ATI - Mental Health
a d
The nurse is caring for a mental health client who exhibits passive-aggressive behavior when interacting with the nursing staff. When reporting client behaviors to the next shift, which actions are consistent with this assessment? Select all that apply a) The client agrees with the staff but then complains to others. b) The client pouts when he/she does not get his/her way. c) The client attacks the nurse and later cries feeling remorse. d) The client feels angry about the group session so he/she scatters papers in the lunchroom. e) The client states that problems are not his/her fault.
b c e f
When beginning a client on newly prescribed antipsychotic medications, which symptoms are commonly seen within the first few weeks of treatment? Select all that apply a) Tardive dyskinesia b) Akathisia c) Neuroleptic malignant syndrome d) Hearing loss e) Orthostatic hypotension f) Acute dystonic reactions
2
The nurse is caring for a client experiencing panic post fireworks display over the holiday weekend. The client routinely takes a prescribed dose of alprazolam 1.5 mg p.o. t.i.d. An additional p.r.n. dosage is also prescribed as 1.5 mg p.o. every 4 hours. The maximum daily dose is 8 mg. How many additional doses of the p.r.n. medication might the client take safely? _______ doses
c d e
The nurse is caring for a client with severe depression. In which conditions would the nurse anticipate the use of electroconvulsive therapy (ECT) as an option? Select all that apply a) The client is undergoing a stressful life change. b) The client also has a neurocognitive disorder. c) The client cannot tolerate monoamine oxidase inhibitors (MAOIs). d) The client has not responded to conventional antidepressant medication therapy. e) The client is having acute suicidal thoughts.
a f
The nurse is leading a group session when the nurse notices that a member of the group is tearful and shaking. Which nursing actions would be therapeutic at this time? Select all that apply a) Ask the client to share the emotions that the client is feeling. b) Redirect the group to another topic, which may evoke a less emotional response. c) Apologize to the client and state that you did not mean to cause emotional pain. d) Ask the client to leave the group and rejoin once feeling better. e) Allow the client to remain in the group and ignore the behavior. f) Direct a staff member to assist the client and continue with the group.
d f
The nurse is meeting a client on the mental health unit. When beginning a therapeutic relationship, which nursing actions are appropriate? Select all that apply a) Discuss the client's feelings with family members. b) Meet the needs and specific desires of the client. c) Provide health advice to the client. d) Help the client explore different problem-solving techniques. e) Exchange social media information with the client. f) Encourage the practice of new coping skills.
c d e
The nurse is monitoring a client with schizophrenia who is prescribed clozapine. During the morning mental health team meeting, which symptoms indicating an adverse effects of the medication would immediately be brought to the psychiatrist's attention? Select all that apply a) Pill-rolling movements b) Polyuria c) Sore throat d) Fever e) Orthostatic hypotension f) Polydipsia
b c d e
A nurse is working in the emergency room when a police officer walks in with a rape victim to be examined. If the nursing goal is to reduce client anxiety, which interventions would be appropriate? Select all that apply a) Begin the examination immediately in order to get it behind her. b) Allow a third party to be present if the client requests it. c) Assure the client of safety in the examination room. d) Ask factual questions to determine the type of assault. e) Admit the client to the treatment area right away. f) Touch the client early on demonstrating the nurse is supportive.
a b d
A nurse selects a priority nursing diagnosis of fear related to being embarrassed in the presence of others for a client who exhibits symptoms of social phobia. Which outcomes, if met, would demonstrate improvement in client's symptoms? Select all that apply a) The client verbalizes feelings that occur in stressful situations. b) The client develops a plan for responding to stressful situations. c) The client develops a plan to avoid situations that may cause stress. d) The client manages fear in group situations. e) The client uses antianxiety medication to deal with underlying fears. f) The client denies feelings that may contribute to irrational fears.
a c d
A rehabilitation nurse is caring for a young client recovering from a motor vehicle accident in which he lost both legs. The client states, "I will never be able to work again or live a normal life." Which responses by the nurse would be considered therapeutic? Select all that apply a) "I am here to help you. Let's devise a plan so that you are working toward your goals." b) "You must be devastated with your loss. Have you sought legal advice?" c) "Losing both legs is hard to accept, how are you feeling now?" d) "The occupational therapist will teach the use of adaptive equipment promoting independence." e) "With a prosthesis, you will be up and walking again soon."
a b d e
A client with a diagnosis of schizophrenia spectrum disorder is admitted to the inpatient unit after developing water intoxication. Once the client is medically stable and no longer exhibiting the behavior of seeking water, which nursing interventions are appropriate at this time? Select all that apply a) Weigh the client every day. b) Provide gum for the client. c) Lock the unit's kitchen and bathroom. d) Maintain a structured environment. e) Monitor the client's intake and output. f) Medicate the client at night.
b c d e
A client, brought to the emergency department by the police, is found wandering the streets of town and appears to be disoriented. During initial contact by the nurse, the client begins to laugh inappropriately and states feeling dizzy. Which client behaviors suggest the client is symptomatic for huffing aerosols? Select all that apply a) An elevated temperature b) A slurred speech during conversation c) Hallucinations of spiders crawling on the bed d) An unsteady gait e) Impaired memory of where he/she had been f) Multiple bruises on the skin
a b c d
A hospitalized client becomes angry and belligerent toward a nurse after speaking on the phone with his mother. The nurse learns that the mother cannot visit as expected due to her work. Which interventions will the nurse use to help the client deal with the displaced anger? Select all that apply a) Acknowledge the client's behavior as inappropriate. b) Invite the client to a quiet place to talk after he has settled down. c) Explore the client's unmet needs. d) Assist the client in identifying alternate ways of approaching the problem. e) Suggest that the client direct the anger at his mother's employer.
a d e f
The nurse is teaching a client diagnosed with a generalized anxiety disorder how to effectively cope with severe distress. Which interventions would the nurse use to promote effective coping with anxiety? Select all that apply a) Teach the client how to label feelings and how to express them. b) Assist the client to acknowledge the major consequences of blaming others. c) Discuss ways to examine the reality of fears. d) Discuss previous methods that were effective in handling stress. e) Encourage the client to limit to a mutually decided amount of time spent on worrying. f) Help the client to establish a goal and develop a plan to meet the goal.
b d e f
A client on a mental health unit becomes increasingly agitated and barricades himself in a corner room holding another client hostage. Verbal exchanges indicate an escalation in client desperation. Which nursing actions would be taken at this time? Select all that apply a) Yell for assistance to obtain help quickly. b) Direct other clients away from the area. c) Speak to the client in an authoritarian manner. d) Identify with the client's perspective and reason for agitation. e) Identify one nurse to interact with the client. f) Discreetly notify security to assist.
b c f
A client who is taking antipsychotic medication to control schizophrenia asks the nurse to explain the causes of the disorder. The nurse knows that an overactive dopamine system in the brain is one of the leading causes of schizophrenia and tells the client that excessive dopamine activity is responsible for symptoms. Which symptoms is the nurse referring to? Select all that apply a) Hypotension b) Hallucinations c) Delusional thinking d) Excessive tearfulness e) Withdrawn behavior f) Suspiciousness
a b c
A nurse is caring for a client displaying extreme mood swings with suicidal tendencies. A healthcare provider prescribes lithium and diagnoses the client with bipolar disorder. When teaching the client, which statements, verbalized by the client, indicate a good understanding of the teaching of medication management? Select all that apply a) "I need to watch for signs and symptoms of drug toxicity including blurred vision and ringing in the ears." b) "The therapeutic effect of the medication takes time to occur." c) "I will need to consistently monitor blood levels." d) "I will adjust my medication depending upon my symptoms." e) "I understand that there is a potential for addiction." f) "I will need to be on a low-tyramine diet."
b d e
A nurse is caring for a client recently diagnosed with cancer and experiencing moderate situational anxiety. Which interventions would the nurse include in the care plan? Select all that apply a) Teach the stages of grieving to the client. b) Maintain a calm, nonthreatening environment. c) Provide positive thinking strategies for the client during periods of stress. d) Encourage the client to verbalize concerns regarding the diagnosis. e) Encourage the client to use deep breathing exercises and other relaxation techniques during periods of increased stress. f) Explain relevant aspects of chemotherapy.
a b d e
A nurse is caring for a client who exhibits behaviors that test the nurse-client relationship. When discussing this behavior at a multidisciplinary team conference, which behaviors would the nurse provide as examples of this behavior? Select all that apply a) Violating the nurse's personal space b) Placing the nurse in the role of parent c) Displaying tattoos and piercings d) Stating information to try to shock the nurse e) Requesting personal information from the nurse f) Dressing in a flamboyant or seductive manner
a b c d
A nurse is caring for a client who has experienced frontal lobe damage in a car accident. Which psychosocial behaviors are indications of this damage? Select all that apply a) Difficulty controlling temper b) Fewer spontaneous facial expressions c) A change in personality d) Overt sexual behavior e) A disinterest in family relationships f) Inability to go out in public settings
b e
A nurse is caring for a client with agoraphobia. Which signs and symptoms would the nurse anticipate? Select all that apply a) Eating disorders b) Inability to leave home c) Tobacco use d) Alcohol consumption e) Panic attacks f) Hallucinations
a c d e
A nurse is caring for a client with borderline personality disorder. Which interventions are appropriate for clients with this disorder? Select all that apply a) Exploring anger in appropriate ways b) Providing antianxiety medications c) Providing emotional consistency d) Promoting gradual separation and individuation e) Ensuring the client's safety f) Identifying a reduction in suicide risk
a b c d f
A nurse is caring for an anorexic client with a nursing diagnosis of imbalanced nutrition: less than body requirements related to dysfunctional eating patterns. Which interventions would be supportive for this client? Select all that apply a) Encourage the client to keep a journal. b) Monitor weight gain. c) Allow the client to determine food choices from a menu. d) Provide small, frequent meals. e) Encourage the client to eat three substantial meals per day. f) Monitor the client during meals and for 1 hour afterward.
a b e f
A nurse is conducting a group session for children and adolescents who have been diagnosed with depression. Which behaviors would a nurse anticipate in this group? Select all that apply a) Irritability b) Suicidal thoughts c) Delusions d) Mania e) Somatic symptoms f) Anxiety
5 4 2 1 3
A nurse is developing a care plan for a client with acute mania. Place the following behaviors according to the order in which they progress from normal through acute mania. All options must be used. 1. Demonstrates poor judgment and impulse control 2. Becomes easily irritated 3. Has delusions of grandeur 4. Shows high productivity and competitive attitude in work and leisure activities 5. Uses relevant, calm speech patterns
a b f
A nurse is employed at an outpatient rehabilitation facility caring for clients withdrawing from opioids. When assessing clients who present for their counseling session, which findings are anticipated at this time? Select all that apply a) Rhinorrhea b) Dilated pupils c) Hypersomnia d) Dry, warm skin e) Feelings of hunger f) Abdominal cramps
a b c d
A nurse is explaining client rights for psychiatric patients to a client who has voluntarily sought admission to an inpatient psychiatric facility. Which rights would the nurse include in the discussion? Select all that apply a) Right to refuse treatment b) Right to a written treatment plan c) Right to personal mail d) Right to confidentiality e) Right to obtain disability benefits f) Right to select health care team members
b e f
A nurse is monitoring a client who appears to be hallucinating. The client is gesturing at a figure on the television and appears agitated with speech containing paranoid content. Which nursing interventions are appropriate at this time? Select all that apply a) In a firm voice, instruct the client to stop the behavior. b) Give simple commands in a calm voice. c) Delegate client assessment to a licensed practical/vocational nurse d) Instruct other team members to ignore the client's behavior. e) Acknowledge the presence of the hallucinations. f) Reassure the client that there is no danger.
a c d f
The nurse is assessing a client who is a polysubstance abuser, with cocaine being one of the drugs most frequently used. Which physiological symptom is suggestive of early (phase 1) cocaine intoxication? Select all that apply a) Psychomotor agitation b) Flaccid paralysis c) Cardiac arrhythmias d) Dilated pupils e) Slurred speech f) Tremors
c
The nurse is preparing the following medication for a client who has a long-term history of situational anxiety and is now experiencing a panic attack. When assessing the client 15 minutes after medication administration, the client notes the following symptoms. Which client symptom is of most concern? a) Weakness b) Nausea c) Ataxia d) Tachypnea
b c d
While assessing a client diagnosed with impulse control disorder, the nurse observes the client's violent, aggressive, and assaultive behavior when having to wait for a lunch tray to be delivered from the dietary department. Which history and assessment findings documented in the medical record is the nurse also likely to find? Select all that apply a) The client has no remorse about the inability to control behavior. b) The client functions well in other areas of life. c) The client has a history of parental alcoholism and a chaotic, abusive family life. d) The degree of aggressiveness is out of proportion to the stressor. e) The violent behavior is usually justified by a stressor.
a b d e
During the nurse's assessment of a 15-year-old client diagnosed with bulimia nervosa, the nurse evaluates for findings that accompany binge eating. Which are most applicable? Select all that apply a) Guilt b) Self-induced vomiting c) Weight loss d) Dental caries e) Normal weight f) Introverted behavior
a b e
A male client states feelings of sadness and is seeking suggestions for strategies to keep active after the loss of his spouse. Which activities might the nurse suggest to the client? Select all that apply. a) Joining a golf league at a club b) Attending regular spiritual/church services c) Attending a midday movie at the theater d) Walking alone at sunrise at the local track e) Participating in a community charity event
b c e f
A nurse has developed a therapeutic relationship with a client who has an addiction disorder. Which client behaviors would indicate that the therapeutic interaction is in the working phase? Select all that apply a) The client expresses uncertainty about what topic to discuss. b) The client acknowledges the addiction's effects on his children. c) The client discusses the financial problems related to the addiction. d) The client reluctantly shares the family history of addiction. e) The client discusses how the addiction has contributed to family distress. f) The client verbalizes difficulty identifying personal strengths.
a c d
A nurse interviews the family of a client hospitalized with severe depression and suicidal ideation. What family assessment information is essential when formulating an effective discharge plan? Select all that apply a) Current family stressors b) Personal responsibilities c) Communication patterns d) Role expectations e) Employment skills f) Physical pain
b d e f
During the nurse's shift in the emergency department, a nurse assesses a client who is suspected of being under the influence of amphetamines. Which symptoms are indicative of amphetamine use? Select all that apply a) Depressed affect b) Shallow respirations c) Hypotension d) Dilated pupils e) Diaphoresis f) Tremors
a b d e f
A nurse is assessing a client for a neurocognitive disorder such as dementia. What history findings would the nurse anticipate while talking with the client and family? Select all that apply a) The family cannot determine when the symptoms first appeared. b) The client has been exhibiting basic personality changes. c) The client acts apathetic and pessimistic. d) The client has great difficulty paying attention to others. e) The progression of symptoms has been slow. f) The client admits to feelings of wanting to be alone.
a c d e
A nurse is assessing a client who talks freely about feeling depressed. During the interaction, the nurse hears the client state, "Things will never change." What other indications of hopelessness would the nurse look for? Select all that apply a) Feelings of worthlessness b) Preoccupation with delusions c) Self-destructive behaviors d) Periods of irritability e) Bouts of anger f) Reliance on family members
a e f
A nurse is assessing a new client and notices clang associations in the speech pattern. From this assessment finding, the nurse begins to evaluate for the potential of which psychiatric conditions? Select all that apply a) Mania b) Narcolepsy c) Intermittent explosive disorder d) Dissociative identity disorder e) Cognitive disorders f) Schizophrenia
b c e f
A client, diagnosed with Alzheimer's disease, is a new resident in a long-term care facility. The client has difficulty finding his/her room and is seen wandering into the room of others. When discussing the situation at a multidisciplinary conference, which client-centered actions would the nurse suggest? Select all that apply a) Provide a map of the unit as a guide with the room highlighted b) Assign the client to a room close to the nursing station for closer monitoring. c) Place a box with familiar personal items outside the client's door for visual recognition. d) Place the client with a roommate having similar cognitive deficits e) Provide verbal cueing as to where the client's room is located. f) Ensure that the client has prescribed hearing aids and glasses on throughout the day.
c d
A delusional client says to a nurse, "I am an alien from Mars," and insists that the nurse refer to him/her as such. The belief appears to be fixed and unchanging. Which nursing interventions would the nurse implement when working with this client? Select all that apply a) Logically point out why the client could not be an alien. b) Allow the client to believe that he/she is an alien as long as there are no safety concerns c) Redirect the client with structured activities. d) Consistently use the client's name in interactions. e) Provide an as-needed medication. f) Kindly, but firmly, state that aliens are in movies.
a b d
A health care provider prescribes haloperidol p.o. 1 mg t.i.d. When assessing the client for extrapyramidal adverse effects, which nursing measures would be initiated? Select all that apply a) Closely monitor vital signs, especially temperature. b) Observe for increased pacing and restlessness. c) Reorient the client during delusions. d) Provide the client with sugar-free hard candy. e) Pad side rails in case of seizure activity. f) Monitor for signs and symptoms of urticaria.
a c f
A nurse is caring for a client diagnosed with persistent depressive disorder. Which defining characteristics are associated with this disorder? Select all that apply a) Appetite disturbance b) Delusions or hallucinations c) Insomnia or hypersomnia d) Symptoms that occur in the winter and resolve in spring e) Onset of symptoms within a 2-week period f) Loss of interest in daily activities
d e
A client has been diagnosed with an adjustment disorder with mixed anxiety and depression. What are the primary nursing diagnoses the nurse would associate with this type of adjustment disorder? Select all that apply a) Self neglect b) Acute confusion c) Activity intolerance d) Impaired social interaction e) Risk for situational low self-esteem f) Impaired memory
a b c e f
A client is being seen in the clinic after returning from military service abroad. The nurse documents restlessness at night with nightmares leaving the veteran irritable and fatigued during the day. When discussing the possibility of posttraumatic stress disorder (PTSD), which statements about PTSD are accurate? Select all that apply a) Psychotic episodes can occur in clients with PTSD. b) Hypervigilance is characteristic of clients with PTSD. c) PTSD is characterized by nightmares and flashbacks. d) PTSD is a syndrome that is only associated with military personnel. e) Substance abuse is a common coping mechanism used by clients with PTSD. f) Clients with PTSD may complain of feeling empty inside.
a b d f
A client is prescribed chlordiazepoxide as needed to control the symptoms of alcohol withdrawal. Which symptoms may indicate the need for an additional dose of this medication? Select all that apply a) Tachycardia b) Tremors c) Mood swings d) Elevated blood pressure and temperature e) Piloerection f) Increasing anxiety
a b d e
A nurse is working with a schizophrenic client who suddenly begins experiencing auditory hallucinations. Which interactions are appropriate at this time? Select all that apply a) Ask the client if he/she has recently taken any drugs or alcohol. b) Tell the client, "I'd like to spend time with you to discuss your hallucinations. Is that okay with you?" c) State, "Do you understand the side effects of your medication?" d) Encourage the client to relate the history of the hallucinations. e) Ask the client, "What are you experiencing right now?" f) Notify the health care provider of hallucinations
b c d f
After interviewing a client diagnosed with recurrent depression, a nurse determines the client's potential to commit suicide. Which factors listed below might contribute to the client's risk of suicide? Select all that apply a) Decreased physical activity b) Impulsive behaviors c) Chronic, debilitating illness d) Overwhelming feelings of guilt e) Psychomotor retardation f) Repression of anger
b d f
An 8-year-old child, diagnosed with obsessive-compulsive disorder, is admitted by the nurse to a psychiatric facility. During the admission assessment, which behaviors would be characterized as compulsions? Select all that apply a) Spending the night at only one friend's house b) Repeatedly washing the hands c) Brushing teeth three times per day d) Checking and rechecking that the television is turned off before going to school e) Wanting to play the same video game each night f) Routinely climbing up and down a flight of stairs three times before leaving the house
b c f
A client is prescribed sertraline, a selective serotonin reuptake inhibitor. Which adverse effects would the nurse review when creating a medication teaching plan? Select all that apply a) Persistent cough b) Sleep disturbance c) Seizures d) Agranulocytosis e) Dry mouth f) Agitation
a d e
A nurse is preparing discharge instructions for a client with resistant depression who was prescribed a new medication regimen that includes phenelzine, a monoamine oxidase inhibitor (MAO inhibitor). If the teaching was successful, what foods would the client state that he/she needs to avoid? Select all that apply a) Wine b) Cottage cheese c) Milk d) Aged cheese e) Salami f) Grapefruit
a c e
In the emergency department, a client reveals to the nurse a lethal plan for dying by suicide and agrees to a voluntary admission to the psychiatric unit. Which information would the nurse discuss with the client to answer the question "How long do I have to stay here?" Select all that apply a) "Let's talk more after the health care team has assessed you." b) "You need legal representation to help you make an informed decision." c) "You may leave the hospital at any time unless you're suicidal or homicidal or unable to meet your basic needs." d) "Once you've signed the papers, you are required to follow the treatment plan." e) "Because you have stated that you want to hurt yourself, you must be safe before being discharged." f) "All clients need a court hearing before leaving the hospital."
c
The nurse documents the following note in the medical record. Which communication is best to determine if domestic abuse is occurring? a) "Do you also have children who have bruises like this?" b) "I hope that you would tell me if abuse at your home is occurring." c) "Do you feel safe in your living situation?" d) "Living in an abusive situation is terrible. I know personally."
b c d e
The nurse is reviewing the process recording of a school aged client describing how the client felt about his mother's recent suicide. Which nursing interventions are appropriate to add to the plan of care? Select all that apply a) Encourage the pediatrician to prescribe an antidepressant b) State "So you are feeling pretty sad." c) Refer client to a support group for kids who have lost parents. d) Offer self by sitting with the client and allowing them to express their feelings e) Sit directly across from and focused on the child. f) Allow the client as much privacy as needed to grieve.
