ATI Mental Health Questions

A nurse is discussing the care of a client following a sexual assault with a newly licensed nurse. Which of the following statements by the new nurse indicates an understanding of teaching? A. "I will administer prophylactic treatment for STIs" B. "I am not required to obtain informed consent before the SANE collects forensic evidence." C. "I can expect manifestations of rape-trauma syndrome to be similar to bipolar disorder." D. "I should use narrative documentation when documenting subjective data."

Correct Answer: A. "I will administer prophylactic treatment for STIs"

A nurse is assessing a client who has major depressive disorder. The nurse should identify which of the following client statements as an overt comment about suicide? (select all) A. "My family will be better off if I'm dead." B. "The stress in my life is too much to handle." C. "I wish my life was over." D. "I don't feel like I can ever be happy again." E. "If I kill myself then my problems will go away."

Correct Answer: A. "My family will be better off if I'm dead." C. "I wish my life was over." E. "If I kill myself then my problems will go away."

A nurse is caring for a client who is screaming at staff members and other clients. Which of the following is a therapeutic response by the nurse to the client? A. "stop screaming, and walk with me outside." B. "why are you so angry and screaming at everyone?" C. "you will not get your way by screaming." D. "what was going through your mind when you started screaming?"

Correct Answer: A. "stop screaming, and walk with me outside."

A nurse is discussing routine follow-up needs with a client who has a new prescription for valproate. The nurse should inform the client of the need for routine monitoring of which of the following? A. AST/ALT and LDH B. Creatinine and BUN C. WBC and granulocyte counts D. Blood sodium and potassium

Correct Answer: A. AST/ALT and LDH

A nurse is caring for a client who is experiencing extreme mania due to bipolar disorder. Prior to administration of lithium carbonate, the client's lithium blood level is 1.2 mEq/L. Which of the following actions should the nurse take? A. Administer the next dose of lithium carbonate as scheduled. B. Prepare for administration of aminophylline. C. Notify the provider for a possible increase in the dosage of lithium carbonate. D. Request a stat repeat of the client's lithium blood level.

Correct Answer: A. Administer the next dose of lithium carbonate as scheduled. During a manic episode, the lithium blood level should be 0.8 to 1.4 mEq/L

A nurse is assisting with the development of protocols to address the increasing number of suicide attempts in the community. Which of the following interventions should the nurse include as a primary intervention? (select all) A. Conducting a suicide risk screening on all new clients B. Creating a support group for family members of clients who completed suicide C. Educating high school teens about suicide prevention D. Initiating 1:1 observation for a client who has current suicidal ideation E. Teaching middle school educators about warning indicators of suicide

Correct Answer: A. Conducting a suicide risk screening on all new clients C. Educating high school teens about suicide prevention E. Teaching middle school educators about warning indicators of suicide

A charge nurse is preparing a staff education session on personality disorders. Which of the following personality characteristics associated with all of the personality disorders should the charge nurse include in the teaching? (select all) A. Difficulty in getting along with other members of a group B. Belief in the ability to become invisible during times of stress. C. Display of defense mechanisms when routines are changed. D. Claiming to be more important than other persons E. Difficulty understanding why it is inappropriate to have a personal relationship with staff

Correct Answer: A. Difficulty in getting along with other members of a group C. Display of defense mechanisms when routines are changed. E. Difficulty understanding why it is inappropriate to have a personal relationship with staff Rationale: A. Difficulty in getting along with other members of a group **Correct** B. Belief in the ability to become invisible during times of stress. **Incorrect: This is only seen in schizotypical, which believes in magical thinking** C. Display of defense mechanisms when routines are changed. **Correct:** D. Claiming to be more important than other persons **Incorrect: This is only seen in narcissistic personality disorder** E. Difficulty understanding why it is inappropriate to have a personal relationship with staff **Correct:**

A nurse is caring for an adult client who has injuries resulting from spousal violence. The client does not wish to report the violence to law enforcement authorities. Which of the following nursing actions is the highest priority? A. advise the client about the location of safe houses and shelters B. encourage the client to participate in a support group for survivors of abuse C. implement case management to coordinate community and social services D. educate the client about the use of stress management techniques

Correct Answer: A. advise the client about the location of safe houses and shelters the priority action is to assist the client with the development of a safety plan that includes the identification of safe places to live

A nurse is caring for a client who has bipolar disorder. The client states, 'I am very rich, and I feel I must give my money to you." Which of the following responses should the nurse make? A. "Why do you think you feel the need to give money away?" B. "I am here to provide care and cannot accept this from you." C. "I can request that your case manager discuss appropriate charity options with you." D. "You should know that giving away your money is inappropriate."

Correct Answer: B. "I am here to provide care and cannot accept this from you." Rationale: A. "Why do you think you feel the need to give money away?" **Incorrect: asking a "why" question is a nontherapeutic form of communication and can promote a defensive client response** B. "I am here to provide care and cannot accept this from you." **Correct: this is a matter-of-fact response and concise** C. "I can request that your case manager discuss appropriate charity options with you." **Incorrect: This does not recognize the possibility of poor judgement, which is associated with bipolar disorder** D. "You should know that giving away your money is inappropriate." **Incorrect: This response conveys disapproval and can be interpreted as aggressive, prompting a defensive response by the client**

A nurse is caring for a client who is prescribed lithium therapy. The client tells of the plan to take ibuprofen for osteoarthitis pain relief. Which of the following statements should the nurse make? A. "That is a good choice. Ibuprofen does not interact with lithium." B. "Regular aspirin would be a better choice than ibuprofen." C. "Lithium decreases the effectiveness of ibuprofen." D. "The ibuprofen will make your lithium level fall too low."

Correct Answer: B. "Regular aspirin would be a better choice than ibuprofen." Aspirin is recommended as a mild analgesic rather than ibuprofen due to the risk for lithium toxicity.

A nurse is caring for a client who is on suicide precautions. Which of the following interventions should the nurse include in the plan of care? A. assign the client to a private room B. document the client's behavior every hour C. allow the client to keep perfume in her room D. ensure that the client swallows medication

Correct Answer: D. ensure that the client swallows medication

A community health nurse is leading a discussion about rape with a neighborhood task force. Which of the following statements by a neighborhood citizen indicates an understanding of the teaching? A. "rape is a crime of passion." B. "acquaintance rape often involves alcohol." C. "young adults are the typical victims of sexual assault." D. "the majority of rapists are unknown to the victims."

Correct Answer: B. "acquaintance rape often involves alcohol." alcohol and drugs are often associated with date/acquaintance rape

A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse include in the teaching? (select all) A. Use caffeine in moderation to prevent relapse. B. Difficulty sleeping can indicate a relapse. C. Begin taking your meds as soon as a relapse begins. D. Participating in psychotherapy can help prevent a relapse. E. Anhedonia is a clinical manifestation of a depressive relapse.

Correct Answer: B. Difficulty sleeping can indicate a relapse. D. Participating in psychotherapy can help prevent a relapse. E. Anhedonia is a clinical manifestation of a depressive relapse. Rationale: A. Use caffeine in moderation to prevent relapse. **Incorrect: A client with bipolar disorder should caffine altogether because it can cause a relapse** B. Difficulty sleeping can indicate a relapse. **Correct: Difficulty sleeping is a sign of a relapse** C. Begin taking your meds as soon as a relapse begins. **Incorrect: The client should always take meds, not just during a relapse** D. Participating in psychotherapy can help prevent a relapse. **Correct** E. Anhedonia is a clinical manifestation of a depressive relapse. **Correct: this is inability to feel pleasure, which is a manifestation of a depressive episode of a relapse**

A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse include in the plan of care? (select all) A. Provide flexible client behavior expectations B. Offer concise explanations C. Establish consistent limits D. Disregard client concerns E. Use a firm approach with communication

Correct Answer: B. Offer concise explanations C. Establish consistent limits E. Use a firm approach with communication Rationale: A. Provide flexible client behavior expectations **Incorrect: establish consistent behavior to prevent manipulation** B. Offer concise explanations **Correct: Improves clients ability to focus and comprehend information** C. Establish consistent limits **Correct prevents manipulation** D. Disregard client concerns **Incorrect: respond to valid concerns to foster a trusting relationship** E. Use a firm approach with communication **Correct: promotes structure, minimizes inappropriate behavior**

A nurse is discussing early indications of toxicity with a client who has a new prescription for lithium carbonate for bipolar disorder. The nurse should include which of the following manifestations in the teaching? (select all) A. Constipation B. Polyuria C. Rash D. Muscle weakness E. Tinnitus

Correct Answer: B. Polyuria D. Muscle weakness Diarrhea is an early indication of toxicity. Tinnitus is an indication of severe toxicity

A nurse is caring for a client who has borderline personality disorder. The client says, "The nurse on the evening shift is always nice! You are the meanest nurse ever!" The nurse should recognize the client's statement as an example of which of the following defense mechanisms? A. Regression B. Splitting C. Undoing D. Identification

Correct Answer: B. Splitting Rationale: A. Regression **Incorrect: this refers to resorting to earlier coping methods - ex: temper tantrum** B. Splitting **Correct** C. Undoing **Incorrect: Undoing means to reverse unacceptable acts or thoughts by doing something nice like buying a gift after an affair D. Identification **Incorrect: Identification means imitating the behavior of someone admired or feared**

A nurse is assessing a client in an inpatient mental health unit. Which of the following findings should the nurse expect if the client is in the preassaultive stage of violence? (select all) A. lethargy B. defensive responses to questions C. disorientation D. facial grimacing E. agitation

Correct Answer: B. defensive responses to questions D. facial grimacing E. agitation

A nurse is preparing a community education seminar about family violence. When discussing types of violence, the nurse should include which of the following? A. refusing to pay bills for a dependent, even when funds are available, is neglect. B. intentionally causing someone to fall is an example of physical violence. C. striking a sexual partner is an example of sexual violence. D. failure to provide a stimulating environment for normal development is emotional abuse.

Correct Answer: B. intentionally causing someone to fall is an example of physical violence. refusing to pay bills is according to ATI "economic abuse" and not neglect striking a partner is physical violence failure to provide a stimulating environment for normal development is neglect

A nurse is caring for a client who states, "I plan to commit suicide." Which of the following assessments should the nurse identify as the priority? A. client's educational and economic background B. lethality of the method and availability of means C. quality of the client's social support D. client's insight into the reasons for the decision

Correct Answer: B. lethality of the method and availability of means

A nurse is reviewing the medical records of multiple clients at a community mental health facility. Which of the following events is an example of client experiencing a maturational crisis? A. rape B. marriage C. severe physical illness D. job loss

Correct Answer: B. marriage

A nurse is caring for a client who is speaking in a loud voice with clenched fists. Which of the following actions should the nurse take? A. insist that the client stop yelling B. request that other staff members remain close by C. move as close to the client as possible D. walk away from the client

Correct Answer: B. request that other staff members remain close by

A nurse is conducting a class for a group of newly licensed nurses on caring for clients who are at risk for suicide. Which of the following information should the nurse include in the teaching? A. a client's verbal threat of suicide is attention-seeking behavior. B interventions are ineffective for clients who really want to commit suicide. C. using the term suicide increases the client's risk for a suicide attempt. D. a no-suicide contract decreases the client's risk for suicide

Correct Answer: D. a no-suicide contract decreases the client's risk for suicide

A nurse manager is discussing the care of a client who has a personality disorder with a newly licensed nurse. Which of the following statements by the new nurse indicates an understanding of the teaching? A. "I can promote my client's sense of control by establishing a schedule." B. "I should encourage clients who have a schizoid personality disorder to increase socialization." C. "I should practice limit-setting to help prevent client manipulation." D. "I should implement assertiveness training with clients who have antisocial personality disorder."

Correct Answer: C. "I should practice limit-setting to help prevent client manipulation." Rationale: A. "I can promote my client's sense of control by establishing a schedule." **Incorrect: Rather than establishing a schedule, the nurse should work with the client for realistic goals to promote the client's sense of control** B. "I should encourage clients who have a schizoid personality disorder to increase socialization." **Incorrect: Avoid over socialization of a client with schizoid personality disorder** C. "I should practice limit-setting to help prevent client manipulation." **Correct** D. "I should implement assertiveness training with clients who have antisocial personality disorder." **Incorrect: This is only true for dependent or histrionic disorder**

A charge nurse is discussing the care of a client who has major depressive disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "Care during the continuation phase focuses on treating continued manifestations of MDD" B. "The treatment of MDD during the maintenance phase lasts for 6-12 weeks." C. "The client is at greatest risk for suicide during the first weeks of an MDD episode." D. "Medication and psychotherapy are most effective during the acute phase of MDD."

Correct Answer: C. "The client is at greatest risk for suicide during the first weeks of an MDD episode." Rationale: A. "Care during the continuation phase focuses on treating continued manifestations of MDD" **Incorrect: the focus of treatment in the continuation phase is relapse prevention. Tx of manifestations is performed in the acute phase of MDD, not continuation.** B. "The treatment of MDD during the maintenance phase lasts for 6-12 weeks." **Incorrect: The maintenance phase can last 1 year or more.** C. "The client is at greatest risk for suicide during the first weeks of an MDD episode." **Correct: Acute phase increases risk of suicide** D. "Medication and psychotherapy are most effective during the acute phase of MDD." **Incorrect: Medications and psychotherapy are most effective during continuation phase to prevent acute/relapse of MDD**

A nurse is caring for a client who was recently sexually assaulted. The client states, "I never should have been out on the street alone at night." Which of the following responses should the nurse make? A. "your actions had nothing to do with what happened." B. "you should focus on recovery rather than blaming yourself for what happened." C. "you believe this wouldn't have happened if you hadn't been out alone?" D. "why do you feel that you should not have been alone on the street at night?"

Correct Answer: C. "you believe this wouldn't have happened if you hadn't been out alone?"

A nurse is caring for a client in an inpatient mental health facility who gets up from a chair and throws it across the day room. Which of the following is the priority nursing action? A. encourage the client to express feelings out loud B. maintain eye contact with the client C. move the client away from others D. tell the client that the behavior is not acceptable

Correct Answer: C. move the client away from others all are appropriate but safety is the priority

A nurse is interviewing a client who has a new diagnosis of persistent depressive disorder. Which of the following findings should the nurse expect? A. wide fluctuations in mood B. report of a minimum of 5 clinical findings of depression C. presence of manifestations for at least 2 years D. inflated sense of self-esteem

Correct Answer: C. presence of manifestations for at least 2 years Rationale: A. wide fluctuations in mood **Incorrect: wide fluctuations of mood are associated with bipolar disorder** B. report of a minimum of 5 clinical findings of depression Incorrect C. presence of manifestations for at least 2 years Correct D. inflated sense of self-esteem **Incorrect: A decreased, not inflated sense of self esteem is associated with persistent depressive disorder**

A nurse is admitting a client who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting a medical history from the client's caregiver, which of the following statements is the priority to report to the provider? A. "Current medical conditions include diabetes that is controlled by diet." B. "Recent medications include a course of prednisone for acute bronchitis." C. "Current vaccinations include a flu vaccine last month." D. "Current medications include furosemide for congestive heart failure."

Correct Answer: D. "Current medications include furosemide for congestive heart failure." Diuretics are contraindicated for use with lithium due to the risk for toxicity. This is the greatest risk for the client and is therefore the highest priority to report to the provider.

A nurse is conducting a group therapy with a group of clients. Which of the following statements made by a client is an example of aggressive communication? A. "I wish you would not make me angry." B. "I feel angry when you leave me." C. "It makes me angry when you interrupt me." D. "You'd better listen to me."

Correct Answer: D. "You'd better listen to me." this statement implies a threat and lack of respect

A charge nurse is leading a peer group discussion about family and community violence. Which of the following statements by a member of the group indicates an understanding of teaching? A. "children older than 5 are at greater risk for abuse" B. "substance use disorder does not increase the risk for violence." C. "entering an intimate relationship increases the risk for violence." D. "pregnancy increases the risk for violence from a spouse or partner."

Correct Answer: D. "pregnancy increases the risk for violence from a spouse or partner."

A nurse is caring for a client who has bipolar disorder. Which of the following is the priority nursing action? A. Set consistent limits for expected client behavior B. Administer prescribed medications as scheduled C. Provide the client with step-by-step instructions during hygiene activities D. Monitor the client for escalating behavior.

Correct Answer: D. Monitor the client for escalating behavior. Rationale: All are correct but safety is priority

A nurse is assessing a client who experienced sexual assault. Which of the following findings indicate the client is experiencing an emotional reaction of rape-trauma syndrome? (select all) A. GU soreness B. difficulties with low self-esteem C. sleep disturbances D. emotional outbursts E. difficulty making decisions

Correct Answer: D. emotional outbursts E. difficulty making decisions

A nurse is teaching a newly licensed nurse about the use of electroconvulsive therapy (ECT) for the treatment of bipolar disorder. Which of the following statements by the newly licensed nurse indicates understanding? A. "ECT is the recommended initial treatment for bipolar disorder." B. "ECT is contraindicated for clients who have suicidal ideation." C. "ECT is effective for clients who are experiencing severe mania." D. "ECT is prescribed to prevent relapse of bipolar disorder."

Correct Answer: C. "ECT is effective for clients who are experiencing severe mania." Rationale: A. "ECT is the recommended initial treatment for bipolar disorder." **Incorrect: pharmacological intervention, not ECT is recommended for initial treatment** B. "ECT is contraindicated for clients who have suicidal ideation." **Incorrect: Suicidal ideation is an indication, not a contraindication.** C. "ECT is effective for clients who are experiencing severe mania." **Correct: this is an indication, along with suicidal ideation** D. "ECT is prescribed to prevent relapse of bipolar disorder." **Incorrect: ECT is indicated for an acute episode**

A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following actions is the nurse's priority? A. placing the client on one-to-one observation B. assisting the client to perform ADLs C. encouraging the client to participate in counseling D. teaching the client about medication adverse effects

Correct answer: A. placing the client on one-to-one observation Rationale: All are correct, but the greatest risk for a client who has MDD and anxiety is injury due to self-harm

A nurse is caring for a client who has major depressive disorder. Which of the following should the nurse identify as a risk factor for depression? (select all) A. male sex B. history of chronic bronchitis C. recent death in client's family D. family history of depression E. personal history of panic disorder

Correct answer: B. history of chronic bronchitis C. recent death in client's family D. family history of depression E. personal history of panic disorder Rationales: A. male sex: Females are twice as likely to experience MDD B. history of chronic bronchitis: Depressive disorders are more common in a client who has a chronic health issue