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ATI RN COMMUNITY HEALTH PROCTORED EXAM || 2025 -
2026|| 3 VERSIONS WITH NGN QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES||A+ GRADE
A nurse working on an acute mental health unit is caring for a client who has 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-A, C, & D. RATIONALE : Manifestations of PTSD include the inability to concentrate, feeling guilty and having a negative self-image, and recurring nightmares. Clients avoid talking about the event and are hyper vigilant. A nurse is involved in 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) * Answer- A. Avoid thinking about the incident when it is over * Answer- B. Take breaks during the incident for food and water * Answer- D. Hold emotions in check in the days following the incident * Answer- F. Take advantage of offered counseling * Answer-B, C, & E. RATIONALE :Taking breaks for food and water, debriefing after the event, and taking advantage of counseling can help prevent development of a trauma-related disorder. A nurse is collecting an admission history for a client who has acute stress disorder (ASD). Which of the following information should the nurse expect to collect? A. The client remembers many details about the traumatic incident B. The client expresses heightened elation about what is happening
C. The client states he first noticed manifestations of the disorder 6 weeks after the traumatic incident occurred. D. The client expresses a sense of unreality about the traumatic event * Answer-D. RATIONALE : The client who has ASD often expresses dissociative manifestations regarding the event, which includes a sense of unreality. Clients with ASD are usually unable to remember details about the incident and react with negative emotions and manifestations occur immediately to a few days following the event. 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? * Answer- A. The client explains that her body seems to be floating above the ground * Answer- B. The client has the idea that someone is trying to kill her and steal her money * Answer- D. The client cannot recall anything that happened during the past 2 weeks
- Answer-C. RATIONALE :Stating that one's surroundings are far away or unreal in some way is an example of derealization. A is depersonalization. B is a paranoid delusion. D is amnesia. 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? * Answer- A. Teach the client to recognize how stress brings on a personality change in the client * Answer- B. Repeatedly present the client with information about past events * Answer- C. Make decisions for the client regarding routine daily activities * Answer- D. Work with the client on grounding techniques * Answer-D. RATIONALE : Grounding techniques are useful for client who have a dissociate disorder and are experiencing manifestations of derealization. A is best for dissociative identity disorder. Flooding should be avoided to decrease anxiety. The nurse should encourage the client to make his own decisions.
A nurse working in an outpatient clinic is providing teaching to a client who has a new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following statements by the client indicates understanding of the teaching? * Answer- A. "I can expect my problems with PMDD to be worst when I'm menstruating." * Answer- C. "I am aware that my PMDD causes me to have rapid mood swings." * Answer- E. "I should increase my caloric intake with a nutritional supplement when my PMDD is active." * Answer-C. RATIONALE :A clinical finding of PMDD is emotional lability. Clinical findings of PMDD are present during the luteal phase of the menstrual cycle just prior to menses. Light therapy is best for SAD. PMDD increases the risk for weight gain due to overeating so the client should not increase her caloric intake. A charge nurse is discussing the care of a client who has MDD with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? * Answer- A. "Care during the continuation phase focuses on treating continued manifestations of MDD." * Answer- B. "The treatment of MDD during the maintenance phase lasts for 6- 12 weeks." * Answer- C. "The client is at greatest risk for suicide during the first weeks of an MDD episode." * Answer- D. "Medication and psychotherapy are most effective during the acute phase of MDD." *** Answer-C. RATIONALE** :The client is at greatest risk for suicide during the acute phase of MDD. Care in the continuation phase focuses on relapse prevention. The maintenance phase of treatment can last for a year or more. Med therapy and psychotherapy are used during the continuation phase. A nurse is interviewing a 25-year-old client who has a new diagnosis of dysthymic disorder. Which of the following findings should the nurse expect? * Answer-
A. Wide fluctuations of mood * Answer- C. Presence of manifestations for at least 2 years * Answer- E. Inflated sense of self-esteem * Answer-C. RATIONALE :Manifestations of dysthymic disorder last for at least 2 years in adults. A occurs in bipolar disorder. B occurs with MDD. Dysthymic disorder causes a decreased self-esteem. Rapid cycling * Answer-Four or more episodes of hypomania or acute mania within 1 year Bipolar I * Answer- Bipolar II * Answer- Cyclothymic disorder * Answer-In BI the client has at least one episode of mania alternating with major depression. In BII the client has one or more hypomanic episodes alternating with major depressive disorders. In cyclothymic disorder the client has at least 2 years of repeated hypomanic manifestations that do not meet the criteria for hypomanic episodes alternating with minor depressive episodes. Mood Disorders Questionnaire * Answer-A standardized tool that places mood progression on a continuum from hypomania (euphoria) to acute mania (extreme irritability and hyperactivity) to delirious mania (completely out of touch with reality) A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse include in the plan of care? (Select all that apply) * Answer-
C. "I can request that your case manager discuss appropriate charity options with you." * Answer- D. "You should know that giving away your money is inappropriate." * Answer-B. This statement is matter of fact and concise and is a therapeutic response. A is a why question. C does not recognize the possibility of poor judgment. D offers disapproval. A nurse in an acute mental health facility is caring for a client who has bipolar disorder. Which of the following is the priority nursing action? * Answer- A. Set consistent limits for expected client behavior * Answer- B. Administer prescribed medications as scheduled * Answer- C. Provide the client with step by step instructions during hygiene activities * Answer- D. Monitor the client for escalating behavior * Answer-D. Monitoring for escalating behavior addresses the client's priority need for safety and is therefore the priority nursing action. A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse include in the teaching? (Select all that apply) * Answer- A. Use caffeine in moderation to prevent relapse * Answer- B. Difficulty sleeping can indicate a relapse * Answer- C. Begin taking your medications as soon as a relapse begins * Answer- D. Participating in psychotherapy can help prevent a relapse * Answer-
E. Anhedonia is a clinical manifestation of a depressive relapse * Answer-B, D, & E. Sleep disturbances and anhedonia can indicate a relapse. Psychotherapy is helpful in preventing a relapse. The client should caffeine use and should take prescribed medications to prevent and minimize a relapse. Schizotypal personality disorder * Answer-The client has impairments of personality (self and interpersonal) functioning but is not as severe as schizophrenia Delusional disorder * Answer-The client experiences delusional thinking for at least 1 month but self or interpersonal functioning are not markedly impaired Brief psychotic disorder * Answer-The client has psychotic manifestations that last 1 day to 1 month in duration Schizophreniform disorder * Answer-The client has manifestations similar to schizophrenia but the duration is 1 - 6 months and social/occupational dysfunction might not be present Positive symptoms of psychotic disorders * Answer-Manifestation of things that are not normally present such as hallucinations, delusions, alterations in speech, and bizarre behavior Negative symptoms of psychotic disorders * Answer-Absence of things that are normally present, more difficult to treat; blunted or flat affect, alogia (poverty of thought or speech), anergia (lack of energy), anhedonia (lack of pleasure or joy), avocation (lack of motivation) Ideas of reference * Answer-Misconstrues trivial events and attaches personal significance to them, such as believing that others are talking about them Persecution * Answer-Feels singled out for harm by others (being hunted down by the FBI) Grandeur * Answer-Believe that they are all powerful and important, like a god
A nurse is completing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms? (Select all that apply) * Answer- A. Auditory hallucination * Answer- B. Lack of motivation * Answer- C. Use of clang association * Answer- D. Delusion of persecution * Answer- E. Constantly waving arms * Answer- F. Flat affect * Answer-A, C, D, & E. Hallucinations, speech alterations, delusions, and bizarre movements are positive symptoms. Lack of motivation and flat affect are negative symptoms. A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization? * Answer- A. "I am a superhero and am immortal." * Answer- B. "I am no one, and everyone is me." * Answer- C. "I feel monsters pinching me all over." * Answer- D. "I know that you are stealing my thoughts." * Answer-B. This indicates the client is experiencing loss of identity or depersonalization. A is a delusion of grandeur. C is a tactile hallucination. D is thought withdrawal.
A nurse is caring for a client on an acute mental health unit The client reports hearing voices that are telling her to "kill your doctor." Which of the following actions should the nurse take first? * Answer- A. Use therapeutic communication to discuss the hallucination with the client * Answer- B. Initiate one-to-one observation of the client * Answer- C. Focus the client on reality * Answer- D. Notify the provider of the client's statement * Answer-B. A client who is experiencing a command hallucination is at risk for injury to self or others and should be placed on one-to-one observation. A nurse is speaking with a client who has schizophrenia when he suddenly seems to stop focusing on the nurse's questions and begins looking at the ceiling and talking to himself. Which of the following actions should the nurse take? * Answer- A. Stop the interview at this point, and resume later when the client is better able to concentrate. * Answer- B. Ask the client, "Are you seeing something on the ceiling?" * Answer- C. Tell the client, "You seem to be looking at something on the ceiling. I see something there, too." * Answer- D. Continue the interview without comment on the client's behavior. * Answer-B. The nurse should ask the client directly about the hallucination to identify client needs and assess for a potential risk for injury. Characteristics of personality disorders * Answer-Inflexibility/maladaptive responses to stress,
D. "I should implement assertiveness training with clients who have antisocial personality disorder."
- Answer-C. When caring for a client who has a personality disorder, limit-setting is appropriate to help prevent client manipulation. The nurse should ask for the client's input instead of making a schedule, avoid trying to increase socialization for a client who has schizoid, and implement assertiveness training for clients who have dependent and histrionic personality disorders. 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? * Answer- A. "I'm scared that you're going to leave me." * Answer- B. "I'll go to group therapy if you'll let me smoke." * Answer- C. "I need to feel that everyone admires me." * Answer- D. "I sometimes feel better if I cut myself." * Answer-A. Clients who have avoidant personality disorder often have fear of abandonment. This type of statement is expected. B occurs in antisocial personality disorder. C occurs in narcissistic personality disorder. D occurs in borderline personality disorder. 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? * Answer- A. Regression * Answer- B. Splitting * Answer- C. Undoing * Answer- D. Identification * Answer-B. Splitting occurs when a person is unable to see both positive and negative qualities at the same time. The client who has BPD tends to see a person as all bad one
time and all good another time. 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) * Answer- A. Demonstrates extreme anxiety when placed in a social situation * Answer- B. Has difficulty making even simple decisions * Answer- C. Attempts to convince other clients to give him their belongings * Answer- D. Becomes agitated if his personal area is not neat and orderly * Answer- E. Blames others for his past and current problems * Answer-C & E. Exploitation/manipulation and failure to accept personal responsibility are findings of antisocial personality disorder. A occurs in avoidant personality disorder. B occurs in narcissistic personality disorder. D occurs in OCD. A charge nurse is preparing a staff education session on personality disorders. Which of the following personality characteristics associated with all of the personality disorders should the charge nurse include in the teaching? (Select all that apply) * Answer- A. Difficulty in getting along with other members of a group * Answer- B. Belief in the ability to become invisible during times of stress * Answer- C. Display of defense mechanisms when routines are changed * Answer- D. Claiming to be more important than other persons * Answer-
C. "You will be screened for underlying kidney disease prior to starting donepezil." * Answer- D. "You should stop taking donepezil if you experience nausea or diarrhea." * Answer-B. Donepezil slows the cognitive deterioration of Alzheimer's disease. Clients should avoid NSAIDs, not acetaminophen. Clients should be screened for heart and pulmonary disease. The client should not abruptly stop the medication. 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? * Answer- A. "You have forgotten that this is your home." * Answer- B. "You cannot go outside without a staff member." * Answer- C. "Why would you want to leave? Aren't you happy with your care?" * Answer- D. "I am your nurse. Let's walk together to your room." * Answer-D. It is appropriate for the nurse to introduce herself with each new interaction and to promote reality in a calm, reassuring manner. A is argumentative. B is a negative statement. C is a why question. A home health nurse is making a visit to a client who has Alzheimer's disease to assess 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) * Answer- A. Install childproof door locks. * Answer- B. Place rugs over electrical cords. * Answer- C. Mark cleaning supplies with colored tape. * Answer-
D. Place the client's mattress on the floor. * Answer- E. Install light fixtures above stairs. * Answer-A, D, & E. Door locks that are difficult to open reduce the risk of the client wandering. Placing the client's mattress on the floor and installing lights above stairs reduce the risk for falls. Rugs are a fall hazard. Cleaning supplies should be in locked cupboards. 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? * Answer- A. Verify that a current power of attorney document is on file. * Answer- B. Instruct the client's partner to offer finger foods to increase oral intake. * Answer- C. Provide information on resources for respite care. * Answer- D. Schedules the client for placement of an enteral feeding tube. * Answer-C. Providing information on resources for respite care is an appropriate action to provide the client's partner with a break from caregiver responsibilities. A nurse is performing an admission assessment for a client who has delirium related to an acute UTI. Which of the following findings should the nurse expect? (Select all that apply) * Answer- A. History of gradual memory loss * Answer- B. Family report of personality changes * Answer- C. Hallucinations * Answer-
Cocaine withdrawal manifestations * Answer-Depression, fatigue, craving, excess sleeping or insomnia, dramatic unpleasant dreams, psychomotor retardation, agitation Effects of amphetamine intoxication * Answer-Impaired judgment, psychomotor agitation, hypervigilance, extreme irritability, tachycardia, elevated BP Amphetamine withdrawal manifestations * Answer-Craving, depression, fatigue, sleeping Effects of nicotine intoxication * Answer-Hypertension, stroke, respiratory disease, irritation to oral mucous membranes, cancer Nicotine withdrawal manifestations * Answer-Abstinence syndrome evidenced by irritability, craving, nervousness, restlessness, anxiety, insomnia, increased appetite, difficulty concentrating, anger, and depressed mood Effects of opioid intoxication * Answer-Slurred speech, impaired memory, pupillary changes, decreased respirations and LOC, and maladaptive behavioral or psychological changes (impaired judgment or social functioning) Opioid withdrawal manifestations * Answer-Abstinence syndrome which begins with sweating and rhinorrhea progressing to piloerection, tremors, and irritability followed by severe weakness, diarrhea, fever, insomnia, pupil dilation, nausea, vomiting, pain in the muscles and bones, and muscle spasms Effects of inhalant intoxication * Answer-Behavioral or psychological changes, dizziness, nystagmus, uncoordinated movements or gait, slurred speech, drowsiness, hyporeflexia, muscle weakness, diplopia, stupor or coma, respiratory depression, and possible death; no withdrawal manifestations Effects of hallucinogen intoxication * Answer-Anxiety, depression, paranoia, impaired judgment, impaired social functioning, pupil dilation, tachycardia, diaphoresis, palpitations, blurred vision, tremors, incoordination, and panic attacks Hallucinogen withdrawal manifestations * Answer-Hallucinogen persisting perception disorder:
visual disturbances or flashback hallucinations can occur intermittently for years Effects of caffeine intoxication * Answer-Commonly occurs with ingestion of greater 250 mg (one 2 oz high energy drink can contain 215-240 mg caffeine); tachycardia and arrhythmias, flushed face, muscle twitching, restlessness, diuresis, GI disturbances, anxiety, insomnia Caffeine withdrawal manifestations * Answer-Can occur within 24 hr of last consumption; headache, nausea, vomiting, muscle pain, irritability, inability to focus, drowsiness A nurse is planning a staff education program on substance use in older adults. Which of the following is appropriate for the nurse to include in the presentation? * Answer- A. Older adults require higher doses of a substance to achieve a desired effect. * Answer- B. Older adults commonly use rationalization to cope with a substance use disorder. * Answer- C. Older adults are at an increased risk for substance use following retirement. * Answer- D. Older adults develop substance use to mask manifestations of dementia. * Answer-C. Retirement and other life change stressors increase the risk for substance use in older adults. A nurse is assessing a client who has alcohol use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect? (Select all that apply) * Answer- A. Bradycardia * Answer- B. Fine tremors of both hands * Answer- C. Hypotension * Answer-
