2019 ATI RN Mental Health Test Bank Version 1 to Version 3 With Answers (361 Solved Questions)

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HESI MENTAL HEALTH RN V1-V3 2019 TEST BANKS (ALL TOGETHER)A client with depression remains in bed most of the day, and declinesactivities. Which nursing problem has the greatest priority for this client?A. Loss of interest in diversional activity.B. Social isolation.C. Refusal to address nutritional needs.D. Low self-esteem.The RN is preparing medications for a client with bipolar disorder and noticesthat the client discontinued antipsychotic medication for several days. Whichmedication should also be discontinued?a. Lithium. (Lithotabs)b. Benzotropine (Cogentin).c.Alprazolam (Xanax).d. Magnesium (Milk of Magnesia).A female client requests that her husband be allowed to stay in the roomduring the admission assessment. When interviewing the client, the RN notesa discrepancy between the client’s verbal and nonverbal communication.What action does the RN take?A. Pay close attention and document the nonverbal messages.B. Ask the client’s husband to interpret the discrepancy.C. Ignore the nonverbal behavior and focus on the client’s verbalmessages.D. Integrate the verbal and nonverbal messages and interpret them asone.A male client approaches the RN with an angry expression on his face andraises his voice, saying “My roommate is the most selfish, self-centered,angry person I have ever met.If he loses his temper one more time with me,I am going to punch him out!” The RN recognizes that the client is usingwhich defense mechanism?A. Denial.B. Projection.C. Rationalization.D. Splitting.A male client with bipolar disorder who began taking lithium carbonate fivedays ago is complaining of excessive thirst, and the RN finds him attemptingto drink water from the bathroom sink faucet. Which intervention should theRN implement?

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A. Report the client’s serum lithium level to the HCP.B. Encourage the client to suck on hard candy to relieve the symptoms.C. No action is needed since polydipsia is a common side effect.D. Tell the client that drinking from the faucet is not allowed.The RN is teaching a client about the initiation of the prescribed abstinencetherapy using disulfiram (Antabuse). What information should the clientacknowledge understanding?A. Completely abstain from heroin or cocaine use.B. Remain alcohol free for 12 hours prior to the first dose.C. Attend monthly meetings of alcoholics anonymous.D. Admit to others that he is a substance user.A male client with schizophrenia is admitted to the mental health unit afterabruptly stopping his prescription for ziprasidone (Geodon) one month ago.Which question is most important for the RN to ask the client?A. Have you lost interest in the things that you used to enjoy?B. Is your ability to think or concentrate decreased?C. How many continuous hours do you sleep at night?D. Do you hear sounds or voices that others do not hear?During an annual physical by the occupational RN working in a corporateclinic, a male employee tells the RN that is high-stress job is causing troublein his personal life. He further explains that he often gets so angry whiledriving to and from work that he has considered “getting even” with otherdrivers. How should the RN respond?A. “Anger is contagious and could result in major confrontation.”B. “Try not to let your anger cause you to act impulsively.”C. “Expressing your anger to a stranger could result in an unsafe situation.”D. “It sounds as if there are many situations that make you feel angry.”A client who has agoraphobia (a fear of crowds) is beginning desensitizationwith the therapist, and the RN is reinforcing the process. Which interventionhas the highest priority for this client’s plan of care?A. Encourage substitution of positive thoughts and negative ones.B. Establish trust by providing a calm, safe environment.C. Progressively expose the client to larger crowds.D. Encourage deep breathing when anxiety escalates in a crowd.Which nursing actions are likely to help promote the self-esteem of a maleclient with modern depression?A. Ask the client what his long term goals are.

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B. Discuss the challenges of his medical condition.C. Include the client in determining treatment protocol.D. Encourage the client to engage in recreational therapy.E. Provide opportunities for the client to discuss his concerns.A male client is admitted to the psychiatric unit for recurrent negativesymptoms of chronic schizophrenia and medication adjustment ofRisperidone (Risperdal). When the client walks to the nurse’s station in alaterally contracted position, he states that something has made his bodycontort into a monster. What action should the RN take?A. Medicate the client with the prescribed antipsychotic thioridazine(Mellaril).B. Offer the client a prescribed physical therapy hot pack for muscle spasms.C. Direct client to occupational therapy to distract him from somaticcomplaints.D. Administer the prescribed anticholinergic benztropine (Cogentin) fordystonia.A mental health worker is caring for a client with escalating aggressivebehavior. Which action by the MHW warrant immediate intervention by theRN?A. Is attempting to physically restrain the patient.B. Tells the client to go to the quiet area of the unit.C. Is using a loid voice to talk to the client.D. Remains at a distance of 4 feet from the client.A client on the mental health unit is becoming more agitated, shouting at thestaff, and pacing in the hallway. When the PRN medication is offered, theclient refuses the medication and defiantly sits on the floor in the middle ofthe unit hallway. What nursing intervention should the RN implement first?A. Transport of the client to the seclusion room.B. Quietly approach the client with additional staff members.C. Take other clients in the area to the client lounge.D. Administer medication to chemically restrain the patient.A client is admitted to the mental health unit and reports taking extraantianxiety medication because, “I’m so stressed out. I just want to go tosleep.” The RN should plan one-on-one observation of the client based onwhich statement?A. “What should I do?Nothing seems to help.”B. “I have been so tired lately and needed to sleep.”

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C. “I really think that I don’t need to be here.”D. “I don’t want to walk.Nothing matters anymore.”A male hospital employee is pushed out the way by a female employeebecause of an oncoming gurney. The pushed employee becomes very angryand swings at the female employee. Both employees are referred forcounseling with the staff psychiatric RN. Which factor in the pushedemployee’s history is most related to the reaction that occurred?A. Is worried about losing his job to a woman.B. Tortured animals as a child.C. Was physically abused by his mother.D. Hates to be touched by anyone.The RN documents the mental status of a female client who has beenhospitalized for several days by court order. The client states, “I don’t needto be here” and tells the RN that she believes the television talks to her. TheRN should document these assessment findings in which section of themental status exam/A. Level of concentration.B. Insight and judgement.C. Remote memory.D. Mood and affect.A client is admitted to the mental health unit reports shortness of breath anddizziness. The client tells the RN, “I feel like I’m going to die”. Which nursingproblem should the RN include in this client’s plan of care?A. Mood disturbance.B. Moderate anxiety.C. Altered thoughts.D. Social isolation.A female client who is wearing dirty clothes and has foul body odor, comes tothe clinic reporting feeling scared because she is being stalked. What actionis most important for the RN to take?A. Offer the client a safe place to relax before interviewing her.B. Ask the client to describe why she is being stalked.C. Recommend that the client talk with a social worker.D. Assure the client that the HCP will see her today.The RN leading a group session of adolescent clients gives the members ahandout about anger management. One of the male clients is fidgety,interrupts peers when they try and talk, and talks about his pets at home.What nursing action is best for the RN to take?

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A. Explore the client’s feelings about his pets and home life.B. Encourage his peers to help involve him in the activity.C. Give the client permission to leave and return in 10 minutes.D. Redirect him by encouraging him to read from the handout.A male adolescent was admitted to the unit two days ago for depression.When the mental health RN tries to interview the client to establish rapport,he becomes very irritated and sarcastic. Which action is best for the RN totake?A. Report the behavior to the next shift.B. Offer to play a game of cards with the client.C. Document the behavior in the chart.D. Plan to talk with the client the next day.A male adult is admitted because of an acetaminophen (Tylenol) overdose.After transfer to the mental health unit, the client is told he has liverdamage. Which information is most important for the nurse to include in theclient's discharge plan?A. Do not take any over the counter meds.B. Eat a high carb, low fat, low protein diet.C. Call the crisis hotline if feeling lonely.D. Avoid exposure to large crowds.After receiving treatment for anorexia, a student asks the school RN forpermission to work in the school cafeteria as part of the school’s work studyprogram. What action should the RN take?A. Refer the student to a psychiatrist for further discussion.B. Recommend assignment to the receptionist’s office.C. Suggest that student work in the athletic department.D. Determine the parent’s opinion of the work assignment.The Rn accepts a transfer to the metal health unit and understands that theclient is distractible and is exhibiting a decreased ability to concentrate. TheRN only has 15 minutes to talk to the client. To develop treatment plan forthis client, which assessment is most important for the RN to obtain?A. Motivation of treatment.B. History of substance use.C. Medication compliance.D. Mental status examination.

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A male client who recently lost a loved one arrives at the mental healthcenter and tells the RN he is no longer interested is his usual activities andhas not slept for several days. Which priority nursing problem should the RNinclude in the client’s plan of care?A. Risk for suicide.B. Sleep deprivation.C. Situational low self-esteem.D. Social isolation.A male client with long history of alcohol dependency arrives in theemergency department describing the feelings of bugs crawling on his body.His blood pressure is 170/102, his pulse rate is 110 bpm, and is blood alcohollevel is 0mg/dL. Which prescription should the RN administer?A. Haloperidol (Haldol).B. Thiamine (Vitamin B1).C. Diphenhydramine (Benadryl).D. Lorazepam (Ativan).A client who refuses antipsychotic medications disrupts group activities, talkswith nonsensical words and wanders into client’s rooms. The RN decides thatthe client needs constant observation based on which of these assessmentfindings?A. Wanders into the clients rooms.B. Refuses antipsychotic medications.C. Talks with nonsensical words.D. Disrupts group activities.A client with schizophrenia explains that she has 20 children and then veryseriously points to the RN and explains that she is one of them. What is themost therapeutic response for the RN to provide/A. “Let’s go ask another RN is this is true.”B. “My name tag shows that I am a RN here.”C. “I can’t possibly be one if your children.”D. “I know that you don’t have 20 children.”

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A high school girl reveals to the high school RN that she has been engagingin self-induced vomiting as weight-control measure. Which initial assessmentshould the RN focus on with this adolescent?A. National percentile of weight and height.B. Frequency of bingeing and purging behaviors.C. Perceptions of family and social relationships.D. School grades and extracurricular activities.Narcan was administered to an adult client following a suicide attempt withan overdose of hydrocodone bitartrate (Vicodin). Within 15 minutes, theclient is alert and oriented. In planning nursing care, which intervention hasthe highest priority at this time?A.Encourage the client to increase fluid intake.B. Obtain the client’s serum Vicodin level.C. Observe the client for further narcotic effects.D. Determine the client’s reason for attempting suicide.Following surgery, a male client with antisocial personality disorderfrequently requests that a specific RN be assigned to is care and isbelligerent when another RN is assigned. What action should the charge RNimplement?A. Reassure the client that his request will be met whenever possible.B. Advise the client that assignments are not based on the client’srequest.C. Ask the client to explain why he constantly requests the RN.D. Encourage the client to verbalize his feelings about the RN.When preparing to administer a prescribed medication to a homeless male ata community clinic, the client tells the RN that he usually takes a differentdosage. What action should the RN take?A. Tell him to take the medication then verify the dosage at the nexthealthcare team meeting.B. Withhold the medication until the dosage can be confirmed.

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C. Inform him that he may refuse the medication and document whetheror not he takes it.D. Explain to the client that the dosage has been changed.The nurse orients a female client with depression to the new room on themental health unit. The client states “It seems strange that I don’t have a T.Vin my room.” Which statement would be best for the RN to provide?A. “You can watch T.V as much as you want outside of your room.”B. “Sometimes clients feel like the T.V is sending them messages.”C. “It’s important to be out of you room and talking to others.”D. “Watching T.V is a passive activity and we want you to be active.”A client admitted with a closed head injury after a fall has a blood alcohollevel of 0.28 (28%) and is difficult to arouse. Which intervention during thefirst 6 hours following admission should the RN identify as the priority?A. Give lorazepam (Ativan) PRN for signs of withdrawal.B. Administer disulfiram (Antabuse) immediately.C. Place in a side lying position with head of bed elevated.D. Provide thiamine and folate supplements as prescribed.The RN is completing the admission assessment of an underweightadolescent who is admitted to a psychiatric unit with a diagnosis ofdepression. Which finding requires notification to the HCP?A. Potassium level of 2.9 mEq/dl.B. Blood pressure of 110/70 mmHg.C. WBC of 10,000mm^3.D. Body mass index of 21.The Rn is planning client teaching for a 35-year-old client with alcoholiccirrhosis. Which self-care measure should the RN emphasize for the client’srecovery?A. Support group meetings.

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B. Vitamin B and multivitamin supplements.C. Diet with adequate calories and protein.D. Alcohol abstinence.A teenager has lost 20 pounds in the last three months is admitted to thehospital with hypotension and tachycardia. The client reports irregularmenses and hair loss. Which intervention is most important for the RN toinclude in the clients plan of care?A. Implement behavioral modification therapy.B. Initiate caloric and nutritional therapy.C. Evaluate the client for low self-esteem.D. Record daily weights and graft trend.While interviewing a client, the nurse takes notes to assist with accuratedocumentation later. Which statement is most accurate regarding note-taking during an interview?A. The client’s comfort level is increased when the RN breaks eye contactto take notes.B. The interview process is enhanced with note taking and allows theclient to speak at a normal pace.C. Taking notes during an interview is a legal obligation of examining RN.D. The RN’s ability to directly observe the client’s non-verbalcommunication is limited with note taking.A client is receiving substitution therapy during withdrawal frombenzodiazepines.Which expected outcome statement has the highestpriority when planning nursing care?a. Client will not demonstrate cross addiction.b. Co-dependent behaviors will be decreased.c.CNS stimulation will be reduced.d. Client's level of consciousness will increase.

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A client who is being treated with lithium carbonate for manic depressionbegins to develop diarrhea, vomiting, and drowsiness.What action shouldthe nurse take?a. Notify the physician immediately and force fluids.b. Prior to giving the next dose, notify the physician of thesymptoms.c.Record the symptoms and continue medication as prescribed.d. Hold the medication and refuse to administer additional amountsof the drug.While caring for an older client, the RN observes multiple bruises inOver the client’s legs, arms, back, and gluteal areas. When the clientContact, the RN suspects elder abuse. What action should the RN take?A. Report family conversations and anger towards the client whenvisiting.B. Ask the client specific questions about someone causing the bruising.C. Question the family members and caregiver how the bruising occurred.D. Measure and document size, shape and color of the bruised areas.The RN is performing intake interviews at a psychiatric clinic. A female clientwith a known history of drug abuse reports that she had a heart attack fouryears ago. Use of which substance places the client at highest risk formyocardial infarction?A. BenzodiazepineB. AlcoholC. MethamphetamineD. MarijuanaAfter receiving treatment for anorexia, a student asks the school RN forpermission to work in the school cafeteria as part of the school’s work studyprogram. What action should the RN take?A. Suggest that the student work in the athletic department.B. Determine the parent’s opinion of the work assignments.C. Refer the student to a psychiatrist for further discussion.D. Recommend assignment to the receptionist’s office.A client who is homeless is diagnosed with schizophrenia and admitted on aninvoluntary basis to a mental health hospital 4 days ago. The client stopped

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taking prescribed antipsychotic drugs approximately one month ago. Sincehospitalization the client continues to have poor judgment and refuses allmedications. What action should the RN take?A. Encourage the client to stay in the hospital so the client does not haveto be homeless.B. Provide the client with medication if the client presents an imminentrisk to self and others.C. Administer a long acting antipsychotic medication so that the clientcan be discharged to a shelter.D. Describe to the client treatment options provided at the communitymental health clinics.A male client comes to the emergency center because he has an erectionthat will not resolve. The client reports that he is taking trazodone (Desyrel)for insomnia. Which information is most important for the nurse ask theclient?A. When was the last time you drank alcoholic beverage?B. ou taken any medications for erectile dysfunction? Have yC. Are you having any other sexual dysfunctions or problems?D. Do you have a history of angina or high blood pressure?On admission to the mental health unit, a client diagnosed withschizophrenia tells the RN that he is the son of god. Based on this statement,which intervention should the RN include in this client’s plan of care?A. Lead the client by his arm to the seclusion room.B. Ensure the client’s environment is safe.C. Schedule activity therapy twice a week.D. Confront his delusion as not consistent with reality.The RN on the day shift receive report about a client with depression whowas in bed most of the weekend. The RN walks into the client’s room in themorning and finds the client in bed. What intervention is best for the RN toimplement?A. Monitor the client’s appetite and pattern of sleep.B. Assess the client’s feelings about the hospital stay.C. Assist the client to get out of bed and involved in an activity.D. Explain that staff will check on the client every 30 minutes.Which client information indicates the need for the RN to use CAGEquestionnaire during the admission interview?

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A. Client’s medication history includes the frequent use ofantidepressants.B. Describe self as a social drinker who drinks alcoholic beverages daily.C. Reports difficulties with short term memory since traumatic braininjury.D. Medical history includes that the client was recently sexually assaulted.A female client admitted to the mental health unit starts to shout and screamat the RN. What is the best approach for the RN to take?A. Stay quietly with the patientB. Tell her that she is out of control.C. Distract her by offering her finger foods.D. Ignore the client’s acting out behavior.A woman is brought to the psychiatric clinic by her husband. He reports thathis wife is reluctant to leave home because of what she describes as a fear ofopen places and crowds. Which nursing problem applies to this client’sbehavior?A. Ineffective protection to guard self from internal or external threats.B. Risk for injury related to inability to communicate.C. Risk prone health behavior related to self-esteem assault.D. Anxiety related to real or perceived threat to physical integrity.A client is receiving benztropine mesylate (Cogentin) for drug-inducedextrapyramidal syndrome (EPS). Which finding indicates that the RN shouldfurther evaluate the client?A. Decreased bowel movements.B. Presence of a dry mouth.C. Decreasing hand tremors.D. Increased mouth movements.A male client in the mental health unit is guarded and vaguely answers thenurse’s questions. He isolates in his room and sometimes opens the door topeek into the hall. Which problem can the RN anticipate?A. Visual hallucinations.B. Auditory hallucinations.C. Excessive motor activity.D. Delusions of persecution.

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A female client with obsessive compulsive personality disorder is admitted tothe hospital for a cardiac catheterization. The afternoon before theprocedure, the client begins to keep detailed notes of the nursing care she isreceiving, and reports her findings to the RN at bedtime. What action shouldthe nurse implement?A. Explain to the client that her behavior invades the rights of the nursingstaff.B. Ask the client to explain why she is keeping a detailed record of hernursing care.C. Teach the client strategies to control her obsessive compulsivebehavior.D. Encourage the client to express her feelings regarding the upcomingprocedure.During admission to the psychiatric unit, a female client is extremely anxiousand states that she is worried about the sun coming up the next day. Whatintervention is most important for the RN to implement during the admissionprocess?A. Assist the client in developing alternative coping skills.B. Remain calm and use a matter of fact approach.C. Ask the client why she is so anxiousD. Administer a PRN sedative to help relieve her anxiety.A female client is brought to the emergency department after police officersfound her disoriented, disorganized, and confused. The RN also determinesthat the client is homeless and is exhibiting suspiciousness. The client’s planof care should include what priority problem?A. Acute confusion.B. Ineffective community copingC. Disturbed sensory perception.D. Self-care deficit.The occupational health nurse is working with a female employee who wasjust notified that her child was involved in a MVA and taken to the hospital.The employee states, “I can’t believe this. What should I do?” Whichresponse is best for the RN to provide in this crisis?A. Tell me what you think should happen.B. How serious was the collision?C. What do you think you should do?

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D. Call for transportation to the hospital.A client tells the RN that he has an IQ of 400+ and is a genius and aninventor. He also reports that he is married to a female movie star and thinksthat his brother wants a sexual relationship with her. What is the prioritynursing problem for admission to the psychiatric unit?A. Ineffective sexual patterns.B. Impaired environmental interpretation.C. Disturbed sensory perception.D. Compromised family coping.The RN is providing care for a client diagnosed with borderline personalitydisorder who has self-inflicted lacerations on the abdomen. Which approachshould the RN use when changing this client’s dressing?A. Provide detailed thorough explanations when cleansing wound.B. Perform the dressing change in a non-judgmental manner.C. Ask in a non-threatening manner why the client cut own abdomen.D. Request another staff member assist with the dressing change.While sitting in the day room of the mental health unit, a male adolescentavoids eye contact, looks at the floor, and talks softly when interactingverbally with the RN. The two trade places, and the RN demonstrates theclient’s behaviors. What is the main goal of this therapeutic technique?A. Initiate a non-threatening conversation with the client.B. Dialog about the ineffectiveness of his interactions.C. Allow the client to identify the way he interacts.D. Discuss the client’s feelings when he responds.An antidepressant medication is prescribed for a client who reports sleepingonly 4 hours in the past 2 days and weight loss of 9 lbs within the last month.Which client goal is most important to achieve within the first three days oftreatment?A. Meet scheduled appointment with dietitian.B. Sleep at least 6 hours a night.C. Understands the purpose of the medication regimen.D. Describes the reasons for hospitalization.When preparing to administer to domestic violence screening tool to afemale client, which statement should the RN provide?A. If your partner is abusing you, I need to ask these questions.B. State law mandates that I ask if you are a victim of domestic violence.

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C. The HCP provider needs to know if you are experiencing any domesticabuse.D. All clients are screened for domestic abuse because it is common inour society.A young adult female visits the mental health clinic complaining of diarrhea,headache, and muscle aches. She is afebrile, denies chills, and all laboratoryfindings are within normal limits. During the physical assessment, the clienttells the RN that her sister thinks she is neurotic and calls her ahypochondriac. Which response is best for the RN to provide?A. Unless your sister has a medical education, ignore her comments.B. I can hear that your sister comments are over-whelming you.C. Do you think it’s possible that you might be a hypochondriac?D. Besides your sister’s comments, what in your life is troubling you?The RN is leading a group on the inpatient psychiatric unit. Which approachshould the RN use during the working phase of group development?A. Establishing a rapport with group members.B. Clarifying the nurse’s role and clients’ responsibilities.C. Discussing ways to use new coping skills learned.D. Helping clients identify areas of problem in their lives.A male client with schizophrenia is demonstrating echolalia, which isbecoming annoying to other clients on the unit. What intervention is best forthe RN to implement?A. Isolate the client from the other clients.B. Administer PRN sedative.C. Avoid recognizing the behavior.D. Escort the client to his room.A client is admitted for bipolar disorder and alcohol withdrawal, depressivephase. Based on which assessment finding will the RN withhold the clonidine(Catapres) prescription?A. Blood pressure readings of 90/62 mmHg to 92/58 mmHg.B. Pulse rate of 68-78 BPM.C. Temperature of 99.5-99.7 F.

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