NGN ATI MENTAL HEALTH 2024
PROCTORED EXAM ACTUAL 170
QUESTIONS WITH DETAILED VERIFIED
ANSWERS AND RATIONALES /A+ GRADE
/BRAND NEW!!
A nurse is
... [Show More] 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?
1. Arrange one-to-one observation of the client
2. Encourage interaction with the client's peers
3. Administer medication for depressive disorder
4. Encourage the client to attend a support group -
....ANSWER...1. Arrange one-to-one observation of the
client
Rationale: The greatest risk to the client is self-injury.
Therefore, the priority nursing intervention is one-toone observation to promote client safety.
A nurse is caring for a client who gave birth to a
stillborn baby. Which of the following statements
should the nurse make?
1. "You probably want to hold your baby."
2. "I'll stay with you just in case you want to talk."
3. "I know how you must be feeling."
4. "It hurts now, but things will be better soon." -
....ANSWER...2. "I'll stay with you just in case you want
to talk."
Rationale: This response indicates the nurse's interest
in the client and a desire to understand the client's
feelings.
A nurse is providing teaching to a client who is to begin
undergoing light therapy at home to treat seasonal
affective disorder. Which of the following should the
nurse include in the teaching?
1. Have a family member present during treatment
2. Increase fluid intake
3. Change position slowly
4. Wear sunglasses when outdoors - ....ANSWER...4.
Wear sunglasses when outdoors.
Rationale: Light therapy, or phototherapy can cause
eye strain and sensitivity to light.
During morning rounds, a nurse finds a client who has
schizophrenia trembling and tearful in her bed. The
client reports that a bomb was placed in her room by a
family member during visiting hours. Which of the
following actions should the nurse take?
1. Ask the client to identify the bomb in the room
2. Initiate disaster protocols per facility policies and
procedures
3. Assess the client for evidence of a perceptual
disturbance
4. Convince the client that there is no bomb in her
room - ....ANSWER...3. Assess the client for evidence
of a perceptual disturbance
Rationale: The nurse should assess the situation to
determine if the client is hallucinating or misperceiving
external stimuli (experiencing illusions).
A nurse on a mental health unit is caring for a group of
clients. Which of the following actions by the nurse is
an example of the ethical principle of justice?
1. Allowing a client to choose which unit activities to
attend
2. Attempting alternative therapies instead of restraints
for a client who is combative
3. Providing a client with accurate information about
his prognosis
4. Spending adequate time with a client who is verbally
abusive - ....ANSWER...4. Spending adequate time
with a client who is verbally abusive
Rationale: By spending adequate time with a client
who is verbally abusive, the nurse is demonstrating the
ethical principle of justice. When the nurse spends an
appropriate amount of time with each client regardless
of their behavior and in keeping with their individual
needs, the nurse guarantees that all clients receive
equal care.
A client who has a recent diagnosis of bipolar disorder
is placed in a room with a client who has severe
depression. The client who has depression reports to
the nurse, "That man in my room never sleeps and he
keeps me up, too." Which of the following appropriate
action for the nurse to take?
1. Move the client who has bipolar disorder to a private
room
2. Administer sleep medication to the client who has
bipolar disorder
3. Move the client who has severe depression to a
private room
4. Administer sleep medication to the client who has
severe depression - ....ANSWER...1. Move the client
who has bipolar disorder to a private room
Rationale: Clients who have bipolar disorder can
disrupt the therapeutic milieu for other clients.
Therefore, the nurse should move this client to a
private room.
A nurse is assessing a client for risk factors for the
development of depression. The nurse should identify
that which of the following factors places the client at
an increased risk for depression?
1. The client is married
2. The client recently received a promotion at work
3. The client has COPD
4. The client is a male - ....ANSWER...3. The client has
COPD
Rationale: Clients who have a medical illness are at an
increased risk for the development of depression
A nurse is assessing a client who has borderline
personality disorder. Which of the following findings
should the nurse expect?
1. Emotional lability
2. Self-sacrificing
3. Suspicious of others
4. Grandiosity - ....ANSWER...1. Emotional lability
Rationale:Emotional lability is the rapid transition from
one emotion to another and is a primary feature of
borderline personality disorder. Clients who have
borderline personality disorder react to situations with
emotional responses that are out of proportion to the
circumstances.
A nurse in a mental health unit observes a client who
has acute mania hit another client. Which of the
following actions should the nurse take first?
1. Call the provider to obtain an immediate prescription
for restraint
2. Prepare to administer benzodiazepine IM
3. Call for a team of staff members to help with the
situation
4. Check the client who was hit for injuries -
....ANSWER...3. Call for a team of staff members to
help with the situation
Rationale: 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
himself or others.
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, she does not respond.
Which of the following actions should the nurse take
before repeating the request to the client?
1. Allow the client time to collect her thoughts
2. Prompt the client to give a response
3. Move on to the next client
4. Offer the client a suggestion for a goal -
....ANSWER...1. Allow the client time to collect her
thoughts
Rationale: Slowed response time is common in clients
who have depression. The nurse should allow the
client time to comprehend and formulate an answer to
the question
A nurse is assessing a client who has major
depressive disorder and has been receiving
amitriptyline for 1 week. Which of the following
outcomes should the nurse expect?
1. Rapid improvement in affect within 30 to 60 min
after taking the medication
2. Greater risk of attempting suicide as affect and
energy improve
3. Onset of frequent loose stools
4. Development of physiologic dependence on the
medication - ....ANSWER...2. Greater risk of
attempting suicide as affect and energy improve
Rationale: An initial response to amitriptyline can
develop in 1 week. For a client who has been severely
depressed with suicidal ideation, the energy to carry
out a plan is more possible after 1 week of treatment
A nurse is preparing to discharge an older adult client
who attempted suicide to his home where he lives
alone and has difficulty performing ADLs. Which of the
following referrals should the nurse initiate? (Select all
that apply)
1. Occupational therapy
2. Meal delivery services
3. Speech therapy
4. Physical therapy
5. Home health services - ....ANSWER...1.
Occupational therapy
2. Meal delivery services
4. Physical therapy
5. Home health services
Rationale: An occupational therapist can assist the [Show Less]