NU 160 Final Exam V1 | NU 160 Mental
Health Concepts | NCLEX (NGN) Q&A with
Rationale (NU160 Final Exam)
1. A nurse is caring for a client with Generalized Anxiety Disorder (GAD). The client states, ‘I
feel like I am constantly on edge and can’t focus on anything.’ Which therapeutic response by
the nurse is most appropriate?
A. Don’t worry, everyone feels a little anxious sometimes.
B. You should try to focus on the positive aspects of your life.
C. Why do you think you are feeling so on edge today?
D. It sounds like your anxiety is making it difficult for you to function lately.
Correct Answer: D
Explanation: This response uses the technique of paraphrasing or reflection to validate the
client’s feelings. Validating the client’s experience fosters trust and encourages further
communication. Using ‘why’ questions can be perceived as accusatory, and offering clichés
dismisses the client’s distress.
2. A client diagnosed with Bipolar I Disorder is prescribed Lithium Carbonate. Which
laboratory result should the nurse prioritize for immediate follow-up?
A. Lithium level of 0.8 mEq/L
B. Potassium level of 3.6 mEq/L
,C. Sodium level of 128 mEq/L
D. BUN level of 15 mg/dL
Correct Answer: C
Explanation: Hyponatremia (low sodium) is a significant risk for lithium toxicity because
the kidneys conserve lithium when sodium levels are low. A sodium level of 128 mEq/L is
critically low and requires immediate intervention to prevent toxicity. The other labs
provided are within or very close to normal physiological ranges.
3. A nurse is assessing a client who has been taking Haloperidol for two days and observes
the client’s neck is twisted to one side in a fixed position. What is the nurse’s priority action?
A. Administer the PRN dose of Benztropine as ordered.
B. Document the finding and monitor the client every 4 hours.
C. Apply a warm compress to the neck muscles.
D. Encourage the client to perform range-of-motion exercises.
Correct Answer: A
Explanation: The client is experiencing an acute dystonic reaction, which is an
extrapyramidal side effect (EPS) of typical antipsychotics. Benztropine, an anticholinergic
medication, is the standard treatment for reversing these symptoms quickly. Failure to
treat this immediately can lead to respiratory distress if the laryngeal muscles are involved.
, 4. A client with Major Depressive Disorder (MDD) states, ‘I don’t see the point in anything
anymore. My family would be better off without me.’ What is the nurse’s priority
assessment?
A. Assess the client’s support system.
B. Review the client’s medication history for antidepressants.
C. Ask the client if they have a specific plan for self-harm.
D. Encourage the client to attend a group therapy session.
Correct Answer: C
Explanation: The client’s statement indicates suicidal ideation, which requires an
immediate and direct safety assessment. Asking about a specific plan is the highest priority
to determine the lethality and imminence of the risk. Safety is always the primary concern
in psychiatric nursing when a client expresses hopelessness.
5. A client is admitted to the psychiatric unit with a diagnosis of Borderline Personality
Disorder. The nurse observes the client praising one nurse while demeaning another nurse on
the same shift. The nurse recognizes this as which defense mechanism?
A. Splitting
B. Projection
C. Reaction Formation
D. Sublimation
Health Concepts | NCLEX (NGN) Q&A with
Rationale (NU160 Final Exam)
1. A nurse is caring for a client with Generalized Anxiety Disorder (GAD). The client states, ‘I
feel like I am constantly on edge and can’t focus on anything.’ Which therapeutic response by
the nurse is most appropriate?
A. Don’t worry, everyone feels a little anxious sometimes.
B. You should try to focus on the positive aspects of your life.
C. Why do you think you are feeling so on edge today?
D. It sounds like your anxiety is making it difficult for you to function lately.
Correct Answer: D
Explanation: This response uses the technique of paraphrasing or reflection to validate the
client’s feelings. Validating the client’s experience fosters trust and encourages further
communication. Using ‘why’ questions can be perceived as accusatory, and offering clichés
dismisses the client’s distress.
2. A client diagnosed with Bipolar I Disorder is prescribed Lithium Carbonate. Which
laboratory result should the nurse prioritize for immediate follow-up?
A. Lithium level of 0.8 mEq/L
B. Potassium level of 3.6 mEq/L
,C. Sodium level of 128 mEq/L
D. BUN level of 15 mg/dL
Correct Answer: C
Explanation: Hyponatremia (low sodium) is a significant risk for lithium toxicity because
the kidneys conserve lithium when sodium levels are low. A sodium level of 128 mEq/L is
critically low and requires immediate intervention to prevent toxicity. The other labs
provided are within or very close to normal physiological ranges.
3. A nurse is assessing a client who has been taking Haloperidol for two days and observes
the client’s neck is twisted to one side in a fixed position. What is the nurse’s priority action?
A. Administer the PRN dose of Benztropine as ordered.
B. Document the finding and monitor the client every 4 hours.
C. Apply a warm compress to the neck muscles.
D. Encourage the client to perform range-of-motion exercises.
Correct Answer: A
Explanation: The client is experiencing an acute dystonic reaction, which is an
extrapyramidal side effect (EPS) of typical antipsychotics. Benztropine, an anticholinergic
medication, is the standard treatment for reversing these symptoms quickly. Failure to
treat this immediately can lead to respiratory distress if the laryngeal muscles are involved.
, 4. A client with Major Depressive Disorder (MDD) states, ‘I don’t see the point in anything
anymore. My family would be better off without me.’ What is the nurse’s priority
assessment?
A. Assess the client’s support system.
B. Review the client’s medication history for antidepressants.
C. Ask the client if they have a specific plan for self-harm.
D. Encourage the client to attend a group therapy session.
Correct Answer: C
Explanation: The client’s statement indicates suicidal ideation, which requires an
immediate and direct safety assessment. Asking about a specific plan is the highest priority
to determine the lethality and imminence of the risk. Safety is always the primary concern
in psychiatric nursing when a client expresses hopelessness.
5. A client is admitted to the psychiatric unit with a diagnosis of Borderline Personality
Disorder. The nurse observes the client praising one nurse while demeaning another nurse on
the same shift. The nurse recognizes this as which defense mechanism?
A. Splitting
B. Projection
C. Reaction Formation
D. Sublimation
