NUR 208/NUR208 Final Exam V1 | Mental
Health Nursing Q&A with Rationale | Fortis
College
1. A patient with schizophrenia is experiencing auditory hallucinations and tells the nurse,
‘The voices are telling me I am a bad person.’ Which response by the nurse is therapeutic?
A. The voices are wrong; you are actually a very good person.
B. Why do you think the voices are saying that to you?
C. Try to ignore them; they are just a symptom of your illness.
D. I don’t hear the voices, but I understand they are real to you.
Correct Answer: D
Expert Explanation: This response acknowledges the patient’s experience while
maintaining a reality-based perspective. Presenting reality without arguing or dismissing
the patient’s feelings is a core therapeutic technique in psychiatric nursing. It helps build
trust and validates the patient’s internal struggle without reinforcing the hallucination.
2. A nurse is caring for a client who has a prescription for Lithium Carbonate. Which of the
following findings should the nurse identify as a sign of lithium toxicity?
A. Coarse hand tremors and ataxia.
B. Fine hand tremors.
C. Mild thirst and polyuria.
,D. Occasional nausea.
Correct Answer: A
Expert Explanation: Coarse tremors and ataxia are significant indicators of advanced
lithium toxicity, which can be life-threatening. Mild thirst, polyuria, and fine tremors are
common side effects usually seen at therapeutic levels. The nurse must recognize these
severe symptoms to prevent neurological damage or renal failure in the patient.
3. During a group session, a client with Borderline Personality Disorder (BPD) attempts to
convince the group that the night nurse is incompetent and ‘evil.’ This behavior is known as:
A. Projection
B. Reaction Formation
C. Rationalization
D. Splitting
Correct Answer: D
Expert Explanation: Splitting is a common defense mechanism in Borderline Personality
Disorder where individuals view others as entirely good or entirely bad. This occurs
because the individual cannot integrate the positive and negative qualities of another
person into a cohesive image. Nurses must use a consistent, team-based approach to
minimize the impact of splitting on the unit.
, 4. A client is admitted to the psychiatric unit after a suicide attempt. Which of the following is
the priority nursing intervention?
A. Implement one-to-one observation.
B. Encourage the client to attend group therapy.
C. Perform a comprehensive skin assessment.
D. Administer prescribed antidepressant medication.
Correct Answer: A
Expert Explanation: Safety is the absolute priority for a client who has recently attempted
suicide. One-to-one observation ensures the client is never alone and prevents further self-
harm attempts. While other interventions like medication and therapy are important for
long-term recovery, immediate physical safety must be established first.
5. A client has been prescribed Phenelzine (Nardil) for depression. The nurse should instruct
the client to avoid which of the following foods?
A. Aged cheddar cheese
B. Fresh strawberries
C. Grilled chicken breast
D. Whole wheat bread
Correct Answer: A
Health Nursing Q&A with Rationale | Fortis
College
1. A patient with schizophrenia is experiencing auditory hallucinations and tells the nurse,
‘The voices are telling me I am a bad person.’ Which response by the nurse is therapeutic?
A. The voices are wrong; you are actually a very good person.
B. Why do you think the voices are saying that to you?
C. Try to ignore them; they are just a symptom of your illness.
D. I don’t hear the voices, but I understand they are real to you.
Correct Answer: D
Expert Explanation: This response acknowledges the patient’s experience while
maintaining a reality-based perspective. Presenting reality without arguing or dismissing
the patient’s feelings is a core therapeutic technique in psychiatric nursing. It helps build
trust and validates the patient’s internal struggle without reinforcing the hallucination.
2. A nurse is caring for a client who has a prescription for Lithium Carbonate. Which of the
following findings should the nurse identify as a sign of lithium toxicity?
A. Coarse hand tremors and ataxia.
B. Fine hand tremors.
C. Mild thirst and polyuria.
,D. Occasional nausea.
Correct Answer: A
Expert Explanation: Coarse tremors and ataxia are significant indicators of advanced
lithium toxicity, which can be life-threatening. Mild thirst, polyuria, and fine tremors are
common side effects usually seen at therapeutic levels. The nurse must recognize these
severe symptoms to prevent neurological damage or renal failure in the patient.
3. During a group session, a client with Borderline Personality Disorder (BPD) attempts to
convince the group that the night nurse is incompetent and ‘evil.’ This behavior is known as:
A. Projection
B. Reaction Formation
C. Rationalization
D. Splitting
Correct Answer: D
Expert Explanation: Splitting is a common defense mechanism in Borderline Personality
Disorder where individuals view others as entirely good or entirely bad. This occurs
because the individual cannot integrate the positive and negative qualities of another
person into a cohesive image. Nurses must use a consistent, team-based approach to
minimize the impact of splitting on the unit.
, 4. A client is admitted to the psychiatric unit after a suicide attempt. Which of the following is
the priority nursing intervention?
A. Implement one-to-one observation.
B. Encourage the client to attend group therapy.
C. Perform a comprehensive skin assessment.
D. Administer prescribed antidepressant medication.
Correct Answer: A
Expert Explanation: Safety is the absolute priority for a client who has recently attempted
suicide. One-to-one observation ensures the client is never alone and prevents further self-
harm attempts. While other interventions like medication and therapy are important for
long-term recovery, immediate physical safety must be established first.
5. A client has been prescribed Phenelzine (Nardil) for depression. The nurse should instruct
the client to avoid which of the following foods?
A. Aged cheddar cheese
B. Fresh strawberries
C. Grilled chicken breast
D. Whole wheat bread
Correct Answer: A
