NSG221/NSG 221 Final Exam V2 | Mental
Health Nursing Q&A with Rationale |
Herzing University
1. A patient with major depressive disorder is being started on a Selective Serotonin
Reuptake Inhibitor (SSRI). Which instruction should the nurse prioritize during patient
education?
A. The medication will take effect immediately to improve your mood.
B. Report any increased suicidal ideation or thoughts of self-harm immediately.
C. Expect to experience significant weight loss within the first week.
D. Stop taking the medication if you experience a dry mouth.
Correct Answer: B
Rationale: SSRIs can lead to a temporary increase in energy before a patient’s mood fully
lifts, which may increase the risk of acting on suicidal thoughts. Patients and families must
be alerted to monitor for worsening depression or suicidal ideation during the initial weeks
of therapy. This assessment is a critical safety priority in mental health nursing according
to Herzing University standards.
2. A nurse is caring for a client who is experiencing a manic episode of Bipolar I Disorder.
Which of the following meal choices is most appropriate?
A. Chicken soup, crackers, and a side salad.
,B. Spaghetti and meatballs with a slice of garlic bread.
C. A turkey sandwich, an apple, and a carton of milk.
D. Steak and mashed potatoes with steamed broccoli.
Correct Answer: C
Rationale: Clients in a manic state often have high energy levels and cannot sit still long
enough to finish a traditional meal. Providing ‘finger foods’ allows the client to consume
nutrients while moving around the unit. This intervention addresses the nutritional needs
of the client without forcing them to remain sedentary.
3. Which clinical finding should the nurse recognize as a potential sign of Lithium toxicity?
A. Fine hand tremors and mild thirst.
B. Increased appetite and weight gain.
C. Coarse tremors, ataxia, and persistent diarrhea.
D. Increased urinary frequency and mild nausea.
Correct Answer: C
Rationale: Lithium has a narrow therapeutic index, usually between 0.6 and 1.2 mEq/L.
Coarse tremors and ataxia are signs of moderate to severe toxicity that require immediate
intervention. While fine tremors are a common side effect, coarse tremors indicate a
dangerous elevation in serum levels.
, 4. A client is admitted to the psychiatric unit with a diagnosis of schizophrenia and is
experiencing auditory hallucinations. What is the nurse’s best initial response?
A. What are the voices saying to you right now?
B. I don’t hear any voices; you are imagining things.
C. Try to ignore the voices and go to the dayroom.
D. I hear the voices too, and they sound very frightening.
Correct Answer: A
Rationale: The nurse must first assess the content of the hallucinations to ensure the
safety of the client and others, particularly if command hallucinations are present.
Validating that the client is experiencing something while clarifying that the nurse does not
hear it is a core therapeutic technique. This approach helps build trust while maintaining a
reality-based environment.
5. A nurse is teaching a client who is prescribed Phenelzine (Nardil) about dietary restrictions.
Which food choice indicates the client understands the instructions?
A. Pepperoni pizza with extra cheese.
B. A glass of red wine and aged cheddar.
C. Grilled chicken with steamed white rice.
D. Smoked salmon and cream cheese bagel.
Correct Answer: C
Health Nursing Q&A with Rationale |
Herzing University
1. A patient with major depressive disorder is being started on a Selective Serotonin
Reuptake Inhibitor (SSRI). Which instruction should the nurse prioritize during patient
education?
A. The medication will take effect immediately to improve your mood.
B. Report any increased suicidal ideation or thoughts of self-harm immediately.
C. Expect to experience significant weight loss within the first week.
D. Stop taking the medication if you experience a dry mouth.
Correct Answer: B
Rationale: SSRIs can lead to a temporary increase in energy before a patient’s mood fully
lifts, which may increase the risk of acting on suicidal thoughts. Patients and families must
be alerted to monitor for worsening depression or suicidal ideation during the initial weeks
of therapy. This assessment is a critical safety priority in mental health nursing according
to Herzing University standards.
2. A nurse is caring for a client who is experiencing a manic episode of Bipolar I Disorder.
Which of the following meal choices is most appropriate?
A. Chicken soup, crackers, and a side salad.
,B. Spaghetti and meatballs with a slice of garlic bread.
C. A turkey sandwich, an apple, and a carton of milk.
D. Steak and mashed potatoes with steamed broccoli.
Correct Answer: C
Rationale: Clients in a manic state often have high energy levels and cannot sit still long
enough to finish a traditional meal. Providing ‘finger foods’ allows the client to consume
nutrients while moving around the unit. This intervention addresses the nutritional needs
of the client without forcing them to remain sedentary.
3. Which clinical finding should the nurse recognize as a potential sign of Lithium toxicity?
A. Fine hand tremors and mild thirst.
B. Increased appetite and weight gain.
C. Coarse tremors, ataxia, and persistent diarrhea.
D. Increased urinary frequency and mild nausea.
Correct Answer: C
Rationale: Lithium has a narrow therapeutic index, usually between 0.6 and 1.2 mEq/L.
Coarse tremors and ataxia are signs of moderate to severe toxicity that require immediate
intervention. While fine tremors are a common side effect, coarse tremors indicate a
dangerous elevation in serum levels.
, 4. A client is admitted to the psychiatric unit with a diagnosis of schizophrenia and is
experiencing auditory hallucinations. What is the nurse’s best initial response?
A. What are the voices saying to you right now?
B. I don’t hear any voices; you are imagining things.
C. Try to ignore the voices and go to the dayroom.
D. I hear the voices too, and they sound very frightening.
Correct Answer: A
Rationale: The nurse must first assess the content of the hallucinations to ensure the
safety of the client and others, particularly if command hallucinations are present.
Validating that the client is experiencing something while clarifying that the nurse does not
hear it is a core therapeutic technique. This approach helps build trust while maintaining a
reality-based environment.
5. A nurse is teaching a client who is prescribed Phenelzine (Nardil) about dietary restrictions.
Which food choice indicates the client understands the instructions?
A. Pepperoni pizza with extra cheese.
B. A glass of red wine and aged cheddar.
C. Grilled chicken with steamed white rice.
D. Smoked salmon and cream cheese bagel.
Correct Answer: C
