NGN ATI RN MENTAL HEALTH EXAM 2020 WITH VERIFIED UPDATED SOLUTION/BEST VERSION/A+ GRADE

When admitting a client to an inpatient mental health facility, a nurse notices that the client
seems withdrawn and appearsfearful. To establish a trusting nurse-client relationship, the nurse
should first
a. Introduce the client to other clients in the day room (working phase)
b. Inform the client that her admission will be confidential (orientation phase)
c. Assist the client in facilitating behavioral change (working phase)
d. Determine coping strategies that the client has used in the past (working phase)
2. A nurse is reviewing the potential adverse effects of lithium with a client who began the
medication 2 weeks ago. For which of the following should the nurse instruct the client to
monitor and report to the provider?
a. Hearing loss
b. Dry persistent cough
c. Bruising
d. Coarse hand tremor (indication toxicity )
3. 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 highest priority?
a. Encourage expression of feelings(acknowledge them)
b. Promote attendance at an assertiveness training group (how to be assertive rather than
aggressive)
c. Assist the client to perform relaxation breathing (assist the child to calm down)
d. Use a therapeutic holding technique (the greatest risk to this child and others is harm?
Therefore, the nurse’s priority intervention isto use a therapeutic holding technique to
de-escalate the behavior and prevent injury)
4. A nurse in a mental health facility observes a client who is experiencing panic level of anxiety.
Which of the following actions should the nurse take first?
a. Teach the client a relaxation technique (after the attack hassubsided to prevent further
escalations of anxiety)
b. Establish an exercise routine for the client (after the attack hassubsided to prevent
further escalations anxiety)
c. Assist the client to identify anxiety triggers
d. Accompany the client to a quiet room
5. A nurse is caring for a client who is taking chlorpromazine for schizophrenia. Which of the
following assessment findingsindicatesthat the client is experiencing extrapyramidal adverse
effects?
a. Fever and sore throat (indicate agranulocytosis)
b. Urinary retention (Anticholinergic side effect)
c. Postural hypotension (cardiovascularside effect)
d. Lip smacking and tongue rolling (indicate long-term extrapyramidal side effects
associated with typical antipsychotic medications)
6. 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 applicable. Do not use a trailing zero.)
NGN ATI RN MENTAL HEALTH EXAM 2020 WITH VERIFIED
UPDATED SOLUTION/BEST VERSION/A+ GRADE
1.5 mL
7. A nurse is assessing a client in the emergency department. The client appears agitated, his blood
pressure is 152/94 mm Hg, his heart rate is 104/min, and his pupils are dilated. The nurse should
suspect intoxication with which of the following substances?
a. Heroin (intoxication constricted pupils, decrease blood pressure)
b. Cocaine (intoxication cause tachycardia, elevated blood pressure, dilated pupils and
agitation)
c. Benzodiazepines(decreased blood pressure)
d. Inhalants(central nervoussystem depression)
8. A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder.
Which of the following characteristics of this disorder should the nurse include in the teaching?
a. Fear of abandonment (separation anxiety disorder)
b. Language delay (autism spectrum disorder)
c. Hostile behavior (oppositional defiant disorder)
d. Motor and verbaltics(Tourette’s disorder)
9. A nurse is leading a group therapy session when a client becomes agitated and yells, “Listening
to all of you is making me worse!” which of the following is an appropriate response?
a. “You sound angry and frustrated. Tell us more about how you are feeling?” ( the nurse
is making observations and exploring the client’sfeelings to demonstrate caring)
b. “Maybe you would like to go to another group from now on.” (nurse’sresponse is
showing disapproval of the client and can make all of the clients defensive)
c. “Let’s not talk about this now. We will talk more about this in our individualsession.”
(minimizing the client’s immediate concerns and feelings)
d. “Do any of the other group members feel this way?”(showing disapproval of the client
and can make all of the clients defensive)
10. A home health nurse is assessing an older adult client who lives alone. Which of the following
finding should indicate to the nurse that the client is experiencing delirium?
a. Sudden onset (suddenly over hoursto days)
b. Euthymic mood ( clients who have delirium have rapidmood swings)
c. Flat affect (demonstrate expressions of feelings)
d. Slow speech (raid, inappropriate speech and language)
11. A nurse is caring for a client who hasschizophrenia. The treatment plan is for the client to
increase his autonomy from his parents. Prior to discharge, the nurse should plan to
a. Stress to the client that he need to be more independent (does not give him skills to gain
autonomy. The nurse must assist the client to learn these skills)
b. Schedule a family conference (Allows the nurse to work with both the client and his
family to make an action plan for increased autonomy. This is a positive step for the
client prior to discharge)
c. Tell the client not to visit hisfamily so often (The client needs emotional support from
hisfamily. Decreasing family visits could be obstructive to his emotional well-being and
would not necessarily increase autonomy)
d. Arrange housing placement for the client in another town (The client needs emotional
support from his family. Moving him to another city could isolate him from this support
an d would not necessarily increase autonomy)
NGN ATI RN MENTAL HEALTH EXAM 2020 WITH VERIFIED
UPDATED SOLUTION/BEST VERSION/A+ GRADE
12. A nurse in a provider’s office is talking with a client who has diabetes mellitus and an HbA1c of
8.5%. The client states that she is under a lot of stress and that she doesn’t want to talk about
her diabetes mellitus right now. Based on these comments, the nurse should note that the client
is demonstrating which of the following defense mechanisms?
a. Suppression ( the client issuppressing her feelings about dealing with having a chronic
illness when she consciously denies her current health status)
b. Conversion (the client demonstrates conversion ifshe unconsciously converted her
anxiety into physical symptoms)
c. Displacement (the client demonstrates displacement ifshe transferred herfeelings
about her illnessto another less threatening situation)
d. Reaction formation (The client demonstratesreaction formation ifshe demonstrated the
opposite behavior of what she is really feeling)
13. A nurse is caring for a client who hasschizophrenia in a mental health facility. Which of the
following placesthe client at greatest risk forself-directed injury or injuring others?
a. Inability to communicate with others
b. Feelings of absence ofself-worth
c. Lack of motivation to perform daily tasks
d. Command hallucinations (A client who hasschizophrenia and is experiencing command
hallucinations may be told to hurt himself or others. Therefore, a client who is
experiencing command hallucinations is at greatest risk for self-directed injury or
injuring others)
14. A nurse is performing an assessment on a 78-year-old client who hasinjuries consistent with
suspected abuse. Which ofthe following statementsindicatesthe greatest potential risk factor
for abuse?
a. “My children manage my finances, but Istill have to sign the checks.”
b. “My son enjoys a couple of drinks each night to unwind.”
c. “My daughter-in-law is expecting another baby soon.”
d. “I plan on living on y own with the help of home health services.”
15. A nurse is obtaining a health history during a client’s admission to a mental health facility. The
client begins to talk on her cell phone. When the client finishes talking, she reports to the nurse
“That wasthe president, I leave in the morning on my new mission.” Which of the following is an
appropriate response?
a. “Do you want to leave so soon?”
b. “I do not think the president will need you on this mission.”
c. “How long have you been having conversations with the president?”
d. “I think you need to talk to your provider about the mission.”
16. A client recently diagnosed with bipolar disorder is placed in a room with a client who has severe
depression reports to the nurse, “That man in my room never sleeps and he keeps me up, too.”
Which of the following is an appropriate intervention for the nurse to take?
a. Move the client who has bipolar disorder to private room (clients who have bipolar
disorder can disrupt the therapeutic milieu for other clients; therefore, the nurse
should move this client to a private room)
b. Administersleep medication to the client who has bipolar disorder (not an appropriate
intervention)
NGN ATI RN MENTAL HEALTH EXAM 2020 WITH VERIFIED
UPDATED SOLUTION/BEST VERSION/A+ GRADE
c. Move the client who has severe depression to a private room (client who have severe
depression are often at risk forself-harm and feel isolated; therefore, the nurse should
not move this client to a private room)
d. Administersleep medication to the client who hassevere depression
17. The nurse is caring for a client who has anorexia nervosa. Which of the following criteria requires
hospitalization?
a. Weight loss 10% of total body weight (weight loss over 30% of total body weight in six
months)
b. Temperature of 35.6˚C (96.1˚F)(severe hypothermia (temperature lower than 96.8˚F)
due to loss of subcutaneous tissue or dehydration requires hospitalization)
c. Serum potassium 3.8 mEq/L (WNL)
d. Heart rate 54/min (HR is less than 40/min)
18. A nurse is caring for a client whose child recently died in motor vehicle crash and states. “I just
want to join him.” Which of the following is the nurse’s priority response?
a. “You may find it helpful to talk about your experience with a support person.”
b. “Would you like me to stay with you so you don’t feel alone?”
c. “Are you thinking about harming yourself?”
d. “What you have gone through must be very difficult.”
19. A nurse is caring for a client receiving imipramine for depression. For which of the following
adverse effects should the nurse monitor?
a. Vertigo
b. Decreased appetite
c. Bradycardia
d. Urinary retention
20. A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the
following medications should the nurse administer?
a. Methadone
b. Disulfiram
c. Naltrexone
d. Chlordiazepoxide (Librium)
21. A nurse is preparing to discharge an older adult client, who attempted suicide, to his home
where he lives alone. The client also has difficulty performing ADLs. Which of the following
referrals should the nurse initiate? (Select all that apply.)
a. Occupationaltherapy
b. Meal delivery services
c. Speech therapy
d. Physicaltherapy
e. Home health services
22. A nurse is caring for a client who is deaf and is scheduled to have electroconvulsive therapy
(ECT). The provider needs to explain the procedure to the client in order to obtain informed
consent. Which of the following actions should the nurse take?
a. Request a professional interpreter to translate
b. Have a family member explain the information
c. Ask an assistive personnel (AP) to use sign language
d. Draw a diagram of the procedure
NGN ATI RN MENTAL HEALTH EXAM 2020 WITH VERIFIED
UPDATED SOLUTION/BEST VERSION/A+ GRADE
23. A nurse is caring for a client who has a history of substance use and was involuntarily admitted
to mental health facility. When the nurse attempts to administer oral Lorazepam, the client
refusesto take the medication and become physically aggressive. Which of the following actions
should the nurse take?
a. Request a prescription for IV Lorazepam
b. Do not administer the Lorazepam
c. Request that another nurse attempt to administer the Lorazepam
d. Place the Lorazepam in the client’s food
24. During a client’s initial interview in a mental health inpatient setting, the nurse recognizes that
the client maintains eye contact and leanstoward him. The nurse should conclude that the client
a. Is beginning to trust the nurse
b. Is attempting to manipulate the nurse
c. Is physically attracted to the nurse
d. Needs to feel accepted by the nurse
25. A nurse is conducting a group therapy session for clients who have bipolar disorder. One of the
clients begins bragging and dominating the conversation. Which of the following actions should
the nurse take?
a. Tell the client to calm down or he will be dismissed from the session
b. Obtain an order form the provider to place the client in seclusion
c. Ignore the client’s behavior and continue the session
d. Interrupt the client and direct the discussion to another group member
26. A nurse is assessing a client in the emergency department who is brought in by a caregiver. The
caregiver states the client fell recently. The nurse observes bruises on the client’s abdomen,
back, and legs and suspects abuse. Which of the following action should the nurse take first?
a. Initiate a referral to socialservices for suspected abuse
b. Check the client for othersigns and symptoms of abuse
c. Assist the client to identify signs of escalating abuse
d. Identify a family member who can provide support to the client
27. A nurse is providing teaching to a client who is to be discharge from an inpatient detoxification
program and plans to attend Alcoholics Anonymous. Which of the following statements by the
client indicates an understanding of the teaching?
a. “I will learn waysto decrease my alcohol use.” (AA promotes abstinence)
b. “I will use peersupport to maintain my abstinence.” (encourage recovery )
c. “I will learn to take responsibility for my addiction.” (promotesresponsibility for
recovery)
d. “I will use a health care professional as my sponsor.”(providesindividual with sponsors
who are in recovery forsubstance use)
28. A nurse is caring for a client with dementia. Which of the following interventions is useful for
orienting a client to reality?
a. Turn on the client’stelevision for entertainment throughout the day
b. Place a large wall calendar in the client’sroom
c. Ask the family to bring the client’s rocking chair
d. Provide the client with current issues of his favorite magazines