NU 160 Exam 3 V1 | NU 160 Mental Health
Concepts | NCLEX (NGN) Q&A with
Rationale (NU160 Exam 3)
1. A client with generalized anxiety disorder (GAD) reports to the nurse, ‘I feel like I am
constantly on edge and cannot stop worrying about everything.’ Which nursing intervention
should be prioritized?
A. Assist the client in identifying specific triggers for their anxiety.
B. Instruct the client to practice deep-breathing exercises immediately.
C. Advise the client to avoid all stressful situations for one week.
D. Administer a PRN dose of Lorazepam as the first line of treatment.
Correct Answer: A
Explanation: Identifying triggers is a key cognitive-behavioral intervention that helps the
client gain a sense of control over their anxiety. Deep breathing is helpful but identifying
triggers allows for long-term management and awareness. Avoiding all stress is unrealistic
and counterproductive to developing coping mechanisms.
2. A client diagnosed with Major Depressive Disorder (MDD) is being started on Fluoxetine.
Which statement by the client indicates an understanding of the medication teaching?
A. I should feel much better and have more energy within 48 hours.
B. I can stop taking this medication as soon as my mood improves.
,C. I must avoid aged cheeses and red wine while taking this drug.
D. I need to notify my doctor if I experience increased thoughts of self-harm.
Correct Answer: D
Explanation: SSRIs like Fluoxetine carry a black box warning for increased suicidal
ideation, especially in young adults and at the start of therapy. Therapeutic effects typically
take 2 to 4 weeks to manifest, not 48 hours. Dietary restrictions for tyramine apply to
MAOIs, not SSRIs.
3. A nurse is assessing a client with Bipolar I Disorder who is experiencing a manic episode.
Which finding requires immediate intervention?
A. The client is wearing brightly colored, mismatched clothing.
B. The client has not slept for 48 hours and is pacing the hallway.
C. The client is speaking rapidly and switching between unrelated topics.
D. The client claims to be a secret agent for the government.
Correct Answer: B
Explanation: Extreme exhaustion from lack of sleep during mania can lead to physical
collapse or cardiac issues, making it a physiological priority. While pressured speech and
delusions are common symptoms, they do not pose the same immediate physical risk as
prolonged insomnia. Safety and physiological stability are always prioritized in NCLEX-
style questions.
, 4. A client is receiving Lithium Carbonate for the treatment of Bipolar Disorder. The nurse
notes a serum lithium level of 1.8 mEq/L. What is the priority action?
A. Administer the next scheduled dose as ordered.
B. Document the findings as within the therapeutic range.
C. Hold the dose and notify the healthcare provider immediately.
D. Encourage the client to increase their intake of free water.
Correct Answer: C
Explanation: A lithium level of 1.8 mEq/L is above the therapeutic range (0.6-1.2 mEq/L)
and indicates moderate toxicity. Symptoms at this level can include tremors, GI upset, and
confusion. Holding the dose is necessary to prevent further toxicity and potential
permanent organ damage.
5. A client with Schizophrenia is experiencing auditory hallucinations, telling them that the
food is poisoned. Which response by the nurse is therapeutic?
A. The food is not poisoned; I saw the chef prepare it myself.
B. I do not hear the voices, but I understand that they are real to you.
C. Why do you think someone would want to poison your food?
D. If the food were poisoned, the other patients would be sick too.
Correct Answer: B
Concepts | NCLEX (NGN) Q&A with
Rationale (NU160 Exam 3)
1. A client with generalized anxiety disorder (GAD) reports to the nurse, ‘I feel like I am
constantly on edge and cannot stop worrying about everything.’ Which nursing intervention
should be prioritized?
A. Assist the client in identifying specific triggers for their anxiety.
B. Instruct the client to practice deep-breathing exercises immediately.
C. Advise the client to avoid all stressful situations for one week.
D. Administer a PRN dose of Lorazepam as the first line of treatment.
Correct Answer: A
Explanation: Identifying triggers is a key cognitive-behavioral intervention that helps the
client gain a sense of control over their anxiety. Deep breathing is helpful but identifying
triggers allows for long-term management and awareness. Avoiding all stress is unrealistic
and counterproductive to developing coping mechanisms.
2. A client diagnosed with Major Depressive Disorder (MDD) is being started on Fluoxetine.
Which statement by the client indicates an understanding of the medication teaching?
A. I should feel much better and have more energy within 48 hours.
B. I can stop taking this medication as soon as my mood improves.
,C. I must avoid aged cheeses and red wine while taking this drug.
D. I need to notify my doctor if I experience increased thoughts of self-harm.
Correct Answer: D
Explanation: SSRIs like Fluoxetine carry a black box warning for increased suicidal
ideation, especially in young adults and at the start of therapy. Therapeutic effects typically
take 2 to 4 weeks to manifest, not 48 hours. Dietary restrictions for tyramine apply to
MAOIs, not SSRIs.
3. A nurse is assessing a client with Bipolar I Disorder who is experiencing a manic episode.
Which finding requires immediate intervention?
A. The client is wearing brightly colored, mismatched clothing.
B. The client has not slept for 48 hours and is pacing the hallway.
C. The client is speaking rapidly and switching between unrelated topics.
D. The client claims to be a secret agent for the government.
Correct Answer: B
Explanation: Extreme exhaustion from lack of sleep during mania can lead to physical
collapse or cardiac issues, making it a physiological priority. While pressured speech and
delusions are common symptoms, they do not pose the same immediate physical risk as
prolonged insomnia. Safety and physiological stability are always prioritized in NCLEX-
style questions.
, 4. A client is receiving Lithium Carbonate for the treatment of Bipolar Disorder. The nurse
notes a serum lithium level of 1.8 mEq/L. What is the priority action?
A. Administer the next scheduled dose as ordered.
B. Document the findings as within the therapeutic range.
C. Hold the dose and notify the healthcare provider immediately.
D. Encourage the client to increase their intake of free water.
Correct Answer: C
Explanation: A lithium level of 1.8 mEq/L is above the therapeutic range (0.6-1.2 mEq/L)
and indicates moderate toxicity. Symptoms at this level can include tremors, GI upset, and
confusion. Holding the dose is necessary to prevent further toxicity and potential
permanent organ damage.
5. A client with Schizophrenia is experiencing auditory hallucinations, telling them that the
food is poisoned. Which response by the nurse is therapeutic?
A. The food is not poisoned; I saw the chef prepare it myself.
B. I do not hear the voices, but I understand that they are real to you.
C. Why do you think someone would want to poison your food?
D. If the food were poisoned, the other patients would be sick too.
Correct Answer: B
