NUR 208/NUR208 Final Exam V3 | Mental
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing a client who has schizophrenia and is experiencing auditory
hallucinations. Which of the following actions should the nurse take first?
A. Ask the client what the voices are saying.
B. Inform the client that the voices are not real.
C. Administer an antipsychotic medication.
D. Provide a quiet environment with low stimulation.
Correct Answer: A
Expert Explanation: Safety is the priority in psychiatric nursing when dealing with
hallucinations. The nurse must first determine if the voices are command hallucinations
that might harm the client or others. By asking what the voices are saying, the nurse can
perform a risk assessment and initiate appropriate safety precautions.
2. A client is admitted to the psychiatric unit for the treatment of severe depression. Which of
the following is the priority nursing intervention during the first 24 hours of admission?
A. Encourage the client to participate in group therapy.
B. Conduct a suicide risk assessment every shift.
C. Monitor the client’s nutritional intake.
,D. Assist the client with personal hygiene.
Correct Answer: B
Expert Explanation: Suicide risk is highest during the initial phase of treatment for severe
depression as energy levels may begin to return before the mood improves. The nurse
must prioritize safety by assessing the client’s intent and plan for self-harm. This
intervention takes precedence over socialization or physical care according to Maslow’s
hierarchy of needs regarding safety.
3. A nurse is caring for a client with Bipolar Disorder who is in the manic phase. Which of the
following snack options is most appropriate?
A. A turkey sandwich and a banana.
B. A bowl of hot vegetable soup.
C. A cup of yogurt with a spoon.
D. A plate of spaghetti and meatballs.
Correct Answer: A
Expert Explanation: Clients in a manic phase often have high activity levels and cannot sit
long enough to eat a full meal. ‘Finger foods’ that are high in protein and calories allow the
client to eat while moving. A turkey sandwich and banana are portable and nutrient-dense,
helping to maintain physical health during periods of hyperactivity.
, 4. A nurse is teaching a client who has a new prescription for Lithium Carbonate. Which of the
following dietary instructions should the nurse include?
A. Limit fluid intake to 1 liter per day.
B. Avoid foods containing tyramine.
C. Maintain a consistent intake of dietary sodium.
D. Restrict salt intake to less than 2 grams per day.
Correct Answer: C
Expert Explanation: Lithium is a salt, and its excretion is closely tied to sodium levels in
the body. If sodium intake decreases, the kidneys retain lithium, which can lead to toxicity.
Conversely, excessive sodium can lead to subtherapeutic lithium levels, making consistency
the most important factor for the client.
5. A client is exhibiting signs of Serotonin Syndrome. Which of the following symptoms should
the nurse expect to find?
A. Hyporeflexia and bradycardia.
B. Constipation and urinary retention.
C. Muscle rigidity, diaphoresis, and tachycardia.
D. Weight gain and sedation.
Correct Answer: C
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing a client who has schizophrenia and is experiencing auditory
hallucinations. Which of the following actions should the nurse take first?
A. Ask the client what the voices are saying.
B. Inform the client that the voices are not real.
C. Administer an antipsychotic medication.
D. Provide a quiet environment with low stimulation.
Correct Answer: A
Expert Explanation: Safety is the priority in psychiatric nursing when dealing with
hallucinations. The nurse must first determine if the voices are command hallucinations
that might harm the client or others. By asking what the voices are saying, the nurse can
perform a risk assessment and initiate appropriate safety precautions.
2. A client is admitted to the psychiatric unit for the treatment of severe depression. Which of
the following is the priority nursing intervention during the first 24 hours of admission?
A. Encourage the client to participate in group therapy.
B. Conduct a suicide risk assessment every shift.
C. Monitor the client’s nutritional intake.
,D. Assist the client with personal hygiene.
Correct Answer: B
Expert Explanation: Suicide risk is highest during the initial phase of treatment for severe
depression as energy levels may begin to return before the mood improves. The nurse
must prioritize safety by assessing the client’s intent and plan for self-harm. This
intervention takes precedence over socialization or physical care according to Maslow’s
hierarchy of needs regarding safety.
3. A nurse is caring for a client with Bipolar Disorder who is in the manic phase. Which of the
following snack options is most appropriate?
A. A turkey sandwich and a banana.
B. A bowl of hot vegetable soup.
C. A cup of yogurt with a spoon.
D. A plate of spaghetti and meatballs.
Correct Answer: A
Expert Explanation: Clients in a manic phase often have high activity levels and cannot sit
long enough to eat a full meal. ‘Finger foods’ that are high in protein and calories allow the
client to eat while moving. A turkey sandwich and banana are portable and nutrient-dense,
helping to maintain physical health during periods of hyperactivity.
, 4. A nurse is teaching a client who has a new prescription for Lithium Carbonate. Which of the
following dietary instructions should the nurse include?
A. Limit fluid intake to 1 liter per day.
B. Avoid foods containing tyramine.
C. Maintain a consistent intake of dietary sodium.
D. Restrict salt intake to less than 2 grams per day.
Correct Answer: C
Expert Explanation: Lithium is a salt, and its excretion is closely tied to sodium levels in
the body. If sodium intake decreases, the kidneys retain lithium, which can lead to toxicity.
Conversely, excessive sodium can lead to subtherapeutic lithium levels, making consistency
the most important factor for the client.
5. A client is exhibiting signs of Serotonin Syndrome. Which of the following symptoms should
the nurse expect to find?
A. Hyporeflexia and bradycardia.
B. Constipation and urinary retention.
C. Muscle rigidity, diaphoresis, and tachycardia.
D. Weight gain and sedation.
Correct Answer: C
