PRN 1562/PRN1562 Final Exam V3 |
Principles of Mental Health Nursing Q&A
with Rationale | Rasmussen University
1. A nurse is caring for a client who states, ‘I am a loser and can’t do anything right.’ Which
response by the nurse is therapeutic?
A. ‘It sounds like you are feeling very discouraged today.’
B. ‘Everyone feels like that sometimes.’
C. ‘Why do you feel like that?’
D. ‘You should focus on your positive qualities.’
Answer: A
Rationale: This response uses the therapeutic technique of reflection and validation of
feelings. It acknowledges the client’s emotional state without being judgmental or
dismissive. Using open-ended validation encourages the client to explore their feelings
further.
2. A client is being treated with Lithium carbonate for bipolar disorder. Which lab value
should the nurse monitor most closely to prevent toxicity?
A. Blood glucose levels
B. Complete blood count
C. Liver function tests
,D. Serum Lithium levels
Answer: D
Rationale: Lithium has a very narrow therapeutic index, making serum level monitoring
critical. The therapeutic range is typically 0.6 to 1.2 mEq/L, and levels above 1.5 mEq/L can
be toxic. Regular blood draws ensure the patient remains within a safe and effective dosage
range.
3. The nurse is assessing a client who has a history of alcohol use disorder and is now
experiencing tremors, tachycardia, and hypertension. What is the nurse’s priority?
A. Administer a dose of Disulfiram.
B. Encourage oral fluid intake.
C. Implement seizure precautions.
D. Obtain a referral for a support group.
Answer: C
Rationale: The client is exhibiting signs of acute alcohol withdrawal, which carries a high
risk for seizures. Implementing safety measures like seizure precautions is the highest
priority to prevent physical injury. This intervention addresses the immediate
physiological safety of the patient during a critical period.
4. A client with schizophrenia is experiencing auditory hallucinations. Which action should the
nurse take first?
A. Tell the client that the voices are not real.
, B. Ask the client what the voices are saying.
C. Leave the client alone to provide privacy.
D. Turn up the television to drown out the voices.
Answer: B
Rationale: The first priority is to assess for command hallucinations that might instruct
the client to harm themselves or others. Asking what the voices are saying allows the nurse
to determine the risk level. This safety assessment is a standard part of psychiatric nursing
care.
5. Which defense mechanism is a client using when they claim they failed an exam because
the teacher ‘hates’ them, rather than admitting they didn’t study?
A. Sublimation
B. Projection
C. Reaction Formation
D. Rationalization
Answer: B
Rationale: Projection involves attributing one’s own unacceptable feelings or failures to
others. By blaming the teacher’s dislike, the client avoids personal accountability for their
lack of preparation. This is a common psychological defense used to protect the ego from
self-blame.
Principles of Mental Health Nursing Q&A
with Rationale | Rasmussen University
1. A nurse is caring for a client who states, ‘I am a loser and can’t do anything right.’ Which
response by the nurse is therapeutic?
A. ‘It sounds like you are feeling very discouraged today.’
B. ‘Everyone feels like that sometimes.’
C. ‘Why do you feel like that?’
D. ‘You should focus on your positive qualities.’
Answer: A
Rationale: This response uses the therapeutic technique of reflection and validation of
feelings. It acknowledges the client’s emotional state without being judgmental or
dismissive. Using open-ended validation encourages the client to explore their feelings
further.
2. A client is being treated with Lithium carbonate for bipolar disorder. Which lab value
should the nurse monitor most closely to prevent toxicity?
A. Blood glucose levels
B. Complete blood count
C. Liver function tests
,D. Serum Lithium levels
Answer: D
Rationale: Lithium has a very narrow therapeutic index, making serum level monitoring
critical. The therapeutic range is typically 0.6 to 1.2 mEq/L, and levels above 1.5 mEq/L can
be toxic. Regular blood draws ensure the patient remains within a safe and effective dosage
range.
3. The nurse is assessing a client who has a history of alcohol use disorder and is now
experiencing tremors, tachycardia, and hypertension. What is the nurse’s priority?
A. Administer a dose of Disulfiram.
B. Encourage oral fluid intake.
C. Implement seizure precautions.
D. Obtain a referral for a support group.
Answer: C
Rationale: The client is exhibiting signs of acute alcohol withdrawal, which carries a high
risk for seizures. Implementing safety measures like seizure precautions is the highest
priority to prevent physical injury. This intervention addresses the immediate
physiological safety of the patient during a critical period.
4. A client with schizophrenia is experiencing auditory hallucinations. Which action should the
nurse take first?
A. Tell the client that the voices are not real.
, B. Ask the client what the voices are saying.
C. Leave the client alone to provide privacy.
D. Turn up the television to drown out the voices.
Answer: B
Rationale: The first priority is to assess for command hallucinations that might instruct
the client to harm themselves or others. Asking what the voices are saying allows the nurse
to determine the risk level. This safety assessment is a standard part of psychiatric nursing
care.
5. Which defense mechanism is a client using when they claim they failed an exam because
the teacher ‘hates’ them, rather than admitting they didn’t study?
A. Sublimation
B. Projection
C. Reaction Formation
D. Rationalization
Answer: B
Rationale: Projection involves attributing one’s own unacceptable feelings or failures to
others. By blaming the teacher’s dislike, the client avoids personal accountability for their
lack of preparation. This is a common psychological defense used to protect the ego from
self-blame.
