Ch. 35- ATI Mental Health Nursing- (Ch. 9, 10, 11, 12, 13, 14, 15, 16, 17)

Question 1

9-1. A nurse is assisting with an educational seminar on stress for other nursing staff. Which of the following information should the nurse recommend for inclusion?

A. Excessive stressors cause the client to experience distress.
B. The body’s initial adaptive response to stress is denial.
C. Absence of stressors results in homeostasis.
D. Negative, rather than positive, stressors produce a biological response.

Answer 1

A. Excessive stressors cause the client to experience distress.

Question 2

9- 2. A nurse is discussing acute vs. prolonged stress with a client. Which of the following effects should the nurse identify as an acute stress response? (Select all that apply)

A. Chronic pain
B. Depressed immune system
C. Increased blood pressure
D. Panic attacks
E. Unhappiness

Answer 2

B. Depressed immune system
C. Increased blood pressure
E. Unhappiness

Question 3

9- 3. A nurse is reinforcing teaching with a client about stress-reduction techniques. Which of the following client statements indicates understanding of the information?

A. “Cognitive reframing will help me change my irrational thoughts to something positive.”
B. “Progressive muscle relaxation uses a mechanical device to help me gain control over my pulse rate.”
C. “Biofeedback causes my body to release endorphins so that I feel less stress and anxiety.”
D. “Mindfulness allows me to prioritize the stressors that I have in my life so that I have less anxiety.”

Answer 3

A. “Cognitive reframing will help me change my irrational thoughts to something positive.”

Question 4

9-4. A nurse is talking with a client who reports experiencing increased stress because a new partner is “pressuring me and my kids to go live with him. I love him, but I’m not ready to do that.” Which of the following recommendations should the nurse make to promote a change in the client’s situation?

A. Learn to practice mindfulness.
B. Use assertiveness techniques.
C. Exercise regularly.
D. Rely on the support of a close friend.

Answer 4

B. Use assertiveness techniques.

Question 5

9- 5. A nurse is caring for a client who states, “I’m so stressed at work because of my coworker. I am expected to finish others’ work because of their laziness!” When discussing effective communication, which of the following statements by the client to the coworker indicates client understanding?

A. “You really should complete your own work. I don’t think it’s right to expect me to complete your responsibilities.”
B. “Why do you expect me to finish your work? You must realize that I have my own responsibilities.”
C. “It is not fair to expect me to complete your work. If you continue, then I will report your behavior to our supervisor.”
D. “When I have to pick up extra work, l feel very overwhelmed. I need to focus on my own responsibilities.”

Answer 5

D. “When I have to pick up extra work, l feel very overwhelmed. I need to focus on my own responsibilities.”

Question 6

10- 1. A nurse is reinforcing teaching to a client who is scheduled to receive ECT for the treatment of major depressive disorder. Which of the following client statements indicates understanding of the information provided?

A. “It is common to treat depression with
ECT before trying medications.”
B. “I can have my depression cured if I receive a series of ECT treatments.”
C. “I should receive ECT once a week for 6 weeks.”
D. “I will receive a muscle relaxant to protect me from injury during ECT.”

Answer 6

D. “I will receive a muscle relaxant to protect me from injury during ECT.”

Question 7

10- 2. A nurse is collecting data from a client following an ECT procedure. Which of the following findings should the nurse expect? (Select all that apply.)

A. Hypotension
B. Paralytic ileus
C. Memory loss
D. Polyuria
E. Confusion

Answer 7

C. Memory loss
E. Confusion

Question 8

10- 3. A nurse is attending a peer group discussion about the indications for ECT. Which of the following indications should the nurse recommend for inclusion in the discussion?

A. Borderline personality disorder
B. Acute withdrawal related to a substance use disorder
C. Bipolar disorder with rapid cycling
D. Dysphoric disorder

Answer 8

C. Bipolar disorder with rapid cycling

Question 9

10- 4. A charge nurse is discussing RTMS with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A. “RTMS is indicated for clients who have schizophrenia spectrum disorders.”
B. “I will provide post-anesthesia care following RTMS.”
C. “RTMS treatments usually last 5 to 10 minutes.”
D. “I will schedule the client for RTMS treatments 3 to 5 times a week for the first several weeks.”

Answer 9

D. “I will schedule the client for RTMS treatments 3 to 5 times a week for the first several weeks.”

Question 10

10- 5. A nurse is contributing to the plan of care for a client following surgical implantation of a VNS device.
The nurse should plan to monitor for which of the following adverse effects? (Select all that apply.)

A. Voice changes
B. Seizure activity
C. Disorientation
D. Cough
E. Neck pain

Answer 10

A. Voice changes
D. Cough
E. Neck pain

Question 11

11- 1. A nurse observes a client who has OCD repeatedly applying, removing, and then reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of the following underlying reasons?

A. Narcissistic behavior
B. Fear of rejection from staff
C. Attempt to reduce anxiety
D. Adverse effect of antidepressant medication

Answer 11

C. Attempt to reduce anxiety

Question 12

11- 2. A nurse is collecting data for a client who has generalized anxiety disorder. Which of the following findings should the nurse expect? (Select all that apply.)

A. Excessive worry for 6 months
B. Impulsive decision-making
C. Delayed reflexes
D. Restlessness
E. Sleep disturbance

Answer 12

A. Excessive worry for 6 months
D. Restlessness
E. Sleep disturbance

Question 13

11- 3. A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?

A. Discuss new relaxation techniques.
B. Show the client how to change the behavior.
C. Distract the client with a television show.
D. Stay with the client and remain quiet.

Answer 13

D. Stay with the client and remain quiet.

Question 14

11- 4. A nurse is assisting in planning care for a client who has body dysmorphic disorder. Which of the following actions should the nurse plan to take first?

A. Collect data about the client’s risk for self-harm.
B. Instill hope for positive outcomes.
C. Encourage the client to participate in group therapy sessions.
D. Assist the client to participate in treatment decisions.

Answer 14

A. Collect data about the client’s risk for self-harm.

Question 15

11- 5. A nurse is caring for a client who is to begin taking fluoxetine for treatment of panic disorders. Which of the following statements indicates the client understands the use of this medication?

A. “I will take the medication at bedtime.”
B. “I will follow a low-sodium diet while taking this medication.”
C. “I will need to discontinue this medication slowly.”
D. “I will be at risk for weight loss with long-term use of this medication.”

Answer 15

C. “I will need to discontinue this medication slowly.”

Question 16

12- 1. A nurse is assisting with a serious and prolonged mass casualty incident in the emergency department. Which of the following strategies should the nurse use to help prevent developing a trauma-related disorder? (Select all that apply.)

A. Avoid thinking about the incident when it is over.
B. Take breaks during the incident for food and water.
C. Debrief with others following the incident.
D. Avoid displays of emotion in the days following the incident.
E. Take advantage of offered counseling.

Answer 16

B. Take breaks during the incident for food and water.
C. Debrief with others following the incident.
E. Take advantage of offered counseling.

Question 17

12- 2. A nurse working on an acute mental health unit is caring for a client who has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect? (Select all that apply.)

A. Difficulty concentrating on tasks
B. Obsessive need to talk about the traumatic event
C. Negative self-image
D. Recurring nightmares
E. Diminished reflexes

Answer 17

A. Difficulty concentrating on tasks
C. Negative self-image
D. Recurring nightmares

Question 18

12- 3. A nurse is assisting with collecting an admission history for a client who has acute stress disorder (ASD). Which of the following client behaviors should the nurse expect?

A. The client remembers many details about the traumatic incident..
B. The client expresses heightened elation about what is happening.
C. The client remembers first noticing manifestations of the disorder 6 weeks after the traumatic incident occurred.
D. The client expresses a sense of unreality about the traumatic incident.

Answer 18

D. The client expresses a sense of unreality about the traumatic incident.

Question 19

12- 4. A nurse is caring for a client who has derealization disorder. Which of the following findings should the nurse identify as an indication of derealization?

A. The client describes a feeling of floating above the ground.
B. The client has suspicions of being targeted in order to be killed and robbed.
C. The client states that the furniture in the room seems to be small and far away.
D. The client cannot recall anything that happened during the past 2 weeks.

Answer 19

D. The client cannot recall anything that happened during the past 2 weeks.

Question 20

12- 5. A nurse in an acute mental health facility is planning care for a client who has dissociative fugue. Which of the following interventions should the nurse add to the plan of care?

A. Reinforce teaching the client to recognize how stress brings on a personality change in the client.
B. Repeatedly present the client with information about past events.
C. Make decisions for the client regarding routine daily activities.
D. Work with the client on grounding techniques.

Answer 20

D. Work with the client on grounding techniques.

Question 21

12- 6. A nurse is caring for a client who takes paroxetine to treat posttraumatic stress disorder. The client states,
“I grind my teeth during the night, which causes pain in my mouth.” The nurse should identify which of the following interventions as possible measures to manage the client’s bruxism? (Select all that apply.)

A. Concurrent administration of buspirone
B. Administration of a different SSRI
C. Use of a mouth guard
D. Changing to a different class of antianxiety medication
E. Increasing the dose of paroxetine

Answer 21

A. Concurrent administration of buspirone
C. Use of a mouth guard
D. Changing to a different class of antianxiety medication

Question 22

13- 1. A charge nurse is discussing the care of a client who has major depressive disorder (MDD) 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 to 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.”

Answer 22

C. “The client is at greatest risk for suicide during the first weeks of an MDD episode.”

Question 23

13- 2. 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 that apply.)

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

Answer 23

B. History of chronic bronchitis
C. Recent death in client’s family
D. Family history of depression
E. Personal history of panic disorder

Question 24

13- 3. 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 five clinical findings of depression
C. Presence of manifestations for at least 2 years
D. Inflated sense of self-esteem

Answer 24

C. Presence of manifestations for at least 2 years

Question 25

13- 4. 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. Place the client on one-to-one observation.
B. Assist the client to perform ADLs.
C. Encourage the client to participate in counseling.
D. Reinforce education about. medication adverse effects.

Answer 25

A. Place the client on one-to-one observation.

Question 26

13- 5. A nurse is monitoring a client 4 hr after the client has received an initial dose of fluoxetine. Which of the following findings should the nurse report to the provider as indications of serotonin syndrome? (Select all that apply.)

A. Hypothermia
B. Hallucinations
C. Muscular flaccidity
D. Diaphoresis
E. Agitation

Answer 26

B. Hallucinations
D. Diaphoresis
E. Agitation

Question 27

14- 1. A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse include? (Select all that apply.)

A. Use caffeine in moderation to prevent relapse.
B. Difficulty sleeping can indicate a relapse.
C. Begin taking your medications 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.

Answer 27

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.

Question 28

14- 2. A nurse is assisting with planning care for a client who has bipolar disorder and is experiencing a manic episode. Sort the following items into interventions that the nurse should include or not include in the plan of care. (Select all that apply)

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.

Answer 28

B. Offer concise explanations.
C. Establish consistent limits.
E. Use a firm approach with communication.

Question 29

14- 3. A nurse is discussing early indications of toxicity with a client who has a prescription for lithium carbonate for bipolar disorder. The nurse should include which of the following manifestations when reinforcing teaching? (Select all that apply.)

A. Constipation
B. Polyuria
C. Rash
D. Muscle weakness
E. Tinnitus

Answer 29

B. Polyuria
D. Muscle weakness

Question 30

14- 4. A nurse is assisting with the admission of 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.”

Answer 30

D. “Current medications include furosemide for congestive heart failure.”

Question 31

14- 5. A nurse is discussing routine follow-up needs with a client who has a 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

Answer 31

A. AST/ALT and LDH

Question 32

15- 1. Determine which symptoms are is positive or negative symptoms of schizophrenia.

A. Hallucinations
B. Avolition
C. Alterations in speech
D. Delusions
E. Bizarre motor movements
F. Flat affect
G. Anhedonia
H. Anergia

Answer 32

Positive:
A. Hallucinations
C. Alterations in speech
D. Delusions
E. Bizarre motor movements

Negative:
B. Avolition
F. Flat affect
G. Anhedonia
H. Anergia

Question 33

15- 2. A nurse is speaking with a client who has schizophrenia when the client suddenly seems to stop focusing on the nurse’s questions and begins looking at the ceiling and talking to themselves. Which of the following actions should the nurse take?

A. Stop the interview at this point, and resume later when the client is better able to concentrate.
B. Ask the client, “Are you seeing something on the ceiling?”
C. Tell the client, “You seem to be looking at something on the ceiling.
I see something there, too.”
D. Continue the interview without commenting on the client’s behavior.

Answer 33

B. Ask the client, “Are you seeing something on the ceiling?”

Question 34

15- 3. A nurse is discussing manifestations of schizophrenia with a newly licensed nurse. Which of the following manifestations should the nurse identify as being effectively treated by first-generation antipsychotics? (Select all that apply.)

A. Auditory hallucinations
B. Withdrawal from social situations
C. Delusions of grandeur
D. Severe agitation
E. Anhedonia

Answer 34

A. Auditory hallucinations
C. Delusions of grandeur
D. Severe agitation

Question 35

15- 4. A nurse is caring for a client who is currently taking perphenazine. Which of the following findings should the nurse identify as an extrapyramidal symptom (EPS)? (Select all that apply.)

A. Decreased level of consciousness
B. Drooling
C. Involuntary arm movements
D. Urinary retention
E. Continual pacing

Answer 35

B. Drooling
C. Involuntary arm movements
E. Continual pacing

Question 36

15- 5. Determine which category each medication listed below belongs to: typical antipsychotics or atypical antipsychotics.

A. Risperidone
B. Haloperidol
C. Quetiapine
D. Loxapine
E. Olanzapine
F. Clozapine

Answer 36

Typical:
B. Haloperidol
D. Loxapine

Atypical:
A. Risperidone
C. Quetiapine
E. Olanzapine
F. Clozapine

Question 37

16- 1. 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

Answer 37

B. Splitting

Question 38

16- 2. A nurse is caring for a client who has avoidant personality disorder. Which of the following statements is expected from a client who has this type of personality disorder?

A. “I’m scared that you’re going to leave me.”
B. “I’ll go to group therapy if you’ll let me smoke.”
C. “I need to feel that everyone admires me.”
D. “I sometimes feel better if I cut myself.”

Answer 38

A. “I’m scared that you’re going to leave me.”

Question 39

16- 3. A nurse is assisting with a court-ordered evaluation of a client who has antisocial personality disorder. Which of the following findings should the nurse expect? (Select all that apply.)

A. Demonstrates extreme anxiety when placed in a social situation
B. Often engages in magical thinking
C. Attempts to convince other clients to relinquish their belongings
D. Becomes agitated if personal area is not neat and orderly
E. Blames others for personal past and current problems

Answer 39

C. Attempts to convince other clients to relinquish their belongings
E. Blames others for personal past and current problems

Question 40

16- 4. A nurse is assisting with the preparation of a staff education session on personality disorders.
Which of the following personality characteristics associated with all of the personality disorders should the nurse include? (Select all that apply.)

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

Answer 40

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

Question 41

16- 5. A nurse is discussing the care of a client who has a personality disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the discussion?

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.”

Answer 41

C. “I should practice limit-setting to help prevent client manipulation.”

Question 42

17- 1. A nurse is performing an admission assessment for a client who has delirium related to an acute urinary tract infection. Which of the following findings should the nurse expect? (Select all that apply.)

A. History of gradual memory loss
B. Family report of personality changes
C. Hallucinations
D. Unaltered level of consciousness
E. Restlessness

Answer 42

B. Family report of personality changes
C. Hallucinations
E. Restlessness

Question 43

17- 2. A nurse is caring for a client who has early-stage Alzheimer’s disease and a prescription for donepezil. The nurse should include which of the following statements when reinforcing teaching the client about the medication?

A. “You should avoid taking over-the-counter acetaminophen while on donepezil.”
B. “You should take this medication before going to bed at the end of the day.”
C. “You will be screened for underlying kidney disease prior to starting donepezil.”
D. “You should stop taking donepezil if you experience nausea or diarrhea.”

Answer 43

B. “You should take this medication before going to bed at the end of the day.”

Question 44

17- 3. A nurse in a long-term care facility is caring for a client who has major neurocognitive disorder and attempts to wander out of the building. The client states, “I have to get home.” Which of the following statements should the nurse make?

A. “You have forgotten that this is your home.”
B. “You cannot go outside without a staff member.”
C. “Why would you want to leave? Aren’t you happy with your care?”
D. “I am your nurse. Let’s walk together to your room.”

Answer 44

D. “I am your nurse. Let’s walk together to your room.”

Question 45

17- 4. A home health nurse is making a visit to a client who has Alzheimer’s disease to collect data regarding the home for safety. Which of the following suggestions should the nurse make to decrease the client’s risk for injury? (Select all that apply.)

A. Install extra locks at the top of exit doors.
B. Place rugs over electrical cords.
C. Put cleaning supplies on the top of a shelf.
D. Place the client’s mattress on the floor.
E. Install light fixtures above stairs.

Answer 45

A. Install extra locks at the top of exit doors.
D. Place the client’s mattress on the floor.
E. Install light fixtures above stairs.

Question 46

17- 5. A nurse is making a home visit to a client who is in the late stage of Alzheimer’s disease. The client’s partner, who is the primary caregiver, wishes to discuss concerns about the client’s nutrition and the stress of providing care. Which of the following actions should the nurse take?

A. Verify that a current power of attorney document is on file.
B. Instruct the client’s partner to offer finger foods to increase oral intake.
C. Provide information on resources for respite care.
D. Schedule the client for placement of an enteral feeding tube.

Answer 46

C. Provide information on resources for respite care.