ATI RN MENTAL HEALTH RETAKE 2025

Nurses' Notes

Admission:25-year-old client admitted with positive symptoms of schizophrenia. Client has a history of substance use, anxiety, and depression. Client demonstrates alterations in speech and persecutory delusions. Client states that they hear voices that are warning them of danger and that they should stay away from a coworker because the coworker is conspiring against them.

Day 5 - Discharge:No delusions or hallucinations noted. Speech is clear and coherent. Client has a well-groomed appearance. Group and individual therapy attended daily.

A nurse is caring for a client who has schizophrenia and is preparing for discharge.ExhibitsThe nurse is providing discharge teaching to the client. Which of the following information should the nurse include when educating the client about relapse prevention? Select all that apply.

-Ask a trusted person to watch for manifestations of illness.

-Notify your provider within 48 hr of manifestations of a relapse.

-Go for a walk to decrease anxiety during times of increased stress.

-Report any adverse effects of the medication to the provider immediately.

A nurse is caring for a client who has cocaine use disorder. Which of the following manifestations should the nurse expect the client to have during withdrawal?

Fatigue

A nurse is caring for a client who is in the emergency department.

1400:34-year-old client admitted to the emergency department with contusions to the face, arms, and abdomen.

1500:Bruises noted in various stages of healing to the face, bilateral arms, and abdomen. Client grimaces and moans with movement. Laceration to the left cheek cleansed and covered with an adhesive bandage. Left shoulder cleansed, antiseptic ointment applied, and covered with gauze dressing. States, “I fell getting out of the shower and scraped my face and shoulder on the bathroom counter. I tried to catch myself when I fell and that is how I fractured my arm.” Client is very tearful, does not make eye contact, and only speaks when spoken to. Client requests not to notify their partner because they do not want them to have to miss work or worry.

X-ray: Spiral fracture to the left arm

-Ask the client if they have been hit, slapped, or kicked within the past year.

-Ask the client to clarify the circumstances of their injuries.

-Discuss with the client the factors that precipitate violence.

A nurse is reviewing the medical records for a group of clients prior to administering the clients medications for which of the following clients should the nurse withhold the prescribed medication and notify the provider?

A client who is taking Fluoxetine and exhibits muscle rigidity and tachycardia

A nurse in an inpatient mental health facility is caring for a client who is showing indications of becoming violent which of the following actions should the nurse take?

Offer the client several options for a time out period

A nurse is discussing with the newly licensed nurse the mental health resources available to meet the needs of a client who has schizoaffective disorder,no transportation and lives at home with their parents which of the following resources should the nurse identify as meeting I need to order client.

Assertive Community Treatment

The nurse is assisting a provider in obtaining informed consent from a client who has depressive disorder and is scheduled to have electroconvulsive therapy the signature of the nurse on the consent form indicates which of the following?

The nurse has witnessed the client's signature on the form

The nurse is caring for a client who refuses to attend group therapy which of the following statements should the nurse make?

You have the right to refuse to attend groups therapy

A nurse is preparing to administer methylphenidate 25 mg PO to a school age child who has ADHD available is methylphenidate 10 Mg/5 ml liquid how many mL should the nurse administer? ( Round the answer to the nearest tenth. using a leading 0 if it applies. do not use a trailing 0)

12.5 mL

A nurse is caring for a client who has a substance use disorder. the client states" the state took my child away after my overdose I don't want to go on living without them". which of the following therapeutic responses should the nurse make?

Have you thought about harming yourself?

A nurse is giving a presentation about intimate partner abuse for a community group. Which of the following statements by a group member indicates an understanding of the teaching?

Survivors of abuse often feel guilty

A nurse is assessing a client who has paranoid personality disorder. Which of the following findings should the nurse expect?

Believes that others are deceiving her

A nurse is caring for a client who has alcohol use disorder. Which of the following statements made by the client indicates the client has a support system?

"I have a sibling who attends AI-Anon"

A nurse on a mental health unit is preparing an in-service about ethical concepts when providing client care. Which of the following definitions should the nurse include when discussing advocacy?

Helping a client fulfill a need that they are unable to complete independently.

A nurse is performing a home visit on a client who has Alzheimer's disease and their partner. The partner states "I wish I had some time to myself and run errands but I need to be here all the time. "Which of the following referrals should the nurse recommend to the client's partner?

Respite care

A nurse is caring for a client who has severe depression and is scheduled to receive electroconvulsive therapy. The nurse should recognize that the client will receive succinylcholine to prevent which of the following adverse effects?

Muscle Distress

A nurse is caring for a client who has a personality disorder. Which of the following statements made by the client indicate they are coping with the maladaptive defense mechanism of displacement?

The night shift nurse is terrible

A nurse is teaching the family of a client who has Alzheimer's disease about safety interventions of nighttime wandering. Which of the following interventions should the nurse include?

Install locks at the bottom of the exit

A nurse is caring for a client who is in physical restraints. Which of the following actions should the nurse take?

Document the interventions used before applying restraints

A nurse is assessing a client following treatment for serotonin syndrome caused by an antidepressant medication. Which of the following findings indicates the treatment has been effective?

Decrease in blood pressure

A nurse is caring for a client who is newly admitted for the treatment of anorexia nervosa. Which of the following actions should the nurse plan to take?

Stay with the client for 15 minutes following meals

A nurse is caring for a client who is seeking treatment for gambling disorder. The clients states "I have gambled away all of my savings. I don't know what I am going to do. "which of the following statements should the nurse make?

"cognitive behavioral therapy can help you confront the beliefs you have about gambling"

A nurse is caring for a client who has a recent diagnosis of alcohol use disorder. Which of the following statements made by the client indicates acceptance of the diagnosis?

My family has a history of alcohol use disorder

A nurse is assessing a client who has post-traumatic stress disorder. Which of the following findings should the nurse expect? (sata)

-has difficulty concentrating on set tasks

-holds persistent negative beliefs about self

-difficulty falling or staying asleep

Nurses' Notes2000:Client presents to the triage desk accompanied by a friend. The client appears anxious and tearful and states, "I need help. I think I was sexually assaulted when I left a restaurant and walked back to my car." The client’s friend states, "I think they may have been drugged."

Allergies: penicillin, doxycycline

Physical examination:

General: exhibits anxiety

Respiratory: breath sounds clear

Cardiovascular: S1, S2, no murmur

Abdomen: soft, mildly tender

A nurse is caring for a client in the emergency department (ED).

Vital Signs:

Blood pressure: 128/88 mm Hg

Heart rate: 80/min

Respiratory rate: 16/min

Temperature: 37° C (98.6° F)

Weight: 67.1 kg (147.9 lb)

Laboratory Results:

2030:Urine drug screen:Gamma-hydroxybutyric acid (GHB): positive(Negative)

The nurse should identify the client’s Fingernail Assessment and Diagnostic result are consistent with sexual assault.

2000:Client presents to the triage desk accompanied by a friend. The client appears anxious and tearful and states, "I need help. I think I was sexually assaulted when I left a restaurant and walked back to my car."The client's friend states, "I think they may have been drugged."

Allergies:

Penicillin

Doxycycline

Physical Examination:

General: exhibits anxiety

Respiratory: breath sounds clear

Cardiovascular: S1, S2, no murmur

Abdomen: soft, mildly tender

Skin: bruising to upper arms bilaterally, broken fingernails

Question:

The nurse is continuing to care for the client in the emergency department (ED).ExhibitsThe nurse should monitor the client for which of the following based on the result of the client's laboratory test?

-Amnesia

-Nausea and Vomiting

-Respiratory Depression

2000:Client presents to the triage desk accompanied by a friend. The client appears anxious and tearful and states, "I need help. I think I was sexually assaulted when I left a restaurant and walked back to my car."The client's friend states, "I think they may have been drugged."

The nurse is continuing to care for the client in the emergency department (ED) Exhibits Which of the following actions should the nurse take?

Determine the client's level of anxiety to check for the risk of self harm

2000:Client presents to the triage desk accompanied by a friend. The client appears anxious and tearful and states, "I need help. I think I was sexually assaulted when I left a restaurant and walked back to my car."The client's friend states, "I think they may have been drugged."

Based on assessment findings which of the following actions should the nurse take? SATA

-Offer emergency contraception

-Collect and preserve evidence

-Administer sexually transmitted infections prophylaxis

Nurses' Notes

2000:

Client presents to the triage desk accompanied by a friend. The client appears anxious and tearful and states, "I need help. I think I was sexually assaulted when I left a restaurant and walked back to my car." The client's friend states, "I think they may have been drugged."

Allergies: penicillin, doxycycline

Physical examination:

General: exhibits anxiety

Respiratory: breath sounds clear

Cardiovascular: S1, S2, no murmur

Abdomen: soft, mildly tender

A nurse is caring for a client in the emergency department (ED). (Item 1/6)

Vital Signs:

Blood pressure: 128/88 mm Hg

Heart rate: 80/min

Respiratory rate: 16/min

Temperature: 37° C (98.6° F)

Weight: 67.1 kg (147.9 lb)

Laboratory Results:

2030:

Urine drug screen:

Gamma-hydroxybutyric acid (GHB): positive

(Negative)

The nurse should ( clarify the antibiotic prescription with the provider) due to the (client’s penicillin allergy)

A nurse is assessing the client 2 months after the assault.

Exhibits

Based on the provider's diagnosis which of the following client manifestations should the nurse expect?

Select the 4 potential findings the nurse should expect.

-irritability

-feelings of emptiness

-sleep disturbance

-guilt

A nurse is caring for a client who lost their child 6 months ago. The client states "not only do I miss my child but I also feel so distant from my partner" Which of the following responses should the nurse make?

Attending a support group may help both you and your partner

A nurse is caring for a client who has dementia. Which of the following actions should the nurse take?

Use symbols to assist the client in finding personal items

A nurse is evaluating the effect of a support group on a client who is experiencing prolonged grieving. Which of the following statements by the clients indicates the support group is effective?

I haven't been feeling angry all the time

A nurse is teaching a group of clients about the effects of various substances. Which of the following statements by a client indicates an understanding of the teaching?

Nicotine causes an increase in blood pressure

A nurse is assessing a client who has Alzheimer's disease. Which of the following findings should the nurse identify as the priority?

The client's engages in wandering

A nurse is supervising a group of staff members on a mental health unit. Which of the following actions require the nurse to complete an incident report?

An assistive personnel applies physical restraints on a client who bis aggressive

A nurse in an outpatient mental health clinic is assessing a new client. Which of the following findings should the nurse immediately report to the provider?

the client is experiencing command hallucinations

A nurse is developing a plan of care for a school aged child who has ADHD. Which of the following interventions should the nurse include in the plan?

Encourage thought stopping techniques

A nurse is teaching a client about the use of cognitive reframing for stress management. Which of the following statements by the client indicates an understanding of the teaching?

I will practice replacing negative thoughts with positive self-statements

A nurse in an emergency department is caring for a client following a domestic dispute. The client states "nothing seems to go right for me and probably never will." Which of the following statements should the nurse make?

Are you thinking of harming yourself?

A nurse is planning care for a client who has a gambling disorder. Which of the following actions should the nurse include in the plan of care?

encourage the client to participate in a self-help group

A nurse is caring for a client who has admitted for alcohol disorder which of the following findings require follow-up by the nurse? SATA

-client's recent loss

-client's recent consumption of alcohol

-gastrointestinal assessment

-neurological assessment

-blood alcohol level

History & Physical

Neurological: Client is intoxicated, has slurred speech, and is unable to coherently respond to questions.Cardiovascular: Normal sinus rhythm and pulses palpable. No history of heart disease.Respiratory: Chest clear to auscultation and no shortness of breath noted. No history of respiratory disorders and client states they quit smoking over 20 years ago.Gastrointestinal: Client reports weight loss over the past 3 months and minimal appetite.Genitourinary: Client reports no known problems.

Client brought in by a family member who states that the client has been drinking "nonstop since the death of the client's parents 3 months ago." Client has a history of alcohol use disorder for over 20 years. Client attended inpatient rehabilitation program 5 years ago and remained sober until several months ago when both parents died.

The client is at risk of developing ALCOHOL WITHDRAWAL SYNDROME as evidenced by the client’s BLOOD ALCOHOL LEVEL OF 310 mg/dL

Part of Exhibit:

A nurse is caring for a client who is at risk for alcohol withdrawal. Click to highlight the manifestations of alcohol withdrawal that require immediate follow-up by the nurse. To deselect a finding click on the finding again.

-seizures

-increased blood pressure

-increased heart rate

-diaphoresis

-vomiting

-tremulousness

Part of exhibit

A nurse is planning care for a client who has alcohol use disorder. For each potential provider's prescription click to specify if the potential prescription is anticipated or contraindicated for the client.

ANTICIPATED

-Diazepam 10 mg PO 3x a day

-Perform Alcohol use Disorders Identifications Test (AUDIT)

-Group therapy

-Complete blood count and basic metabolic profile

-Nutritional consult

-Propranolol 40 mg PO twice a day

CONTRAINDICATED

-Schedule electroconvulsive therapy (ECT)

-Methadone 40 mg PO daily

Part of Exhibit

Complete the following sentence by using the lists of options

the nurse should first ADMINISTER METOCLOPRAMIDE 10 MG IM Followed by ADMINISTER DIAZEPAM 10 mg PO

Client brought in by a family member who states that the client has been drinking "nonstop since the death of the client's parents 3 months ago."

Client has a history of alcohol use disorder for over 20 years.

Client attended inpatient rehabilitation program 5 years ago and remained sober until several months ago when both parents died.

According to the client's family member, the client has been unable to cope with the sudden death of their parents.

Client is currently unemployed after being laid off.

A nurse is reviewing the day 5 vital signs and nurses' notes.

Exhibits

A nurse is evaluating the client's response to treatment.

Select the 4 findings that indicate the client is progressing with their plan of care.

A. Vital signs

B. Cognition

E. Movement through the stages of grief

F. Participation in group therapy

A nurse in a mental health facility is caring for a newldy admitted client. Which of the following resources should the nurse recommend to help the client adapt to the health care setting?

A community meeting

A nurse is caring for a client who has been placed in restraints. Which of the following actions should the nurse take?

Observe the client's behavior once every 15 min

A nurse is providing teaching to a client who has depressive disorder and a new prescription for doxepin. Which of the following instructions should the nurse include in the teaching?

Sit on the side of the bed for a few minutes before standing

A nurse is working with a client who is the caregiver of a family member who has a serious mental illness. Which of the following statements by the client indicate acceptance of the role change?

I would like to have information about support groups

A charge nurse in an emergency department isa assigning tasks. Which of the following tasks should the nurse delegate to an assistive personnel?

Transfer a client who has delirium from a bed to a wheelchair

A nurse in the emergency department is caring for a client who is exhibiting manifestations of a panic level of anxiety. Which of the following interventions should the nurse initiate?

Guide the client to a location that is quiet and stay with the client

A nurse is planning care for a school aged child who has autism spectrum disorder and is nonverbal. Which of the following interventions should the nurse include in the plan of care?

Provide positive reinforcement when the child uses eye contact

A charge nurse on a mental health unit is preparing an in-service about client rights for staff members. Which of the following information should the nurse include?

Client can refuse to attend group therapy

A nurse at a community health center is preparing a presentation on alcohol use disorder. Which of the following risk factors should the nurse include in the presentation?

Genetic predisposition

A nurse in a provider's office is assessing a client who has dementia. Which of the following findings should the nurse expect?

Difficulty finding words

A nurse in alcohol treatment facility is caring for a client who states My job is so stressful that the only way I can cope is to drink should recognize that the client is displaying which of the following defense mechanisms? (THIS IS IN THE EXAM)

Rationalization

A nurse is caring fir a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? SATA ((THIS IS IN THE EXAM)

-Talk to the client using short simple sentences

-Identify the client's stressors

A nurse is caring for a client who reports difficulty coping with several recent stressors. Which of the following responses should the nurse take?

Tell me about your support system

A nurse is caring for a client who has dementia and is experiencing disorientation. Which of the following actions should the nurse take?

Approach the client from the front

A nurse is reviewing the medical record of a client who has a new prescription for Selegiline transdermal. Which part of the following findings should the nurse identify as a contraindication for administration of this medication to the client?

Takes St. John Wort daily

A nurse is planning care for a client who ahs acute delirium. Which of the following instructions should the nurse include in the plan?

Reinforce the client's orientation with a calendar

A nurse in an emergency department is caring for a client following and assault. Which of the following actions should the nurse take first?

Determine if the client is experiencing thoughts of self-harm

A nurse in a long term care facility is caring for a client who has dementia and reports difficulty falling asleep at night. Which of the following actions should the nurse take to promote adequate rest?

Schedule the client for a morning group fitness class at the facility

A client presents to the emergency department with a family member for concerns about the client's mental health. The client's partner states the client has had a deterioration in memory and job performance over the last few months. The client's partner states the client "keeps telling me their deceased grandparent is sending them messages."

The nurse notes that the client has pressured speech and motor agitation. Client pacing and restless.

1500:Client becoming more aggressive and agitated. Provider notified.

Nurse’s Notes (1800 and Today, 1000)

1800:The client is admitted to the inpatient psychiatric unit for an acute schizophrenic episode.

Today, 1000:The client reports a dry mouth and “blurry vision.” The client states, “I just feel terrible.”

The nurse identifies the clients HEART RATE and TEMPERATURE can indicate a life-threatening reaction to the client’s scheduled medication.

A nurse is leading a group therapy session. A client with a history of violence stands up and appears angry. Which of the following actions should the nurse take?

Ask the client to describe how they are feeling

Nurses Notes - Plan of Care

2 weeks ago, 1300:Client is a 19-year-old student requesting the form to participate in a sport on the college campus. Client states the form is a waste of time because of having extreme talent in the sport, and the team would benefit from their participation; expects to be drafted to play for a national team while still in college and says team members are going to be envious of their abilities. Physical form completed.

Today:Client experienced an injury while participating in a team sport coming to the student health clinic to be cleared before continued participation. Client states other team members are jealous of the client's abilities and wanted them to be injured;

A nurse in the student health clinic is caring for a client

ExhibitsComplete the following sentence by using the lists of options.

The nurse should care for the client by REMAINING NEUTRAL and EXPLAINING THAT THE CLIENT IS NOT ENTITLED TO PLAY ON A PROFESSIONAL TEAM

Nurses' NotesClient appears irritable and restless. Client is fidgeting in chair, tapping foot, and biting fingernails during intake interview. Seems preoccupied and questions must be repeated before they are acknowledged and answered by client.

Client acknowledges they like "nice" clothes, prides themselves on "looking fit,"

Vital Signs

BP: 118/76 mm Hg

Temperature: 36.9° C (98.4° F)

Heart rate: 116/min

Respiratory rate: 24/min

A nurse is caring for a client who was recently admitted.

ExhibitsComplete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Actions to Take

Encourage the client to problem solve.

Encourage the client to engage in physical activity.

Potential Condition

Moderate anxiety

Parameters to Monitor

Ability to focus on the task at hand

Heart rate