NU 160 Exam 2 V2 | NU 160 Mental Health
Concepts | NCLEX (NGN) Q&A with
Rationale (NU160 Exam 2)
1. A client with schizophrenia is experiencing auditory hallucinations and appears distressed.
Which is the priority nursing action?
A. Tell the client that the voices are not real and to ignore them.
B. Ask the client directly what the voices are saying to them.
C. Place the client in a quiet room with minimal stimulation.
D. Administer a PRN dose of an antianxiety medication immediately.
Correct Answer: B
Explanation: Assessing the content of hallucinations is the first priority to determine if
they are command hallucinations that could lead to harm. The nurse should validate that
the client is experiencing something but clarify that the nurse does not hear the voices. This
assessment guides safety interventions and the overall plan of care.
2. A nurse is providing teaching to a client starting Lithium Carbonate for Bipolar Disorder.
Which statement by the client indicates a need for further instruction?
A. I will make sure to drink at least 2 to 3 liters of water every day.
B. I need to limit my salt intake to prevent the medicine from building up.
C. I will have my blood levels checked regularly as ordered by my doctor.
,D. I should call the clinic if I experience persistent diarrhea or vomiting.
Correct Answer: B
Explanation: Clients taking Lithium should maintain a consistent intake of dietary sodium
rather than restricting it. Low sodium levels can lead to decreased lithium excretion and
potential toxicity. Consistent fluid and salt intake are essential for maintaining a
therapeutic drug level.
3. A client is admitted to the unit following a suicide attempt. What is the most important
nursing intervention during the first 24 hours of admission?
A. Encourage the client to attend all group therapy sessions.
B. Administer prescribed antidepressants to stabilize the mood.
C. Assist the client in identifying positive coping mechanisms.
D. Assign a staff member for one-on-one continuous observation.
Correct Answer: D
Explanation: Safety is the highest priority for a client who has recently attempted suicide.
One-on-one observation ensures that the client cannot harm themselves while in the
hospital environment. While therapy and medication are important, they do not provide
the immediate safety required during the acute phase.
4. A nurse is caring for a client with Major Depressive Disorder who is starting Phenelzine (an
MAOI). Which food choice should the nurse instruct the client to avoid?
A. Fresh grilled chicken breast
, B. Whole grain bread and butter
C. Steamed broccoli and carrots
D. Aged cheddar cheese and pepperoni
Correct Answer: D
Explanation: Phenelzine is an MAOI that requires a low-tyramine diet to prevent a
hypertensive crisis. Aged cheeses and cured meats like pepperoni are high in tyramine and
must be avoided. The nurse must educate the client on identifying safe versus dangerous
food options.
5. A client with Borderline Personality Disorder (BPD) is being manipulative with the staff,
trying to get special privileges. Which nursing approach is most effective?
A. Ensure all staff members maintain consistent limits and boundaries.
B. Confront the client aggressively about their manipulative behavior.
C. Allow the privileges occasionally to build a therapeutic rapport.
D. Ignore the behavior so the client does not get extra attention.
Correct Answer: A
Explanation: Consistency among the multidisciplinary team is crucial when treating
clients with BPD to prevent ‘splitting.’ Clear boundaries provide a sense of security and
help the client learn appropriate social interactions. Limit-setting must be done calmly and
firmly by all staff members.
Concepts | NCLEX (NGN) Q&A with
Rationale (NU160 Exam 2)
1. A client with schizophrenia is experiencing auditory hallucinations and appears distressed.
Which is the priority nursing action?
A. Tell the client that the voices are not real and to ignore them.
B. Ask the client directly what the voices are saying to them.
C. Place the client in a quiet room with minimal stimulation.
D. Administer a PRN dose of an antianxiety medication immediately.
Correct Answer: B
Explanation: Assessing the content of hallucinations is the first priority to determine if
they are command hallucinations that could lead to harm. The nurse should validate that
the client is experiencing something but clarify that the nurse does not hear the voices. This
assessment guides safety interventions and the overall plan of care.
2. A nurse is providing teaching to a client starting Lithium Carbonate for Bipolar Disorder.
Which statement by the client indicates a need for further instruction?
A. I will make sure to drink at least 2 to 3 liters of water every day.
B. I need to limit my salt intake to prevent the medicine from building up.
C. I will have my blood levels checked regularly as ordered by my doctor.
,D. I should call the clinic if I experience persistent diarrhea or vomiting.
Correct Answer: B
Explanation: Clients taking Lithium should maintain a consistent intake of dietary sodium
rather than restricting it. Low sodium levels can lead to decreased lithium excretion and
potential toxicity. Consistent fluid and salt intake are essential for maintaining a
therapeutic drug level.
3. A client is admitted to the unit following a suicide attempt. What is the most important
nursing intervention during the first 24 hours of admission?
A. Encourage the client to attend all group therapy sessions.
B. Administer prescribed antidepressants to stabilize the mood.
C. Assist the client in identifying positive coping mechanisms.
D. Assign a staff member for one-on-one continuous observation.
Correct Answer: D
Explanation: Safety is the highest priority for a client who has recently attempted suicide.
One-on-one observation ensures that the client cannot harm themselves while in the
hospital environment. While therapy and medication are important, they do not provide
the immediate safety required during the acute phase.
4. A nurse is caring for a client with Major Depressive Disorder who is starting Phenelzine (an
MAOI). Which food choice should the nurse instruct the client to avoid?
A. Fresh grilled chicken breast
, B. Whole grain bread and butter
C. Steamed broccoli and carrots
D. Aged cheddar cheese and pepperoni
Correct Answer: D
Explanation: Phenelzine is an MAOI that requires a low-tyramine diet to prevent a
hypertensive crisis. Aged cheeses and cured meats like pepperoni are high in tyramine and
must be avoided. The nurse must educate the client on identifying safe versus dangerous
food options.
5. A client with Borderline Personality Disorder (BPD) is being manipulative with the staff,
trying to get special privileges. Which nursing approach is most effective?
A. Ensure all staff members maintain consistent limits and boundaries.
B. Confront the client aggressively about their manipulative behavior.
C. Allow the privileges occasionally to build a therapeutic rapport.
D. Ignore the behavior so the client does not get extra attention.
Correct Answer: A
Explanation: Consistency among the multidisciplinary team is crucial when treating
clients with BPD to prevent ‘splitting.’ Clear boundaries provide a sense of security and
help the client learn appropriate social interactions. Limit-setting must be done calmly and
firmly by all staff members.
