NURS 222 Mental Health/Psychiatric Nursing: Module Exam 2 2026
|WCU
1. A client with schizophrenia is started on Clozapine. Which laboratory value is
the most critical for the nurse to monitor throughout the course of treatment?
A. Absolute Neutrophil Count (ANC)
B. Serum glucose levels
C. Serum creatinine
D. Liver function tests
Answer: A
Rationale: Clozapine carries a high risk of agranulocytosis, a potentially fatal drop in white
blood cell count. Mandatory monitoring of the Absolute Neutrophil Count (ANC) is required
by the FDA to ensure client safety.
2. The nurse observes a client receiving Haloperidol demonstrating a sudden
onset of high fever, muscle rigidity, and tachycardia. What is the priority nursing
action?
A. Administer a dose of Benztropine as ordered
B. Discontinue the medication and notify the provider immediately
C. Apply cooling blankets to reduce the fever
D. Perform a complete Mental Status Examination
Answer: B
Rationale: These symptoms are indicative of Neuroleptic Malignant Syndrome (NMS), a
life-threatening emergency. The primary intervention is to stop the antipsychotic and
provide supportive care/medical stabilization.
,3. A client diagnosed with Bipolar I Disorder is prescribed Lithium Carbonate.
Which dietary instruction is most important for the nurse to provide?
A. Restrict sodium intake to less than 1500mg per day
B. Maintain a consistent intake of sodium and fluids
C. Avoid foods high in Tyramine such as aged cheese
D. Limit caffeine intake to one cup per day
Answer: B
Rationale: Lithium is a salt; variations in sodium and water intake can significantly impact
lithium levels. Low sodium levels lead to lithium retention and toxicity, while high sodium
can lower therapeutic levels.
4. A nurse is caring for a client with Borderline Personality Disorder who uses
‘splitting.’ How should the nurse best respond to this behavior?
A. Acknowledge the client’s frustration and change the nurse’s schedule to accommodate them
B. Explain to the client why their perception of the staff is incorrect
C. Allow the client to choose their preferred nurse for each shift
D. Hold a staff meeting to ensure a consistent, unified approach to the client’s care
Answer: D
Rationale: Splitting involves seeing others as ‘all good’ or ‘all bad.’ Consistency among the
healthcare team is essential to prevent staff manipulation and provide a stable therapeutic
environment.
, 5. A client is admitted for alcohol withdrawal. Which clinical manifestation
should the nurse recognize as the most immediate indicator of Delirium
Tremens (DTs)?
A. Mild hand tremors and anxiety
B. Hypotension and bradycardia
C. Visual hallucinations and fluctuating levels of consciousness
D. Increased appetite and lethargy
Answer: C
Rationale: Delirium Tremens is the most severe form of alcohol withdrawal, characterized
by altered consciousness, autonomic hyperactivity, and hallucinations. It typically occurs
48-72 hours after the last drink.
6. A nurse is assessing a client for suicidal ideation. Which statement by the
client represents the highest risk?
A. I have been thinking about ending it all lately
B. I have a gun in my garage and I plan to use it tonight
C. My family would be better off if I weren’t here
D. I feel like there is no hope left for my future
Answer: B
Rationale: The presence of a specific plan, access to a lethal method, and a designated
timeframe (lethality and intent) indicate the highest immediate risk for suicide.
7. A client taking Phenelzine (an MAOI) presents with a pounding headache and
a blood pressure of 210/120. Which question should the nurse ask first?
A. Did you recently consume any aged cheeses or red wine?
B. Have you been feeling more depressed lately?
C. When was the last time you took your medication?
D. Are you experiencing any blurred vision or chest pain?
Answer: A
|WCU
1. A client with schizophrenia is started on Clozapine. Which laboratory value is
the most critical for the nurse to monitor throughout the course of treatment?
A. Absolute Neutrophil Count (ANC)
B. Serum glucose levels
C. Serum creatinine
D. Liver function tests
Answer: A
Rationale: Clozapine carries a high risk of agranulocytosis, a potentially fatal drop in white
blood cell count. Mandatory monitoring of the Absolute Neutrophil Count (ANC) is required
by the FDA to ensure client safety.
2. The nurse observes a client receiving Haloperidol demonstrating a sudden
onset of high fever, muscle rigidity, and tachycardia. What is the priority nursing
action?
A. Administer a dose of Benztropine as ordered
B. Discontinue the medication and notify the provider immediately
C. Apply cooling blankets to reduce the fever
D. Perform a complete Mental Status Examination
Answer: B
Rationale: These symptoms are indicative of Neuroleptic Malignant Syndrome (NMS), a
life-threatening emergency. The primary intervention is to stop the antipsychotic and
provide supportive care/medical stabilization.
,3. A client diagnosed with Bipolar I Disorder is prescribed Lithium Carbonate.
Which dietary instruction is most important for the nurse to provide?
A. Restrict sodium intake to less than 1500mg per day
B. Maintain a consistent intake of sodium and fluids
C. Avoid foods high in Tyramine such as aged cheese
D. Limit caffeine intake to one cup per day
Answer: B
Rationale: Lithium is a salt; variations in sodium and water intake can significantly impact
lithium levels. Low sodium levels lead to lithium retention and toxicity, while high sodium
can lower therapeutic levels.
4. A nurse is caring for a client with Borderline Personality Disorder who uses
‘splitting.’ How should the nurse best respond to this behavior?
A. Acknowledge the client’s frustration and change the nurse’s schedule to accommodate them
B. Explain to the client why their perception of the staff is incorrect
C. Allow the client to choose their preferred nurse for each shift
D. Hold a staff meeting to ensure a consistent, unified approach to the client’s care
Answer: D
Rationale: Splitting involves seeing others as ‘all good’ or ‘all bad.’ Consistency among the
healthcare team is essential to prevent staff manipulation and provide a stable therapeutic
environment.
, 5. A client is admitted for alcohol withdrawal. Which clinical manifestation
should the nurse recognize as the most immediate indicator of Delirium
Tremens (DTs)?
A. Mild hand tremors and anxiety
B. Hypotension and bradycardia
C. Visual hallucinations and fluctuating levels of consciousness
D. Increased appetite and lethargy
Answer: C
Rationale: Delirium Tremens is the most severe form of alcohol withdrawal, characterized
by altered consciousness, autonomic hyperactivity, and hallucinations. It typically occurs
48-72 hours after the last drink.
6. A nurse is assessing a client for suicidal ideation. Which statement by the
client represents the highest risk?
A. I have been thinking about ending it all lately
B. I have a gun in my garage and I plan to use it tonight
C. My family would be better off if I weren’t here
D. I feel like there is no hope left for my future
Answer: B
Rationale: The presence of a specific plan, access to a lethal method, and a designated
timeframe (lethality and intent) indicate the highest immediate risk for suicide.
7. A client taking Phenelzine (an MAOI) presents with a pounding headache and
a blood pressure of 210/120. Which question should the nurse ask first?
A. Did you recently consume any aged cheeses or red wine?
B. Have you been feeling more depressed lately?
C. When was the last time you took your medication?
D. Are you experiencing any blurred vision or chest pain?
Answer: A
