ATI mental health practice test

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

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

A nurse is planning care for a client who has made repeated physical threats toward others on the unit. Although the client does not want to leave the unit, the nurse requests the provider to transfer the client to a unit that is equipped to manage violent behavior. Which of the following ethical principles should the nurse apply in this situation? A. Nonmaleficence B. Veracity C. Justice D. Autonomy

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

A nurse is preparing to discharge to home an older adult client who attempted suicide. The client lives alone and has difficulty performing ADLs. Which of the following referrals should the nurse initiate? SATA A. Occupational therapy B. Meal delivery services C. Speech-language pathologist D. Physical therapy E. Home health services

A. Occupational therapy B. Meal delivery services D. Physical therapy E. Home health services Occupational therapy is correct. An occupational therapist can assist the client to perform ADLs. Meal delivery services is correct. Meal delivery services are necessary due to the client's difficulty performing ADLs. Speech-language pathologist is incorrect. There is no indication that the client needs a referral for a speech-language pathologist. This referral would be indicated if the client had difficulty swallowing. Physical therapy is correct. A physical therapist can assess the client's mobility needs and assist with ADLs. Home health services is correct. Home health services provide a nursing assessment of the client's physical and mental status, as well as assistance with ADLs.

A nurse in an emergency department is caring for a femail adolescent who has a diagnosis of bulimia nervose and has a fainting episode during a ballet performance. Which of the following statements by the parent acknowledges the client's diagnosis? A. "She works so hard at ballet. Will she still be able to perform?" B. "She won't let me take the trash from her room. I'm concerned about what she has in there." C. "She told me she was tired, so I did her chores for her today." D. "She is happier with her appearance now that she's lost some weight."

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

A nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and fear of gaining weight. The client states, "I'm so fat I can't even stand to look at myself." Which of the following therapeutic responses demonstrates the nurse's use of summarizing? A. "You've discussed several concerns about your weight. Let's go back and talk about your belief that you are fat." B. "You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight." C. "You don't want to look at yourself because you think you are fat." D. "You and I can work together to overcome your fears of gaining weight."

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

A nurse is facilitating a community meeting for acute care clients. One client is constantly talking and using the majority of the group's time. Which of the following interventions should the nurse implement? A. Tell the client to talk less or risk being removed from the meeting. B. Ask group members to discuss their feelings about this client's monopolizing behavior. C. End the group meeting and take the client aside to discuss the disruptive behavior. D. Focus on other group members and ignore the client who is doing all the talking.

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

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? A. Orient the client to person, place, and time B. Assist the client with deep-breathing exercises. C. Calm the client by using therapeutic touch D. Have the client sit alone in a quiet room

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

A nurse is planning discharge teaching with a family member of a client who has diagnosis of depression. Which of the following information about relapse should the nurse include? A. Additional acute episodes of depression are unlikely following inpatient care. B. Early identification of changes, such as decreased social involvement, is important. C. Medication compliance will prevent further need for inpatient hospitalization. D. It is helpful to regularly reinforce to the client that things will get better.

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

A nurse is planning prevention strategies for partner violence in the community. Which of the following strategies should the nurse include as a method of secondary prevention? A. Provide teaching about the use of positive coping mechanisms. B. Establish screening programs to identify at-risk clients. C. Refer survivors of intimate partner abuse to a legal advocacy program. D. Organize rehabilitation therapy for clients who have experienced intimate partner abuse.

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

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

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

A nurse 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. "I will avoid social events until my partner has completed treatment." B. "It is important for me to focus my attention on my partner's addiction." C. "I will not take charge of my partner's work responsibilities." D. "I want my partner to promise to change addictive behaviors."

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

A nurse is caring for an older adult client who begins to cry and states, "I knew God would punish men and I deserve this horrible sickness!" Which of the following responses should the nurse make? A. "Why do you think you deserve this punishment?" B. "Don't worry about being punished by God." C. "Let's talk about what is upsetting you." D. "You shouldn't say things that will upset you so much."

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

A nurse is teaching a group of newly licensed nurses about the use of mechanical restraints. Which of the following information should the nurse include in the teaching? A. Complete documentation about the client's status every hour while they are in restraints. B. Maintain the client in restraints for a minimum of 4 hr. C. Apply restraints when other means of managing the client's behavior have failed. D. Request that the provider assess the client within 8 hr of the application of restraints.

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

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

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

A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan of care? A. Encourage the client to participate in group therapy B. Instructing the client to avoid napping during the day C. Offer the client high-calorie finger foods frequently D. Decrease the client's daily fiber intake

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

A nurse is caring for an older adult client who is experiencing delirium. Which of the following interventions should the nurse include in the client's plan of care? A. Offer the clients various choices for meal selection B. Assign different nursing personnel for each shift C. Permit the client to perform daily rituals to decrease anxiety D. Maintain an environment that has low lightning

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

A nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others or the unit. Which of the following interventions should the nurse include in the plan? A. Document the client's behavior every 8 hr. B. Limit the client's fluid intake to 50 mL/hr. C. Renew the prescription for the client every 4 hr. D. Toilet the client every 4 hr.

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

A nurse in a mental health clinic is caring for a client who has post-traumatic stress disorder (PTSD) after returning from military deployment. Which of the following is the priority action for the nurse to take? A. Assist the client to identify personal areas of strength. B. Encourage the client to talk about experiences during the deployment. C. Stay with the client when flashbacks occur. D. Teach the client stress-management techniques.

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

A nurse in a community health center is teaching families of clients who have post-traumatic stress disorder (PTSD) about expected clinical manifestations. Which of the following manifestations should the nurse include? A. Repeatedly talks about the traumatic incident B. sleeps excessively C. experiences feelings of isolation D. uses repetitive speech

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

A nurse is planning discharge teaching for a client who has severe schizoaffective disorder. The nurse should identify that which of the following treatment options can offer interdisciplinary services for the client at home? A. Community mental health center B. Mental health day program C. Partial hospitalization program D. Assertive community treatment

D. Assertive community treatment Assertive community treatment provides comprehensive, community-based services to clients who have severe mental illness based upon individualized needs. Services are available in any setting, including the client's home, 24 hr per day and provide crisis intervention, medication services, and advocacy.

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

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

A school nurse is assessing a school-age child who experienced the traumatic loss of a parent 8 months ago. Which of the following findings should the nurse identify as an indication that the child is experiencing post-traumatic stress disorder (PTSD)? A. Clinging behaviors directed toward a teacher B. Increased time spent sleeping C. Intense focus on school work D. Lack of interest in an upcoming holiday

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 nurse is planning care for a client who is to undergo electroconvulsive therapy (ECT). Which of the following actions should the nurse include in the plan? A. Administer phenytoin 30 min prior to the procedure. B. Instruct the client to expect a headache following the procedure. C. Place the client in four point restraints prior to the procedure. D. Monitor the client's cardiac rhythm during the procedure.

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

A nurse on a mental health unit observes a client who has acute mania hit another client. Which of the following actions should the nurse take first? A. Call the provider to obtain an immediate prescription for restraint. B. Prepare to administer benzodiazepine IM. C. Call for a team of staff members to help with the situation. D. Check the client who has was hit for injuries.

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