 35 yr old who has major depressive disorder*

5. 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?

– Tell the client to talk less or risk being removed from the meeting

– Ask the group members to discuss their feelings about the client’s monopolizing behavior *

– End the group meeting and take the client aside to discuss the disruptive behavior

– Focus on other group members and ignore the client who is doing all the talking

6. A nurse in a community health center is teaching families of clients who has post-traumatic

stress disorder (PTSD) about expected clinical manifestations. Which of the following

manifestations should the nurse include?

– Repeatedly talks about the traumatic event

– Sleeps excessively

– Experiences feelings of isolation *

– Uses repetitive speech

7. 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?

1.5 mL

8. 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?

– Provide teaching about the use of positive coping mechanisms

– Establish screening programs to identify at risk clients *

– Refer survivors of intimate partner abuse to a legal advocacy program

– Organize rehab therapy for clients who have experiences intimate partner abuse

9. 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?

– The client is married

– Recent promotion at work

– COPD *

– Male

10. A nurse is preparing to discharge to home an older adult client who attempted suicide. The

client lives alone and has difficulty performing ADL’s. Which of the following referrals should the

nurse initiate? Select all that apply

– Occupational therapy *

– Meal delivery services *

– Speech language pathologist

– Physical therapy *

– Home health services *

11. A nurse is receiving change of shift report for four clients. Which of the following clients

should the nurse plan to see first?

– A avoidant personality disorder

– Bipolar disorder and reports being kidnapped by aliens over night

– Taking bupropion and reports having insomnia the past two nights

– Taking clozapine and reports a sore throat and chills *

12. A nurse in a mental health clinic is planning care for four clients. Which of the following

tasks should the nurse delegate to the AP?

– Discuss outpatient resources with a client who has PTSD

– Create a plan of care for a client who is experiencing alcohol withdrawal

– Explain sleep hygiene to a client who has insomnia

– Stay with a client who has anorexia nervosa for 1 hr after mealtimes *

13. 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?

– Call the provider to obtain an immediate prescription for restraint

– Prepare to administer benzodiazepine IM

– Call for a team of staff members to help with the situation *

– Check the client who was hit for injuries

14. 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?

– Complete documentation about the clients states Q1H while they are in restraints

– Maintain the client in restraints for a minimum of 4 hr

– Apply restraints when other means of managing the client’s behavior have failed

– Request that the provider assess the client within 8H of the application of restraints

15. 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 child’s illness?

– The disease will increase our child’s risk for high blood pressure

– It is important for our child to have regular dental check ups *

– We need to weigh our child daily for several weeks, then once per week

– Bleeding during our child’s periods will increase because of the disease.

16. 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?

– I will spend extra time at work to keep from feeling depressed

– I will talk about my feelings with a close friend *

– I will be able to learn how to prevent my partner’s attacks

– I will use meditation instead of taking my antidepressant

17. 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?

– Offer the client various choice for meal selection

– Assign different nursing personnel for each shift

– Permit the client to perform daily rituals to decrease anxiety *

– Maintain an environment that has low lighting

18. A nurse in a mental health clinic is caring for a client who has PTSD after returning from

military deployment. Which of the following in the priority action for the nurse to take?

– Assist the client to identify personal areas of strength

– Encourage the client to talk about experiences during the deployment

– Stay with the client when flashbacks occur *

– Teach the client stress management techniques

19. A nurse is caring for a client who gave birth to a stillborn baby. Which of the following

statements should the nurse make?

– You probably want to hold your baby

– I’ll stay with you just in case you want to talk *

– I know how you must be feeling

– It hurts now, but things will get better soon

20. 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 priority?

– Encourage expression of feelings

– Support the child’s attendance at an assertiveness training group

– Asist the child to perform relaxation breathing

– Reduce environmental stimuli *

21. A nurse is caring for an older adult client who begins to cry and states, “I knew God would

punish me and I deserve this horrible sickness!” Which of the following response should the

nurse make?

– Why do you think you deserve this punishment

– Don’t worry about being punished by God

– Let’s talk about what is upsetting you *

– You shouldn’t say things that will upset you so much

22. A nurse is performing 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?

– Slow onset

– Aphasia

– Confabulation

– Easily distracted *

23. A nurse on a med/surg unit assessing a client who sustained injuries 12H 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 client is experiencing alcohol

withdrawal?

– Somnolence

– BP 154/96 *

– Pinpoint pupils

– Blood glucose 210

24. 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?

– Obsessive attention to detail

– Inability to sleep *

– Reports of fatigue

– Isolation from others

25. 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?

– Allowing a client to choose which unit activities to attend

– Attempting alternative therapies instead of restraints for a client who is combative

– Providing a client with accurate information about their prognosis

– Spending adequate time with a client who is verbally abusive *

26. 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

transfer the client to a unit that is equipped to manage violent behavior. Which of the following

ethical principles should the nurse apply in this situation?

– Nonmaleficence *

– Veracity

– Justice

– Autonomy

27. 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?

– Develop a code worse that means “time to go”

– Identify signs of escalation of violence *

– Have a predetermined place to go in the event of violence

– Keep a hidden package of necessities

28. A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following lab

findings should the nurse expect?

– Increased CPK *

– increased LDL

– Decrease fasting blood glucose

– Decreased AST

29. A nurse is assessing a client who has major depressive disorder and has been receiving

amitriptyline for 1 wk. Which of the following outcomes should the nurse expect?

– Rapid improvement in affect within 30-60 min after taking the medication

– Greater risk of attempting suicide as affect and energy improve *

– Onset of frequent, loose stools

– Development of physiologic dependence on the medication

30. 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?

– I will use the same plan of care and interventions for each client who has depression

– Each nurse will develop a separate plan of care for each client who has depression

– I will update the plan of care as the client’s manifestations of depression change *

– An AP can use the plan of care for client teaching

31. A nurse on an acute mental health facility is receiving change of shift report for four clients.

Which of the following clients should the nurse assess first?

– A client who does not recognize familiar people

– A client who cannot verbalize their needs

– A client who is awake and disoriented at night

– A client who is experiencing delusion of persecution *

32. 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?

– Include a liquid supplement with meals

– Identify the client’s trigger foods*

– Allow the client at least 1H for each meal

– Weigh the client at bedtime each day

33. 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?

– Calling family members

– Spending time alone

– Giving away possessions *

– Excessive crying

34. 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 died 6 months ago. Reports decreased

appetite, low energy levels, and insomnia for several weeks; some memory

loss.

Graphic Results

SaO2 96% on room air

Respiratory rate 20/min

Blood pressure 112/76 mm Hg (lying)Document continues below

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Blood pressure 104/68 mm Hg (standing)

Heart rate 68/min

Temperature 36° C (96.8° F)

Medication Administration Record

Captopril 12.5 mg by mouth three times daily

Digoxin 0.125 mg by mouth each morning

Multivitamin with iron one by mouth daily

Docusate sodium 50 mg by mouth each evening

– Use a screening tool to evaluate the client for depression *

– Ask the provider to decrease the dose of the client’s BP med

– Instruct the client to decease intake of vitamin B12

– Suggest the client go for a brisk walk 20 min before bedtime

35. A nurse is planning care for a client who is to undergo ECT. Which of the following actions should the

nurse include in the plan?

– Administer phenytoin 30 min prior to the procedure

– Instruct the client to expect a headache following the procedure

– Place the client in four point restraints prior to the procedure

– Monitor the client’s cardiac rhythm during the procedure *

36. 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?

– Inform the client that this admission is confidential *

– Introduce the client to other clients in the day room

– Asist the client in facilitating behavioral change

– Determine coping strategies that the client has used in the past

37. 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?

– Encourage the parents to avoid discussing the death with their other children to protect their feelings

– Recommend each parent grieve in private to avoid hindering each other’s healing

– Suggest forming a weekly support group for parents who have experienced the death of a child *

– Advice the parents to begin counseling if they are still grieving in a few months

38. A nurse is providing teaching to the partner of a client who is in a rehab 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?

– I will avoid social events until my partner has completed treatment

– It is important for me to focus my attention on my partner’s addiction

– I will not take charge of my partner’s work responsibilities *

– I want my partner to promise to change addictive behaviors

39. A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the

following findings?

– Amenorrhea

– Lanugo

– Cold extremities

– Tooth erosion *

40. A nurse is caring for a client who is experiencing a panic attack. Which of the following

actions should the nurse take?

– Orient the client to person, place and time

– Assist the client with deep breathing exercises *

– Calm the client by using therapeutic touch

– Have the client sit alone in a quiet room

41. 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?

– Inability to communicate with others

– Feelings of absence of self-worth

– Lack of motivation to perform daily tasks

– Command hallucinations *

42. A nurse in an ER is caring for a female adolescent who has a diagnosis of bulimia nervosa

and had a fainting episode during a ballet performance. Which of the following statements by

the parent acknowledges the client’s diagnosis?

– She works so hard at ballet. Will she be able to perform?

– She won’t let me take the trash from her room. I’m concerned about what she has in there *

– She told me she was tired, so I did her chores for her today

– She is happier with her appearance now that she’s lost some weight

43. 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?

– Community mental health center

– Mental health day program

– Partial hospitalization program

– Assertive community treatment *

44. A school nurse is assessing a school age child who experienced the traumatic loss of a

parent 8 mo ago. Which of the following findings should the nurse identify as an indication that

the child is experiencing PTSD?

– Clinging behaviors directed toward a teaching

– Increased time spent sleeping

– Intense focus on school work

– Lack of interest in an upcoming holiday *

45. A nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative

use and a fear or gaining weight. The client states, “I’m so fat I can’t even stand to look at

myself.” Which of the following therapeutic response demonstrates the nurse’s use of

summarizing?

– You’ve discussed several concerns about your weight. Let’s go back and talk about your belief

that you are fat

– You’re saying that you think you are fat and are using laxatives because you are afraid of

gaining weight *

– You don’t want to look at yourself because you think you are fat

– You and I can work together to overcome your fears of gaining weight

46. 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?

– Encourage the client to participate in group therapy

– Instruct the client to avoid napping during the day

– Offer the client high-calorie finger foods frequently

– Decrease the client’s daily fiber intake

47. A nurse is planning care for a client who has generalized anxiety disorder. At which of

following levels of anxiety should the nurse plan to teach the client relaxation techniques?

– Panic

– Moderate

– Severe

– Mild

48. A nurse is admitting a client who has major depressive disorder and a new prescription for

tranylcypromine. Which of the following OTC meds that the client reports taking should alert

the nurse to potential adverse reaction?

– Lansoprazole

– Naproxen

– Magnesium hydroxide

– Phenylephrine *

49. A nurse in an ER is caring for four clients. Which of the following clients is the nurse required

to report as potential victim of abuse?

– School age child who has bruises on the knees

– Older adult client who is bedbound and had stage IV pressure ulcer *

– An adolescent who has vaginal candida infection

– Young adult who is pregnant and has a sprained ankle

50. 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?

– Clients can’t refuse to take meds if they are admitted involuntarily

– You can notify a client’s family if they are admitted involuntarily

– Clients who are admitted involuntarily maintain the right to give informed consent for

procedures *

– You can remove a client’s privileges if they are admitted involuntarily and refuse to attend

therapy sessions

51. A nurse is assisting a client who has 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

52. 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?

– 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

– The program will need a prescription from the client’s provider prior to attendance

53. 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?

– Fear of abandonment

– Motor and verbal tics

– Hostile behavior

– Language delay *

54. 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?

– 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

55. A nurse is creating a plan of care for a client who has been placed in seclusion after

threatening to harm others on the unit. Which of the following interventions should the nurse

include in the plan?

– Document the client’s behavior Q8H

– Limit the client’s fluid intake to 50 mL/Hr

– Renew the prescription for the client Q4H *

– Toilet the client 4H

56. 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 effect of methylphenidate?

– weight gain

– tinnitus

– Tachycardia *

– Increased salivation

57. A nurse is planning discharge teaching with a family member of a client who has a new

diagnosis of depression. Which of the following information 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

58. 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?

– Blurred vision

– Orthostatic hypotension

– Dry mouth

– Acute dystonia *

59. A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following

manifestations should the nurse except?

– Sedation

– Rhinorrhea *

– Bradycardia

– Hypothermia

60. 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?

– 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

ATI RN MENTAL HEALTH STUDY NURSING GUIDE WITH QUESTIONS,ANSWERS

AND RATIONALE{100%CORRECT AND VERIFIED}

1. A nurse is caring for a client whose child has a terminal illness. The client requests information

about

how to deal with the upcoming loss. Which of the following statements should the nurse make:

a. “It will be better for you to keep busy to avoid thinking about your child’s death.”

Encouraging the client to avoid thinking about the child’s death will not allow the client to begin

anticipatory grieving.

b. “You will complete the grieving process about a year after your child’s death.”

The grief process has no timeline. It varies for each individual.

c. “The grief process will start once your child actually dies.”

The client can begin anticipatory grieving during the child’s illness.

d. “It is not uncommon to feel angry toward yourself or others.”

Feelings of blame and anger towards oneself or others are an expected reaction when a client is

experiencing a loss.

2. A nurse is teaching a client who has bipolar disorder and a prescription for lithium. Which of the

following instructions should the nurse include in the teaching?

a. “Take this medication with food.”

Lithium can cause gastrointestinal distress. Therefore, this medication should be taken with food.

b.”Reduce sodium intake to 1,000 milligrams each day.”

The client should maintain an adequate and consistent sodium intake to decrease the risk for lithium

toxicity. The recommended sodium intake for adults is 1,500 mg/day.

c.”Limit fluid intake to 1,200 milliliters each day.”

The client should consume 2,000 to 3,000 mL/day of fluids during initial treatment with lithium.

d.”Be aware that this medication can be addictive.”

Lithium is not classified as an addictive medication.

3. A nurse is planning care for four clients in a mental health facility. Which of the following clients is at

the greatest risk for injury when performing ADLs

a. A client who has severe Alzheimer’s disease

The greatest risk to this client is injury from performing ADLs. Clients who have severe

Alzheimer’s disease are typically confused, have memory difficulties, tend to wander, and need

assistance to perform ADLs.

b.A client who is in the maintenance phase of schizophrenia

Clients who are in the maintenance phase of schizophrenia are calm and able to provide self-care with

minimal risk for injury. Therefore, another client is at a greater risk for injury.

C.A client who has obsessive-compulsive disorder

A client who has obsessive-compulsive disorder typically performs ADLs repetitively and precisely. The

client should be able to provide self-care with minimal risk for injury. Therefore, another client is at a

greater risk for injury.

d.A client who has dysthymic disorder

Clients who have dysthymic disorder may have low energy or chronic fatigue, but they should be able to

provide self-care with minimal risk for injury. Therefore, another client is at a greater risk for injury..

4. A nurse who works with newborns is assessing the potential for abuse or neglect. Which of the

following family groups should the nurse identify as the highest potential for future child abuse

a. A family in which both parents are adolescents

A family in which both parents are adolescents indicates a risk for the parents to become abusive

toward the newborn due to lack of experience and knowledge regarding parenting. However,

another family group is at a higher risk for potential abuse.

b. A family in which the parents respond indifferently toward their newborn

A family in which the parents act indifferently about their newborn indicates a risk for the

parents to become abusive toward the newborn due to impaired bonding. However, another

family group is at a higher risk for potential abuse.

c. A family where one or both parents witnessed intimate partner violence in the home as children

Parents who witnessed intimate partner violence as children are more likely to become abusive

themselves. Therefore, this is the family group with the greatest potential for future child abuse.

d. A family in which one or both parents has a developmental disability

A family in which one or both parents have a developmental disability indicates a risk for the

parents to become abusive toward the newborn due to difficulty learning new skills. However,

another family group is at a higher risk for potential abuse.

5. 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 her admission 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

b.Introduce the client to other clients in the day room.

The nurse should introduce the client to other clients in the day room to help the client interact

with others during the working phase of the nurse-client relationship. However,

evidence-based practice indicates that the nurse should take a different action first.

c.Assist the client in facilitating behavioral change.

The nurse should assist the client with behavioral change during the working phase of the nurse-

client relationship. However, evidence-based practice indicates that the nurse should

take a different action first.

d.Determine coping strategies that the client has used in the past.

The nurse should determine what coping strategies the client used in the past during the

working phase of the nurse-client relationship. However, evidence-based practice

indicates that the nurse should take a different action first.

6. A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions

the client regarding his admission, the client states, “I’m red, in the head, and I’m going to bed!” The

nurse should document the client’s speech pattern as which of the following

a. Clang association

The nurse should document that the client’s speech uses clang associations, which often rhyme

or contain a string of words that can have the same beginning sound.

b.Word salad

In word salad, words are completely meaningless and disorganized. This client’s speech pattern is not

word salad.

c.Neologism

Neologism consists of words that are made up by the client. This client’s speech pattern does not contain

neologisms.

d.Echolalia

In echolalia, the client repeats the words of another person. This client’s speech pattern is not echolalia.

7. A nurse is caring for four clients in an inpatient mental health facility. Which of the following clients

can give informed consent

.

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.A 17-year-old client who lives with friends

Individuals younger than 18 years of age can only provide informed consent if they are married,

pregnant, parents, or emancipated.

b.A 50-year-old client who has a blood alcohol level of 0.08

A client who is intoxicated cannot legally give informed consent.

d.A 65-year-old client who just received a dose of morphine

A client who has just received morphine, an opioid analgesic, is functionally incompetent due to the

medication’s effect on the CNS.

8. A nurse in a mental health unit is admitting a client who is anxious because he often hears voices

telling him what to do. Which of the following actions should the nurse take.

d. Ask the client what the voices are saying.

It is important for the nurse to ask the client directly about the hallucinations to determine if the

client or others are at risk for injury.

a.Tell the client that the voices do not really exist.

The nurse should avoid negating the client’s hallucination.

b.Touch the client to help reduce his anxiety.

Touching the client violates his personal space and may increase, rather than decrease, his anxiety.

c.Instruct the client to go to a quiet room when he hears voices.

The nurse should instruct the client to listen to music or use other auditory distractions when he hears

voices.

9. A nurse is educating 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.

d. Language delay

A child who has autism spectrum disorder usually has language delay.

a.Fear of abandonment

Fear of abandonment is a manifestation of separation anxiety disorder rather than autism spectrum

disorder.

b.Motor and verbal tics

Motor and verbal tics are a manifestation of Tourette’s syndrome rather than autism spectrum disorder.

c.Hostile behavior

Hostile behavior is a manifestation of oppositional defiant disorder rather than autism spectrum

disorder.

10. A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above his ideal

body weight? Which of the following interventions should the nurse include in the plan?

.

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 his thoughts and behavior that relate to the food..

a.Include a liquid supplement with meals.

The nurse should include a liquid supplement for a client who is below ideal body weight and

might not be able to eat solid foods at first or might need the additional nutrition to gain

weight.

c.Allow the client at least 1 hr for each meal.

The nurse should limit the client’s meal times to about 30 min to prevent putting excessive focus

on food.

d.Weigh the client at bedtime each day.

The nurse should weigh the client immediately after he wakes up and voids and prior to oral

intake. The nurse should weigh the client daily for the first week and then three times

per week.

11. A nurse is caring for an older adult client who begins to cry and states, “I knew God would punish me

and I deserve this horrible sickness!” Which of the following responses should the nurse make

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.”Why do you think you deserve this punishment?”

Asking a “why” question can make the client feel defensive.

b.”Don’t worry about being punished by God.”

The nurse is minimizing the client’s feelings. This response does not show empathy toward the client and

is belittling the client’s feelings.

d.”You shouldn’t say things that will upset you so much.”

The nurse is showing disapproval, which can make the client defensive.

12. A nurse is providing care for a client who has bipolar disorder and is experiencing acute mania. The

client’s morning lithium level is 1.5 mEq/L. Which of the following laboratory findings should the nurse

report to the provider? (Click on the “Exhibit” button below for additional client information. There are

three tabs that contain separate categories of data

a.

b.

c.

d. Sodium level 125 mEq/L

In the presence of low sodium levels, renal excretion of lithium is reduced and the client is at risk for

lithium toxicity. Therefore, the nurse should report this laboratory value to the provider.

Erythrocyte sedimentation rate 18 mm/hr

This finding is within the expected reference range and the nurse does not need to report this laboratory

value to the provider.

Hemoglobin 15 g/dL

This finding is within the expected reference range and the nurse does not need to report this laboratory

value to the provider.

Serum T4 5 mcg/dL

This finding is within the expected reference range and the nurse does not need to report this laboratory

value to the provider.

13. 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

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.

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 such as holidays.

a.Clinging behaviors directed toward a teacher

PTSD manifestations seen in children include detachment or estrangement from others rather than

clinging behavior.

b.Increased time spent sleeping

The child who has PTSD exhibits difficulty sleeping and distressing dreams.

c.Intense focus on school work

The child who has PTSD has difficulty concentrating on tasks.

14. A nurse in the emergency department is caring for a client who has alcohol toxicity and is

unresponsive. Which of the following interventions should the nurse take

a. Gather supplies for endotracheal intubation.

The nurse should gather supplies for endotracheal intubation since an expected finding of an

unresponsive client who has alcohol toxicity is respiratory depression. .

b.Administer a beta blocker intravenously.

Hypotension is an expected finding in a client who has alcohol toxicity. Therefore, it is not an appropriate

nursing action to administer medications that will lower the client’s blood pressure.

c.Position the client in a low-Fowler’s position.

Aspiration of emesis is a potential risk for a client. The nurse should implement measures to reduce the

risk of aspiration of emesis for a client who has alcohol poisoning. Low-Fowler’s position can increase the

client’s risk for aspiration.

d.Place a cooling blanket over the client.

The nurse should expect the client who has alcohol toxicity to have cool skin. Therefore, the nurse

should place a warming blanket over the client.

15. A nurse in an acute mental health facility is receiving change-of-shift report for four clients. Which of

the following clients should the nurse assess first

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 him. Therefore, the nurse should

assess this client first.

A.A client who does not recognize familiar people

The nurse should assess this client to determine if this is a manifestation of a chronic disorder,

such as Alzheimer’s disease, or an acute change in the client’s mental status. However,

there is another client that the nurse should assess first.

b.A client who cannot verbalize his needs

The nurse should assess this client to determine if the client has any current needs. However,

there is another client that the nurse should assess first.

c.A client who is awake and disoriented at night

The nurse should assess this client to determine if this is a manifestation of a chronic disorder,

such as Alzheimer’s disease, or an acute change in the client’s mental status. However,

there is another client that the nurse should assess first.

16. A nurse in a mental health facility is planning discharge for a client who has a long history of alcohol

use disorder. Which of the following post discharge activities should the nurse plan to include?

b. Attending a relapse prevention group several times each week

The most effective strategy for relapse prevention is a 12-step program, such as Alcoholics

Anonymous.

a.Taking the oral medication buprenorphine to prevent alcohol use

Buprenorphine is used to prevent heroin use disorder, not alcohol use disorder.

c.Beginning a methadone treatment program at a local center

Methadone is used as a substitute for heroin use disorder, not alcohol use disorder.

d.Living with her mother who has promised to keep her away from alcohol

The client should take responsibility for her own actions, not assign the responsibility to another family

member.

17. A nurse is reviewing the medication administration record for a client who is experiencing the

adverse effects of chlorpromazine. The nurse should administer benztropine to relieve which of the

following adverse effects.

d. Acute dystonia

The nurse should administer benztropine, an anticholinergic agent, to relieve acute dystonia,

which is an extrapyramidal adverse effect of chlorpromazine.

a.Blurred vision

Blurred vision is an anticholinergic effect that can occur with the use of chlorpromazine. However,

benztropine is not used to relieve this adverse effect.

b.Orthostatic hypotension

Orthostatic hypotension can occur with the use of chlorpromazine. However, benztropine is not used to

relieve this adverse effect.

c.Dry mouth

Dry mouth is an anticholinergic effect that can occur with the use of chlorpromazine. However,

benztropine is not used to relieve this adverse effect.

18. A nurse is communicating with a client in an inpatient mental health facility. Which of the following

actions by the nurse demonstrates the use of active listening.

c. Attention to body language

Use of active listening involves identifying verbal and nonverbal communication by the client,

which includes attention to body language.

a.Offering self

The nurse uses this therapeutic technique to demonstrate genuine interest in the client.

b.Use of silence

The nurse uses this therapeutic technique to demonstrate willingness to wait for the client’s

response.

d.Reflection of feelings

The nurse uses this therapeutic technique to encourage the client to acknowledge his feelings.

19. A nurse is talking with a client who is beginning chemotherapy. The client tells the nurse that

she is mourning the loss of her hair. Which of the following actions should the nurse take first

c. Discuss the importance of hair with the client.

The first action the nurse should take using the nursing process is to assess the client’s needs.

The experience of anticipatory grieving begins with acknowledging the importance of the

expected loss.

a.Recommend the client shave her hair.

The nurse can recommend that the client shave her hair. However, there is another action the nurse

should take first.

b.Suggest wearing a scarf to cover her hair loss.

The nurse should suggest wearing a scarf to the client to cover her hair loss as a part of anticipatory

grieving. However, there is another action the nurse should take first.

d.Provide information on resources for obtaining a wig.

The nurse should provide the client with information on resources for obtaining a wig. However, there is

another action the nurse should take first.

20. A nurse is planning care for a client who constantly threatens 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 violent behavior. Which of the following ethical principles should the nurse apply in

this situation?

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

his behavior and thereby prevent injury to others on the unit..

b.Veracity

The nurse applies the ethical principle of veracity when being truthful with clients and others.

c.Justice

The nurse applies the ethical principle of justice when treating all individuals equally and fairly.

d.Autonomy

The nurse applies the ethical principle of autonomy by respecting a client’s right to make independent

choices.

21. A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) and will receive

succinylcholine. The client asks the nurse about this medication. What is an appropriate response by the

nurse

a.

b. “Succinylcholine is given to reduce muscle movements during therapy.”

Succinylcholine is a muscle-paralyzing agent that will decrease muscle movement during the

procedure so that injury is less likely to occur.

c.

d.

“Succinylcholine will enhance the therapeutic effects of this treatment.”

The purpose of succinylcholine is not to increase the therapeutic effects of ECT.

“Succinylcholine will decrease the anxiety level that you might experience with this treatment.”

Succinylcholine is not an antianxiety agent.

“Succinylcholine is used as a general anesthetic to make sure you are sleeping during the

procedure.”

Succinylcholine is not a general anesthetic.

22. 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.

b.

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.

d.

Calling family members

The nurse should report that the client is calling family members to indicate that the client has a

support system. However, another behavior is the priority.

Spending time alone

The nurse should report that the client is spending time alone to indicate the client is withdrawn

from others. However, another behavior is the priority.

Excessive crying

The nurse should report that the client is crying excessively to indicate the client is showing signs

of depression. However, another behavior is the priority.

23. A nurse in a community health center is counseling a family of two parents and two children. Which

of the following statements by a family member indicates manipulative behavior

a. “If you do my homework for me, I won’t bother you for the rest of the day.”

This is an example of manipulative behavior. It is an example of manipulation when the family

member uses a behavior to get what they desire rather than directly asking for what they want.

b.

c.

d.

“Mom is always upset.”

This is an example of generalizing. Instead of dealing with areas of conflict, family members use terms

like “always” and “never” to avoid addressing specific problems.

“It’s not the children’s fault. It’s mine.”

This is an example of placating behavior, where one member of the family takes the blame in order to

prevent an argument.

“It’s your fault that we’re having problems as a family.”

This is an example of blaming behavior, where a family member blames others rather than taking

responsibility for any failure.

24. A nurse is planning discharge teaching with a family member of a client who has a new diagnosis of

depression. Which of the following information about relapse should the nurse include

a.

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.

c.

d.

Additional acute episodes of depression are unlikely following inpatient care.

Inpatient care does not guarantee the prevention of recurring acute episodes of depression.

Medication compliance will prevent further need for inpatient hospitalization.

Medication is not always effective for all clients, and the nurse cannot guarantee that additional

inpatient care will not be necessary.

It is helpful to regularly reinforce to the client that things will get better.

Platitudes, such as telling the client that things will get better, can minimize the client’s feelings.

25. A nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations

should the nurse expect during the admission assessment

a.

b.

c.

d. Orthostatic hypotension

Low weight, electrolyte imbalances, starvation, and dehydration cause orthostatic hypotension.

Diarrhea

Constipation is a manifestation of anorexia nervosa. Decreased food and fluid intake cause

constipation.

Heavy menstrual bleeding

Amenorrhea is a manifestation of anorexia nervosa. Low weight, decreased body fat, and poor

nutrition cause amenorrhea.

Tachycardia

Bradycardia is a manifestation of anorexia nervosa. Starvation and dehydration cause

cardiovascular abnormalities, including bradycardia.

26. A charge nurse is developing an educational program about schizophrenia. Which of the following

manifestations should the nurse include as a negative symptom of schizophrenia

a.

b. Thought blocking

Thought blocking is a negative symptom of schizophrenia. This manifestation is a sudden

interruption in a client’s thought processes, usually due to an internal stimulus. The client may

abruptly stop talking mid-sentence.

c.

d.

Concrete thinking

Concrete thinking is a positive symptom of schizophrenia. It describes an inability of the client to think in

abstract terms.

Echolalia

Echolalia is a positive symptom of schizophrenia. It occurs when the client repeats another person’s

words. It is often seen in a client who has catatonia.

Posturing

Posturing is a positive symptom of schizophrenia. It occurs when a client assumes an unusual or illogical

position or facial expression. Grimacing is commonly exhibited when a client is posturing.

27. A nurse is teaching the parent of a 10-year-old child who has ADHD and a new prescription for

dextroamphetamine. Which of the following instructions should the nurse include in the teaching

a.

b.

c.

d. “Administer the last dose of medication to your child 6 hours before bedtime.”

An adverse effect of dextroamphetamine is insomnia. Therefore, the nurse should instruct the

parent to administer the last dose of medication to the child 6 hr before bedtime.

“You should expect your child to gain weight while taking this medication.”

The parent can expect the child to lose weight while taking this medication.

“Administer the first dose of medication to your child 30 minutes before breakfast.”

The parent of the child should administer the first dose of medication following breakfast due to

the appetite suppression effect of the medication.

“You should expect your child to have diarrhea while taking this medication.”

The parent can expect the child to experience constipation while taking this medication.

28. A nurse is caring for a client who is receiving hospice care for an inoperable brain tumor. When

completing a spiritual assessment as part of end-of-life care, which of the following interventions should

the nurse implement

a. Discuss spiritual issues in a conversational manner.

Clients receiving end-of-life care prefer that discussions of spirituality occur in ordinary

conversation.

b.

c.

d.

Engage in a formal discussion of the client’s religious beliefs.

A discussion that complements the client’s formal religious beliefs is best done by a pastoral counselor or

chaplain.

Prompt the client to be specific when asking questions related to his own spirituality.

It can be difficult for clients to ask direct questions related to their feelings. It is important for the nurse

to be able to discover these questions in other ways.

Offer suggestions based on personal spiritual values.

The focus should be on the values of the client and family. Nurses should be present to offer support and

not to influence or change the client’s or family’s viewpoints.

29. A nurse is planning care for a newly admitted client who has bipolar disorder. Which of the following

is the priority action by the nurse

a.

b.

c. Provide frequent high-calorie snacks.

The priority action the nurse should take when using Maslow’s hierarchy of needs is to meet the

client’s need for adequate nutrition. Therefore, providing high-calorie snacks is the priority

action for the nurse to take.

d.

Schedule the client for group therapy sessions.

The nurse should incorporate group therapy in the client’s care. However, this is not the priority

action for the nurse to take.

Maintain consistent rules.

The nurse should maintain consistent rules to minimize the client’s manipulation of the staff.

However, this is not the priority action for the nurse to take.

Avoid the use of value judgments.

The nurse should avoid value judgments to minimize escalating mania. However, this is not the

priority action for the nurse to take.

30. 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.

b. Inability to sleep

During acute mania, the client is extremely active and does not sleep, which can lead to relapse.

Therefore, the nurse should instruct the partner to report this finding.

c.

d.

Obsessive attention to detail

During the manic phase of bipolar disorder, a client’s behavior becomes disorganized and

chaotic, which renders the client unable to focus on detail.

Reports of fatigue

Although the client who is experiencing acute mania may eventually become exhausted, there is

a characteristic unawareness of fatigue during this phase.

Isolation from others

Clients in the manic phase of bipolar disorder often talk and joke incessantly and are highly

interactive.

31. A client who has paranoid schizophrenia is attending a treatment planning conference with a family

member. During the discussion of the medication adherence portion of the plan, the nurse notices that

the family member seems distracted. Which of the following actions should the nurse take

a.

b.

c. Ask the family member if she has any thoughts or questions about the treatment plan.

This action involves the family member and allows her a venue to communicate about the

client’s medication treatment plan.

d.

Call the family member to the side to inquire if she has questions or concerns about the treatment plan.

This action might exacerbate the client’s paranoia. Calling the family member aside can lead the client to

assume that the nurse is sharing undisclosed information with the family member and not with the

client.

Advise the family member that this treatment plan has been developed specifically for the client to

follow.

This action dismisses the family member’s concern and does not encourage participation in treatment

planning.

Document that the family member does not support the medication treatment plan.

This action demonstrates that the nurse is making an assumption.

32. A nurse is admitting a client who has alcohol use disorder. Which of the following statements by the

client indicates that the client is using denial as a defense mechanism

a.

b.

c.

d. “I am able to go to work every day, so I don’t have a problem.”

By insisting that his drinking is not a problem because he can go to work every day, the client is

using the defense mechanism of denial. This allows the client to ignore the existence of his

substance use disorder.

“I put in extra hours at work so I won’t think about drinking.”

A client who consciously avoids thinking about uncomfortable feelings or thoughts is using the defense

mechanism of suppression.

“I know that wine is good for my heart, so that’s why I drink some each evening.”

By relating his drinking every evening to his heart health, the client is using the defense mechanism of

rationalization.

“I make up for my drinking by taking my partner on nice vacations.”

A client who attempts to make up for an undesirable act by doing something positive is using the

defense mechanism of undoing.

33. A nurse in a provider’s office is collecting a health history from the parent of a school-age child who

has been taking atomoxetine. Which of the following adverse effects reported by the parent is the

priority for the nurse to report to the provider

a.

b.

c. Dark urine

The greatest risk for the child is liver damage from atomoxetine, which can progress to liver

failure and death. Therefore, this is the nurse’s priority finding.

d.

Reduced appetite

Although reduced appetite is an adverse effect of this medication and the child should be

weighed regularly to monitor this adverse effect, another finding is the nurse’s priority

Fatigue

Although fatigue is an adverse effect of this medication, another finding is the nurse’s priority.’

Sweating

Although sweating is an adverse effect of this medication, another finding is the nurse’s priority.

34. A nurse who is working on a mental health unit should recognize that which of the following are

indications for the use of electroconvulsive therapy (ECT)? (Select all that apply.)

a. A client who is suicidal and in need of rapid treatment.

A client who is suicidal and in need of rapid treatment is correct. ECT can be used when there is

a need for a rapid, definitive response for a client who is suicidal.

b. A client who has recently been diagnosed with severe depression.

ECT is not an appropriate first-line treatment for a client with a recent diagnosis of depression.

c. A client who has bipolar disorder with rapid cycling.

ECT works best for a client who has bipolar disorder with rapid cycling.

d. A client who has mania and has not responded to medication therapy.

ECT is indicated for clients who have mania and have not responded to medication therapy.

e. A client whose depression is secondary to situational difficulties.

A client whose depression is secondary to situational difficulties is incorrect. ECT is not effective

for clients whose depression stems from situational or social problems.

35. A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following

manifestations should the nurse expect

a.

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.

c.

d.

Sedation

The nurse should expect the client experiencing opioid withdrawal to have insomnia.

Bradycardia

The nurse should expect the client experiencing opioid withdrawal to have tachycardia.

Hypothermia

The nurse should expect the client experiencing opioid withdrawal to have hyperthermia.

36. 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.

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 awareness of when danger is imminent and it is time to leave.

c.

d.

Develop a code word that means “time to go.”

Developing a code to use when it is time to leave is important to protect the safety of the family

members. However, this it is not the first component of a safety plan.

Have a predetermined place to go in the event of violence.

Selecting a predetermined place to go in the event of violence is an essential part of the safety plan.

However, it is not the first component of the safety plan.

Keep a hidden packed bag of necessities.

Keeping a hidden packed bag of necessities will make it easier for the client when out of the home.

However, it is not the first component of the safety plan.

37. A nurse is caring for a client who has a history of substance use disorder and was involuntarily

admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client

refuses to take the medication and becomes physically aggressive. Which of the following actions should

the nurse take?

a. Do not administer the lorazepam.

Clients who are in a facility due to an involuntary admission retain the right to refuse treatment.

Therefore, the nurse should hold the medication and document the client’s wishes.

b.

c.

d.

Request a prescription for IV lorazepam.

Requesting a prescription for and administering IV lorazepam violates the client’s rights.

Request that another nurse attempt to administer the lorazepam.

Requesting that another nurse attempt to administer the lorazepam violates the client’s rights.

Place the lorazepam in the client’s food.

Placing the lorazepam in the client’s food violates the client’s rights.

38. A nurse is caring for a client who has borderline personality disorder. Which of the following goals is

the priority when planning care for this client

a.

b.

c. The client will refrain from self-mutilation.

The greatest risk to the client is injury to self and others. Therefore, the priority goal is for the

client to refrain from self-mutilation.

d.

The client will take prescribed medications as scheduled.

Taking prescribed medications as scheduled to maintain therapeutic blood levels is an important goal.

However, this is not the priority goal.

The client will express feelings of frustration.

Expressing feelings of frustration in order to acknowledge these feelings is an important goal. However,

this is not the priority goal.

The client will participate in group therapy.

Participating in group therapy as part of his treatment plan is an important goal. However, this is not the

priority goal.

39. A nurse is teaching coping strategies to a client who is experiencing depression related to intimate

partner abuse. Which of the following statements by the client indicates an understanding of the

teaching

a.

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.

c.

d.

“I will spend extra time at work to keep from feeling depressed.”

Spending extra time at work to keep from feeling depressed is a maladaptive coping mechanism.

Examples of adaptive coping strategies include problem solving, learning new skills, and

building self-esteem.

“I will be able to learn how to prevent my partner’s attacks.”

The client should not expect to prevent an attack from an abuser. The client should instead learn

to identify warning signs and develop a safety plan to assist in escaping an unsafe

environment.

“I will use meditation instead of taking my antidepressant.”

While coping strategies, such as meditation, are often helpful in coping with feelings related to

intimate partner violence, such as fear, anxiety, and depression, the client should

continue to take medications as prescribed by the provider.

40. A nurse is caring for a client who has moderate Alzheimer Disease. Which of the following nursing

interventions assists in orienting the client to reality?

a.

b.

c. Talk with the client about scheduled daily activities.

Discussing scheduled daily activities assists in orienting the client to time and reality throughout

the day.

d.

Discourage the client from reminiscing about her past.

Encouraging the client to reminisce about her past can promote communication and serves as a

reference point in time.

Overlook the client’s frustration with communication.

A client who has moderate Alzheimer’s disease might experience frustration with communication.

Overlooking the client’s frustration is not therapeutic.

Present multiple options when offering the client choices.

The client should be presented with only one option at a time to keep her from becoming overwhelmed.

41. A nurse in a clinic is assessing a client whose partner died 4 months ago. Which of the following

statements indicates that the client is at risk for complicated grief

a.

b.

c.

d. “I feel so empty without my wife that it’s hard to get up every morning.”

When a client has difficulty carrying on normal activities following a loss, this is an indication

that there is a risk for complicated grief.

“I wish I had been nicer and more generous with my wife before she died.”

The client is expressing guilt, which is expected during bereavement.

“I told my wife to go to the doctor, but she wouldn’t listen to me.”

The client is expressing anger, which is expected during bereavement.

“I think about my wife all the time when I go on outings with my family.”

The client is expressing preoccupation with the image of the deceased, which is expected during

bereavement.

42. 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.

b.

c. Permit the client to perform daily rituals to decrease anxiety.

Allowing clients who have delirium to practice daily rituals will decrease frustration and anxiety.

d.

Offer the client various choices for meal selection.

Clients who have delirium may become easily frustrated when presented with too many

decisions to make.

Assign different nursing personnel for each shift.

Clients who have delirium should have consistent caregivers.

Maintain an environment that has low lighting.

Clients who have delirium should have a well-lit environment to decrease shadows and minimize

misinterpretation of stimuli.

43. A nurse in the emergency department is admitting a client who reports a headache along with heart

palpitations after having a glass of wine with dinner a few hours ago. The client has a history of

depression and has a blood pressure of 210/105 mm Hg. Which of the following questions should the

nurse ask first

a.

b.

c. Correct Answer: “What medications are you currently taking?”

The nurse should verify what medication the client is currently taking, including MAOI

medication to treat depression. The client’s history of depression indicates that this client is at

the greatest risk for hypertensive crisis from MAOI medications used to treat depression. These

medications can precipitate a hypertensive crisis if consumed with tyramine-containing foods,

including wine.

d.

“Do you have a family history of hypertension?”

The nurse should ask the client about a family history of hypertension. However, there is another

question the nurse should ask first.

“When did you last see your primary provider?”

The nurse should ask about the client’s last visit to his primary provider. However, there is

another question the nurse should ask first.

“Do you currently use relaxation techniques for increased stress?”

The nurse should ask how the client normally handles stress. However, there is another question

the nurse should ask first.

44. 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.”

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.

b.

c.

d.

“I am going to stop paying my bills since I won’t be around much longer.”

The client is verbalizing hopelessness and demonstrating the grieving stage of depression. This

does not indicate acceptance.

“I wish you would go take care of somebody who actually needs you.”

The client is expressing anger, which is a behavioral response to grief. This does not indicate

acceptance.

“I am sure I’m going to be able to continue to care for myself without help.”

The client is expressing denial, which is a behavioral response to grief. This does not indicate

acceptance.

45. 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.

b.

c. “I will not take charge of my partner’s work responsibilities.”

It is important for the individual who has the substance use disorder to take charge of personal

responsibilities.

d.

“I will avoid social events until my partner has completed treatment.”

Avoiding social events is a codependent behavior.

“It is important for me to focus my attention on my partner’s addiction.”

Focusing attention on the partner’s substance use disorder is a codependent behavior.

“I want my partner to promise to change addictive behaviors.”

Requiring promises from the individual who has the substance use disorder is a codependent

behavior.

46. A nurse is caring for a client who is experiencing a situational crisis. Which of the following findings

should the nurse expect?

a. The client recently lost a grandparent in a motor vehicle crash.

The client experiences a situational crisis when an unexpected event occurs.

b.

c.

d.

The client’s town was hit by a tornado.

The client experiences an adventitious crisis when an external disaster occurs.

The client’s youngest son is leaving for college.

The client experiences a maturational crisis during a natural life event.

The client is ambivalent about her upcoming retirement.

The client experiences a maturational crisis during a natural life event.

47. A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder.

Which of the following strategies should the nurse use when communicating with this client

a.

b. Set realistic limits on the client’s behavior.

Clients who have antisocial personality disorder can seem to be in control of their behavior, but

are manipulative and impulsive and can suddenly become aggressive and assaultive. The nurse

should establish clear limits on specific aggressive and demanding behaviors.

c.

d.

Behave in a friendly manner toward the client.

Clients who have antisocial personality disorder might perceive friendliness as an invitation for

manipulative and seductive behavior. This strategy should be used for clients who have

avoidant personality disorder.

Show respect for the client’s need for isolation.

Clients who have antisocial personality disorder do not seek isolation. They show antagonistic

behavior toward others and often have a history of criminal misconduct. This strategy

should be used for clients who have schizotypal personality disorder.

Act as a role model for assertiveness.

Clients who have antisocial personality disorder do not lack assertiveness. They tend to act in an

aggressive and exploitative manner. This strategy should be used for clients who have

dependent or histrionic personality disorders.

48. A community health nurse is planning an education program about depressive disorders. Which of

the following factors should the nurse include as increasing the risk for depression

a.

b.

c.: Substance use disorder

Clients who have a substance use disorder are at an increased risk for the development of

depressive disorders.

d.

Male gender

Females are at an increased risk for the development of depressive disorders.

Hyperthyroidism

Clients who have hypothyroidism are at an increased risk for the development of depressive disorders.

Being married

Clients who are single are at an increased risk for the development of depressive disorders.

49. A nurse is caring for an older adult client who has dementia and has wandered into the day room

looking for her deceased partner. Which of the following actions should the nurse take?

a.

b.

c.

d. Talk with the client about activities she enjoyed with her partner.

Talking about positive experiences can help distract the client from her disorientation.

Move the client to a room near the nurses’ station.

When caring for a client who has dementia, avoid unfamiliar settings whenever possible.

Limit visitors until the client is oriented to her environment.

Family members should be encouraged to interact with the client regardless of the client’s state of

dementia.

Tell the client that her partner is deceased.

Confrontation should not be used for a client who is disoriented.

50. A nurse is assessing a client who recently used cocaine. Which of the following findings should the

nurse expect?

a.

b. Hypertension

Cocaine is a stimulant that increases blood pressure. It also increases heart rate, body

temperature, energy levels, and metabolism.

c.

d.

Polyphagia

Cocaine is a stimulant that decreases appetite.

Decreased temperature

Cocaine is a stimulant that increases body temperature.

Depressed mood

Cocaine is a stimulant that causes feelings of exhilaration and increased energy.

51. During a client’s initial interview in a mental health inpatient setting, the nurse identifies that the

client is maintaining eye contact and leaning forward. Which of the following assumptions should the

nurse make based on the client’s nonverbal behaviors?

a. The client is interested in what the nurse is saying.

The client’s posture and eye contact demonstrate that she is interested in the interview and

what the nurse is saying.

b.

c.

d.

The client is attempting to manipulate the nurse.

This client’s nonverbal behavior shows no evidence of manipulation.

The client is physically attracted to the nurse.

This client’s nonverbal behavior shows no evidence of physical attraction to the nurse.

The client needs to feel accepted by the nurse.

The client is demonstrating a level of interest and awareness. There is no indication at this point of the

client’s need for acceptance.

52. A charge nurse is planning a teaching session regarding the code of ethics for registered nurses.

Which of the following information should the nurse include in the teaching?

a.

b.

c.

d.: The right to treatment ensures individualized care.

The Hospitalization of the Mentally Ill Act of 1964 requires that clients admitted to an inpatient

mental health facility have a right to individualized treatment.

Client confidentiality applies until the client dies.

Client confidentiality protects clients while they are alive and after death.

Privileged communication protects nurse-to-nurse communication.

Privileged communication protects professional staff from divulging communication between clients and

professional staff, not communication between nurses.

The duty to protect third parties requires a nurse to testify about a client.

The duty to protect third parties requires a nurse to take action if she is given information regarding

potential harm to another person. It does not require a nurse to testify.

53. A nurse is teaching the parents of a client about their daughter’s diagnosis of bulimia nervosa. Which

of the following statements made by the parents indicates an understanding of their daughter’s illness?

a.

b. “It is important for our daughter to have regular dental checkups.”

For a client who has bulimia nervosa, repeated vomiting erodes tooth enamel and predisposes

the teeth to caries. Thus, frequent dental checkups are essential.

c.

d.

“This disease will increase our daughter’s risk for high blood pressure.”

Orthostatic hypotension is more likely to occur in a client who has bulimia nervosa.

“We need to weigh our daughter daily for several weeks, then once per week.”

Although it is important to monitor the client’s weight, daily weighing can exacerbate the client’s

preoccupation with her weight.

“Bleeding during our daughter’s periods will increase because of this disease.”

Clients who have bulimia nervosa are unlikely to experience menstrual changes, unless they lose

excessive amounts of weight. Excessive weight loss can cause amenorrhea, or missed periods.

54. A nurse is caring for a client who was admitted following an overdose of amitriptyline. The nurse

should monitor the client for which of the following adverse effects associated with this medication

a.

b. Urinary retention

Urinary retention is an anticholinergic effect of amitriptyline. Therefore, the nurse should

monitor for this as an adverse effect.

c.

d.

Loose stools

An overdose of amitriptyline can result in anticholinergic effects and the client is more likely to

experience constipation rather than loose stools.

Fever

Fever is not an adverse effect of an overdose of amitriptyline.

Dyspnea

Dyspnea is not an adverse effect of an overdose of amitriptyline.

55. 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)

An increase in CPK, a muscle enzyme released when muscle tissue is damaged, occurs with

cardiomyopathy.

b.

c.

d.

Increased low-density lipoproteins (LDL)

LDL does not increase when a client is experiencing alcoholic cardiomyopathy.

Decreased fasting blood glucose (FBG)

FBG does not decrease when a client is experiencing alcoholic cardiomyopathy.

Decreased aspartate aminotransferase (AST)

AST does not decrease when a client is experiencing alcoholic cardiomyopathy.

56. A nurse is teaching a client who has a depressive disorder about fluoxetine. Which of the following

information should the nurse include in the teaching

a.

b. You may experience difficulties with sexual functioning while taking this medication.”

Fluoxetine is a selective serotonin reuptake inhibitor that can cause sexual dysfunction such as

anorgasmia and impotence. The nurse should instruct the client to notify the provider if sexual

dysfunction occurs.

c.

d.

“You may notice an increase in saliva while taking this medication.”

Fluoxetine does not cause an increase in saliva production. The nurse should instruct the client

that he may experience dry mouth while taking fluoxetine.

“You should expect an improvement in symptoms of depression in 3 to 4 days.”

The nurse should instruct the client that improvement in mood takes 1 to 3 weeks or longer

following the initiation of therapy with fluoxetine.

“You may notice a temporary ringing in the ears when starting this medication.”

Fluoxetine does not cause tinnitus. The nurse should instruct the client that he might experience

visual disturbances, but the medication does not affect the ears.

57. 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.

b.: An older adult client who is bed-bound and has a stage IV pressure ulcer

A stage IV pressure ulcer on an older adult client who is bed-bound can indicate physical neglect

and warrants mandatory reporting.

c.

d.

A school-age girl who has bruises on her knees

Bruises on the knees is an expected finding for a school-age child due to minor injuries and falls

during this stage of a life.

An adolescent who has a vaginal candida infection

Vaginal yeast infections can occur for an adolescent and are not an indicator of abuse.

A young adult who is pregnant and has a sprained ankle

The physiological change in the center of gravity during pregnancy is a common cause for losing

balance, tripping, and spraining an ankle.

58. A nurse is assessing a school-age child who has conduct disorder. Which of the following

characteristics should the nurse expect the child to demonstrate

a.

b.

c.

d.: Aggression toward animals

Aggression toward people and animals is an expected characteristic of a child who has conduct

disorder.

Feelings of remorse

Remorse is not an expected characteristic of a child who has conduct disorder.

Extended periods of depression

A child who has bipolar disorder is likely to have extended periods of depression. This is not an

expected characteristic of a child who has conduct disorder.

Deficits in intellectual functioning

A child who has intellectual deficit disorder exhibits deficits in intellectual functioning, such as

reasoning, abstract thinking, and academic ability. A deficit in intellectual functioning is

not an expected characteristic of a child who has conduct disorder.

59. 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 not use a trailing zero.)

Ratio and Proportion

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 the dose available? Dose available = Have 5 mg

STEP 4: Should the nurse convert the units of measurement? No

STEP 5: What is the quantity of the dose available? 1 mL

STEP 6: Set up an equation and solve for X.

Have/Quantity = Desired/X

5 mg/1 mL = 7.5mg/X mL

X = 1.5

STEP 7: Round if necessary.

STEP 8: Reassess to determine whether the amount to administer makes sense. If there are 5 mg/mL and the

prescription reads 7.5 mg, it makes sense to administer 1.5 mL. The nurse should administer diazepam 1.5 mL

IV bolus.

Desired Over Have

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 the dose available? Dose available = Have 5 mg

STEP 4: Should the nurse convert the units of measurement? No

STEP 5: What is the quantity of the dose available? 1 mL

STEP 6: Set up an equation and solve for X.

Desired x Quantity/Have = X

7.5 mg x 1 mL/5 mg = X mL

1.5 = X

STEP 7: Round if necessary.

STEP 8: Reassess to determine whether the amount to administer makes sense. If there are 5 mg/mL and the

prescription reads 7.5 mg, it makes sense to administer 1.5 mL. The nurse should administer diazepam 1.5 mL

IV bolus.

Dimensional Analysis

STEP 1: What is the unit of measurement the nurse should calculate? mL

STEP 2: What is the quantity of the dose available? Quantity 1 mL

STEP 3: What is the dose available? Dose available = Have 5 mg

STEP 4: What is the dose the nurse should administer? Dose to administer = Desired 7.5 mg

STEP 5: Should the nurse convert the units of measurement? No

STEP 6: Set up an equation and solve for X.

X = Quantity/Have x Conversion (Have)/Conversion (Desired) x Desired/

X mL= 1 mL/5 mg x 7.5 mg/

X = 1.5

STEP 7: Round if necessary.

STEP 8: Reassess to determine whether the amount to administer makes sense. If there are 5 mg/mL and the

prescription reads 7.5 mg, it makes sense to administer 1.5 mL. The nurse should administer diazepam 1.5 mL

IV bolus.

60. A nurse is caring for a client who is taking clozapine. For which of the following findings should the

nurse withhold the medication?

a. The client reports a sore throat.

Clozapine can lead to a potentially fatal blood disorder known as agranulocytosis.

Agranulocytosis is a severe drop in a client’s WBCs, which leaves the client highly susceptible to

infection. The nurse should withhold the medication for any indications of infection and notify

the provider.

b. The client reports being constipated for 2 days.

Constipation is an expected adverse effect of clozapine. Increasing fluid and fiber intake or the

administration of stool softeners will decrease the risk for constipation.

c. The client reports feeling dizzy when getting out of bed.

Orthostatic hypotension is an expected adverse effect of clozapine. Encouraging the client to rise

slowly when transitioning from a sitting to a standing position will help to prevent falls and will

increase client safety.

d. The client has gained 1.4 kg (3 lb) in the past month.

Weight gain is an expected adverse effect of clozapine. Following a calorie-controlled diet and

participating in regular exercise can help minimize weight gain.