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Mental Health Nursing: Assessment and Care, Exams of Nursing

Houston Community College SystemNursing

Answers to various mental health nursing scenarios, covering topics such as assessment, diagnosis, and intervention for clients with mental health conditions. It includes situations related to substance use, schizophrenia, depression, borderline personality disorder, and more.

Typology: Exams

2023/2024

Available from 04/12/2024

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ATI MENTAL HEALTH PRACTICE A
A nurse is assessing a client who recently used cocaine. Which of the following findings
should the nurse expect? - correct answer Hypertension
A nurse is caring for a group of clients. Which of the following findings should the nurse
report? - correct answer A client who is taking lamotrigine and has developed a rash
A nurse on a mental health unit is admitting a client who is anxious and tells the nurse,. "I
hear voices telling me what to do." Which of the following actions should the nurse take? -
correct answer Ask the client what the voices are saying.
A nurse is communicating with a client in an inpatient mental health facility. Which of the
following actions by the nurse demonstrates the use of active listening? - correct answer
Attention to body language
A client who has paranoid schizophrenia is attending a treatment planning conference with
a family member. During the discussion of the medication adherence portion of the plan, a
nurse notices that the family member seems distracted. Which of the following actions
should the nurse take? - correct answer Ask the family member if they have any thoughts
or questions about the treatment plan.
A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The
nurse should identify that which of the following findings indicates a potential psychiatric
emergency? - correct answer The client reports command hallucinations.
A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the
following medications should the nurse administer first? - correct answer Diazepam 5 mg
IV bolus
A nurse is reviewing the electronic medical record of a client who has schizophrenia and is
taking clozapine. Which of the following findings is the priority for the nurse to notify the
provider? - correct answer The client reports an inability to breathe easily.
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ATI MENTAL HEALTH PRACTICE A

A nurse is assessing a client who recently used cocaine. Which of the following findings should the nurse expect? - correct answer Hypertension A nurse is caring for a group of clients. Which of the following findings should the nurse report? - correct answer A client who is taking lamotrigine and has developed a rash A nurse on a mental health unit is admitting a client who is anxious and tells the nurse,. "I hear voices telling me what to do." Which of the following actions should the nurse take? - correct answer Ask the client what the voices are saying. A nurse is communicating with a client in an inpatient mental health facility. Which of the following actions by the nurse demonstrates the use of active listening? - correct answer Attention to body language A client who has paranoid schizophrenia is attending a treatment planning conference with a family member. During the discussion of the medication adherence portion of the plan, a nurse notices that the family member seems distracted. Which of the following actions should the nurse take? - correct answer Ask the family member if they have any thoughts or questions about the treatment plan. A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The nurse should identify that which of the following findings indicates a potential psychiatric emergency? - correct answer The client reports command hallucinations. A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse administer first? - correct answer Diazepam 5 mg IV bolus A nurse is reviewing the electronic medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to notify the provider? - correct answer The client reports an inability to breathe easily.

A nurse in a community health center is counseling a family of two parents and two children. Which of the following statements by a family member indicates manipulative behavior? - correct answer "If you do my homework for me, I won't bother you for the rest of the day." A nurse is caring for a client who has schizophrenia and began taking a conventional antipsychotic medication yesterday. Which of the following findings indicates the nurse should administer benztropine 2 mg IM? - correct answer Shuffling gait A nurse is delegating client care tasks to a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN? - correct answer Change the dressings of a client who has borderline personality disorder and superficial self-inflicted wounds. While observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors is consistent with this condition? - correct answer The client needs excessive external input to make everyday decisions. A nurse is planning care for a 7-year-old child who has ADHD. Which of the following interventions should the nurse identify as the priority? - correct answer Remove unnecessary equipment from the child's surroundings. A nurse in an outpatient mental health setting is collecting a health history from a client who is taking paroxetine for depression. The client reports to the nurse that he also takes herbal supplements. The nurse should advise the client that which of the following supplements interacts adversely with paroxetine? - correct answer St. John's wort A nurse is documenting admission assessment findings for a client who has major depressive disorder. The nurse should identify which of the following findings as clinical manifestations? (Select all that apply.) - correct answer Feelings of hopelessness Anhedonia Flat facial expression

A home health nurse is assessing an older adult client whose sibling is the primary caregiver. Which of the following findings should the nurse identify as a possible indicator of neglect? - correct answer Inappropriate dress A nurse is planning care for a client who has schizophrenia and reports auditory hallucinations. Which of the following interventions should the nurse include in the plan? - correct answer Promote the use of music to compete with the client's auditory hallucinations. A nurse is admitting a client who has alcohol use disorder. Which of the following statements by the client indicates that the client is using denial as a defense mechanism? - correct answer "I am able to go to work every day, so I don't have a problem." A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse identify as an indication the client requires hospitalization? - correct answer Total body fat 8.7% A client who has a diagnosis of depression is attending group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. When it is the client's turn, they do not respond. Which of the following actions should the nurse take before repeating the request to the client? - correct answer Allow the client time to formulate an answer. A community health nurse is planning an education program about depressive disorders. Which of the following factors should the nurse include as increasing the risk for depression? - correct answer Substance use disorder A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder. Which of the following strategies should the nurse use when communicating with this client? - correct answer Set realistic limits on the client's behavior. A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who weights 110 lb. Available is chlorpromazine syrup 10 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) - correct answer 14 mL

A nurse is planning care for an adolescent who is being admitted to an acute care unit following a suicide attempt. Which of the following interventions should the nurse identify as the priority? - correct answer Arrange one-to-one observation of the client. A nurse is caring for a client in a mental health facility. The nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse take? - correct answer Report the occurrence to the charge nurse. A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder? - correct answer Anhedonia A nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that they stopped taking lithium 2 weeks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the client to stop taking the medication? - correct answer Hand tremors A nurse is reviewing routine laboratory values for several clients who are taking lithium carbonate. Which of the following clients should the nurse assess further for flings indicating lithium toxicity? - correct answer A client who has a sodium level of 128 mEq/L A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding their admission, the client states, "I'm red, in the head, and I'm going to bed!" The nurse should document the client's speech pattern as which of the following? - correct answer Clang association A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? - correct answer A client was administered one-half of the prescribed dose of medication. A charge nurse is preparing an education session for a group of newly licensed nurses to review client rights under the law. Which of the following statements should the nurse make? - correct answer "In the event a client threatens harm to others, medications can be administered without consent."

A nurse is planning care for a client who is experiencing acute mania. Which of the following interventions should the nurse include in the plan to promote sleep? - correct answer Encourage frequent rest periods throughout the day. A nurse is caring for a client who has a history of substance use disorder and was involuntarily admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take? - correct answer Do not administer the lorazepam. A nurse in a clinic is assessing a client whose partner died 4 months ago. Which of the following statements indicates that the client is at risk for complicated grief? - correct answer "I feel so empty without my wife that it's hard to get up every morning." A nurse in a mental health clinic is planning care for a client who has a new prescription for olanzapine. Which of the following interventions should the nurse identify as the priority? - correct answer Instruct the client to avoid driving during initial therapy. A nurse in a provider's office is collecting a health history from the guardian of a school- age child who has been taking atomexetine. Which of the following adverse effects reported by the guardian is the priority for the nurse to report to the provider? - correct answer Dark urine During a client's initial interview in a mental health inpatient setting, a nurse identifies that the client is maintaining eye contact and leaning forward. Which of the following assumptions should the nurse make based on the client's nonverbal behaviors? - correct answer The client is interested in what the nurse is saying. A nurse is planning care for a client who has depression and has made frequent suicide attempts. Which of the following statements indicates the client has a decreased risk for suicide? - correct answer "It is easier to talk about my feelings now." A nurse is assessing a school-age child who has conduct disorder. Which of the following characteristics should the nurse expect the child to demonstrate? - correct answer Aggression toward animals

A nurse is caring for a client who has a recent diagnosis of mild Alzheimer's disease. The client's partner asks the nurse about expected manifestation. The nurse should teach the partner to expect which of the following manifestations to occur first? - correct answer Frequently misplaces objects A nurse in an emergency department is admitting a client who reports experiencing a headache and heart palpitations after having a glass of wine 1 hr ago. The client has a history of depression and a blood pressure of 210/105 mm Hg and temperature of 39.9 C (103.8 F). Which of the following actions should the nurse take first? - correct answer Determine the client's prescribed medication regimen. A nurse in a mental health facility is planning discharge for a client who has a history of alcohol use disorder. Which of the following post discharge activities should the nurse plan to include? - correct answer Attending a relapse prevention group several times each week A nurse is caring for a group of clients. Which of the following findings is the nurse required to report? - correct answer A client who has borderline personality disorder threatened to harm their roommate. A nurse is planning discharge for a client who has bipolar disorder and has a prescription for lithium. Which of the following client statements indicates understanding of the teaching about the medication? - correct answer "I should eat a regular diet with normal amounts of salt and fluids."