ATI RN MENTAL HEALTH PROCTORED EXAM 2019 WITH NGN QUESTIONS 100% PASS WITH RATIONALES LATEST UPDATES QUESTION AND DETAILED ANSWERS

A nurse is caring for a group of patients. For which of the following situations should the nurse
complete an incident report? - ANS - A client was administered one-half of the prescribed dose
of medication
Rationale: An incident report is a recording of any occurrence that does not meet the standard of
care. The nurse should report medication errors using the facility's incident or occurrence form.
A nurse is caring for a group of patients. Which of the following findings is the nurse required to
report? - ANS - A client who has borderline personality disorder threatened to harm their
roommate
Rationale: Signs and symptoms of BPD include interpersonal relationships accompanied by
threats and other-directed violence. While it is important for the nurse to maintain the patients
confidentiality, when another individual might be in danger, the nurse is required by law to
report it to authorities.
A nurse is caring for a patient who has borderline personality disorder. Which of the following
goals is the priority when planning care for this patient?
a. The patient will take the prescribed medications as scheduled
b. The patient will express feelings of frustration
c. The patient will refrain from self-mutilation
d. The patient will participate in group therapy - ANS - c. The client will refrain from selfmutilation
Rationale: The greatest risk to the patient is injury to self and others. Therefore, the priority goal
is for the patient to refrain from self-mutilation
a. Taking prescribed medications as scheduled to maintain therapeutic blood levels is an
important goal. However, this is not the priority goal
b. Expressing feelings of frustration to acknowledge these feelings is an important goal.
However, this is not the priority goal
d. Participating in group therapy as part of the treatment plan is an important goal. However, this
is not the priority goal
A nurse is discussing the home care of a patient who has advanced Alzheimer's disease. The
patient's caregiver is planning to go out of town for several days. Which of the following
resources should the nurse recommended to the caregiver?
a. Respite care
b. Partial hospitalization
c. Adult day care program
d. Geropsychiatric unit - ANS - a. Respite care
Rationale: Respite care programs allow the patient to stay in a nursing facility for a set number
of days, allowing the caregivers to go on vacation or have some time to themselves
b. Partial hospitalization provides services for several hours during the day, but they are not
designed to offer 24-hr care. A patient with advanced Alzheimer's disease is unable to safely
remain at home unattended
c. Adult day care programs can provide services throughout the day to patient's with Alzheimer's
disease, allowing the caregiver the ability to work or have a break. The patient's return home in
the evening. A patient who has advanced Alzheimer's disease is unable to safely remain at home
unattended.
d. A geropsychiatric unit provides care for patients requiring acute psychiatric services due to
sudden mental status changes, psychosis, or other mental health services. These services are ideal
for patients who are at risk of harming themselves or others
A nurse is caring for an older adult patient who has dementia and has wandered into the day
room looking for their deceased partner. Which of the following actions should the nurse take?
a. Move the patient to a room near the nurses' station
b. Limit visitors until the patient is oriented to the environment
c. Tell the patient their partner is deceased
d. Talk with the patient about activities they enjoyed with their partner - ANS - Talk with the
patient about activities they enjoyed with their partner
Rationale:
Talking about positive experiences can help distract the patient from their disorientation
a. When caring for a patient with dementia, avoid placing them in unfamiliar settings when
possible.
b. Family members should be encouraged to interact with the patient regardless of the patient's
state of dementia
c. Confrontation should not be used for a disoriented patient
A nurse is admitting a patient with schizophrenia to an acute care setting. When the nurse
questions the patient regarding their 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
b. Word salad
c. Neologism
d. Echolalia - ANS - a. Clang association
Rationale: The nurse should document that the patients speech uses clang associations which
often rhyme or contain a string of words that can have a similar sound
b. In word salad, words are completely meaningless and disorganized.
c. Neologism consists of words that are made up by the patient
d. In echolalia, the patient repeats the words of another person
A nurse is assessing a patient who has schizophrenia. Which of the following findings should the
nurse document as a negative symptom of this disorder?
a. Delusions
b. Neologisms
c. Anhedonia
d. Echopraxia - ANS - Anhedonia
Rationale:
Positive symptoms of schizophrenia usually appear suddenly and are alteration in behavior,
perception, speech, and thought. Delusions, inability to think abstractly, neologisms (made up
words), echolalia (repeating of someone else's words, motor agitation, and echopraxia
(mimicking someone else's movements) are all positive symptoms of schizophrenia.
Negative symptoms of schizophrenia affect a person's ability to interact with others and are less
dominant than positive symptoms. Negative symptoms develop over time.
Examples of negative symptoms include flat affect, anergia (lack of energy), anhedonia (inability
to enjoy otherwise pleasurable activities), and thought blocking (inability to think, speak, or
move in response to outside stimuli)
A nurse is delegating patient care tasks to a licensed practical nurse (LPN) and an assistive
personnel. Which of the following tasks should the nurse assign to the LPN? - ANS - Change
the dressing of a client who has borderline personality disorder and superficial self-inflicted
wounds
Rationale: A patient who has borderline personality disorder is at risk for self-mutilation such as
cutting, self-inflicted wounds, scratching or picking at wounds. It is within the LPNs scope of
practice to change the dressing, cleanse the wound, and collect data regarding the healing of the
wound.
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. Feelings of remorse
b. Extended periods of depression
c. Deficits in intellectual functioning
d. Aggression towards animals - ANS - d. Aggression toward animals
Rationale: The nurse should identify that aggression toward people and animals is an expected
characteristic of a child who has conduct disorder
a. The nurse should identify that lack of remorse is an expected characteristic of a child who has
conduct disorder
b. The nurse should identify that 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
c. The nurse should identify that 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
A nurse in a mental health clinic is planning care for a client who has a new prescription for
Olanzapine. Which of the following interventions should the nurse identify as the priority? -
ANS - Instruct the client to avoid driving during initial therapy
Rationale: The greatest risk to the patient is injury resulting from drowsiness or dizziness.
Therefore, the nurse's priority intervention is to instruct the patient to avoid activities that require
mental alertness during initial medication therapy
A nurse is caring for a patient 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
patient refuses to take the medication and becomes physically aggressive. Which of the
following actions should the nurse take?
a. Do not administer the Lorazepam
b. Request a prescription for IV lorazepam
c. Request that another nurse attempt to administer the lorazepam
d. Place the lorazepam in the patient's food - ANS - a. Do not administer the Lorazepam
Rationale: Patients 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 patient's refusal
b. Requesting a prescription for and administering IV lorazepam violates the patient's right to
refuse treatment
b. Requesting that another nurse administer the lorazepam violates the patient's right to refuse
treatment
d. Placing the lorazepam in the patient's food violates the patient's right to refuse treatment
A nurse is caring for a patient who has schizophrenia and is experiencing psychosis. The nurse
should identify that which of the following findings indicates a potential psychiatric emergency?
a. The patient is exhibiting echolalia
b. The patient reports command hallucinations
c. The patient reports loss of motivation
d. The patient is exhibiting blunted affect - ANS - b. The patient reports command
hallucinations
Rationale: The nurse should identify that command hallucinations can indicate a potential
psychiatric emergency for a patient who has schizophrenia. Command hallucinations can direct
the patient to harm themselves or others.
a. The nurse should identify that echolalia, or the repeating of another's words, is an expected
manifestation of schizophrenia
c. The nurse should identify that a loss of motivation, or avolition, is an expected manifestation
of schizophrenia
A nurse is assessing a patient who has borderline personality disorder. Which of the following
findings should the nurse expect?
a. Emotional lability
b. Self-sacrificing
c. Suspicious of others
d. Grandiosity - ANS - a. Emotional lability
Rationale: It is the rapid transition from one emotion to another and is a primary feature of
borderline personality disorder. Patients who have BPD react to situations with emotional
responses that are out of proportion to the circumstances.
While observing group therapy, a nurse recognizes that a patient is behaving in a way suggestive
of dependent personality disorder. Which of the following behaviors is consistent with this
condition? - ANS - The patient needs excessive external input to make everyday decisions
Rationale: patients who have dependent personality disorder need excessive input from others to
make everyday decisions
A home health nurse is assessing an older adult patient whose sibling is the primary caregiver.
Which of the following findings should the nurse identify as a possible indicator of neglect?
a. Increased confusion
b. Sleep disturbances
c. Cluttered environment
d. Inappropriate dress - ANS - d. Inappropriate dress
Rationale: Clothing that is soiled or not appropriate for weather conditions is a possible indicator
of neglect
a. Increased confusion is an indicator of psychological abuse
b. Sleep disturbances are an indicator of psychological abuse
c. A cluttered environment is not an indicator of neglect
A nurse is establishing a therapeutic relationship with a patient who has antisocial personality
disorder. Which of the following strategies should the nurse use when communicating with this
client? - ANS - Set realistic limits on the clients behavior
Rationale: Patients 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.
A nurse in the emergency department is caring for a patient who has alcohol toxicity and is
unresponsive. Which of the following interventions should the nurse take? - ANS - Gather
supplies for endotracheal intubation
Rationale: The nurse should gather supplies for endotracheal intubation because an expected
finding of an unresponsive patient who has alcohol toxicity is respiratory depression
A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who weighs
110 lb. Available is chlorpromazine syrup 10 mg/ 5 mL. How many mL should the nurse
administer?
mL - ANS - 14mL
Rationale: 110lb/2.2kg * 0.55mg/kg * 5ml/10mg = 14
A nurse is planning care for a patient experiencing acute mania. Which of the following
interventions should the nurse include in the plan to promote sleep? - ANS - Encourage frequent
rest periods throughout the day
Rationale: a patient experiencing acute mania is at risk for sleep disturbances and might go for
extended periods of time without sleep. Encouraging periods of rest throughout the day can limit
the risk of exhaustion.
A nurse is reviewing routine laboratory values for several patients who are taking lithium
carbonate. Which of the following patients should the nurse assess further for findings indicating
lithium toxicity? - ANS - A client who has a sodium level of 128 mEq/L
Rationale: A sodium level of 128 mEq/L should alert the nurse that the patient is at risk for
lithium toxicity because renal excretion of lithium is decreased in the presence of low sodium
levels
A nurse is admitting a female patient who has anorexia nervosa. Which of the following
manifestations should the nurse expect during the admission assessment?
a. Diarrhea
b. Heavy Menstrual bleeding
c. Tachycardia
d. Orthostatic hypotension - ANS - d. Orthostatic hypotension
Rationale: Low weight, electrolyte imbalances, starvation, and dehydration can cause orthostatic
hypotension
a. Constipation is a manifestation of anorexia nervosa. Decreased food and fluid intake cause
constipation
b. Amenorrhea is a manifestation of anorexia nervosa. Low weight, decreased body fat, and poor
nutrition cause amenorrhea
c. Bradycardia is a manifestation of anorexia nervosa. Starvation and dehydration cause
cardiovascular abnormalities, including bradycardia
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? - ANS
- "If you do my homework for me, I won't bother you for the rest of the day."
Rationale: This is an example of manipulative behavior. It is an example of this when the family
member uses a behavior to get what they desire rather than directly asking for what they want
A charge nurse is preparing an educational session for a group of newly licensed nurses to
review patient rights under the law. Which of the following statements should the nurse make? -
ANS - "In the event a patient threatens to harm others, medications can be administered without
consent"
Rationale: The charge nurse should inform the participants that their primary commitment is to
the patient and their priority is always to advocate for and protect their health and safety. During
an emergency situation, if the patient is threatening harm themselves or others, medications can
be administered without the patients consent or court order.
A patient 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, a nurse
notices that the family member seems distracted. Which of the following actions should the
nurse take? - ANS - Ask the family member is they have any thoughts or questions about the
treatment plan
Rationale: This action involves the family member and allows them a venue to communicate
about the patients medication treatment plan
A nurse is planning care for a newly admitted patient who has bipolar disorder and is
experiencing mania. Which of the following is the priority action by the nurse? - ANS - Provide
frequent high-calorie snacks
Rationale: The priority action the nurse should take when using Maslow's Hierarchy of Needs, is
to meet the patients need for adequate nutrition. Therefore, providing high-calorie snacks is the
priority action for the nurse to take
A nurse is caring for a patient who is experiencing alcohol withdrawal. Which of the following
medications should the nurse administer fist? - ANS - Diazepam 5 mg IV bolus
Rationale: The greatest risk to the patient who is experiencing alcohol withdrawal are seizures,
elevated HR, and elevated BP. IV diazepam acts rapidly to prevent seizures, stabilize vital signs,
and decrease the intensity or withdrawal manifestations
A nurse in a clinic is assessing a patient whose partner died 4 months ago. Which of the
following statements indicates that the client is at risk or complicated grief? - ANS - "I feel so
empty without my wife that it's hard to get up every morning."
Rationale: The nurse should identify that when a patient has difficulty carrying on normal
activities following a loss, this is an indication that there is a risk for complicated grief
A nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that
they stopped taking lithium 2 weeks ago. The nurse should recognize which of the following as
an expected adverse effect that might have caused the client to stop taking the medication?
a. Sore throat
b. Photophobia
c. Hand tremors
d. Constipation - ANS - c. Hand tremors
Rationale: Fine hand tremors are an expected adverse effect of lithium and can interfere with
performance of ADLs causing the patient to stop taking the medication
a. A sore throat is not an expected adverse effect of lithium.
b. Photophobia is not an expected adverse effect of lithium.
d. Diarrhea is an early manifestation of lithium toxicity.
A nurse is teaching a patient who has a depressive disorder about fluoxetine. Which of the
following information should the nurse include in the teaching?
a. "You might notice an increase in saliva while taking this medication"
b. "You might experience difficulties with sexual functioning while taking this medication"
c. "You should expect an improvement of symptoms of depression in 3 to 4 days"
d. "You may notice a temporary ringing in the ears when starting this medication" - ANS - "You
might experience difficulties with sexual functioning while taking this medication."
Rationale: b. Fluoxetine is an SSRI that can cause sexual dysfunction such as anorgasmia and
impotence. The nurse should instruct the patient to notify MD if sexual dysfunction occurs
a. Fluoxetine does not cause in increase in saliva productions. The nurse should instruct the
patient that they might experience dry mouth while taking fluoxetine
c. The nurse should instruct the patient that improvements in mood takes 1 to 3 weeks or longer
following the initiation of therapy with fluoxetine
d. Fluoxetine does not cause tinnitus. The nurse should instruct the patient that they might
experience visual disturbances, but this medication does not affect the ears
A nurse on a mental health unit is admitting a patient who is anxious and tells the nurse, "I hear
voices telling me what to do." Which of the following actions should the nurse take?
a. Tell the patient that the voices do not really exist
b. Touch the patient to help reduce feelings of anxiety
c. Instruct the patient to go to a quiet room when the voices start talking
d. Ask the patient what the voices are saying - ANS - d. Ask the client what the voices are
saying
Rationale: It is important for the nurse to ask the patient directly about the hallucinations to
determine if the patient or others are at risk for injury
a. The nurse should avoid negating the patient's hallucination
b. The nurse should avoid touching the patient without first asking for the patient's permission.
Touching the Patient violates one's personal space and can increase, rather than decrease,
feelings of anxiety.
c. The nurse should instruct the patient to listen to music or use other auditory distractions when
the voices are talking