PNR 200/PNR200 Final Exam V2 | Mental Health
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client who has a prescription for lithium carbonate. Which of the
following findings should the nurse identify as an early sign of lithium toxicity?
A. Coarse hand tremors
B. Constipation
C. Slurred speech
D. Muscle weakness
Correct Answer: D
Explanation: Early signs of lithium toxicity include muscle weakness, fine hand tremors,
and gastrointestinal distress such as nausea or diarrhea. Coarse tremors and slurred
speech are associated with advanced toxicity levels. The nurse must monitor these early
indicators to prevent progression to more severe neurological or systemic damage.
2. A client is admitted to the psychiatric unit for treatment of obsessive-compulsive disorder
(OCD). Which action should the nurse take first when the client begins a repetitive ritual?
A. Interrupt the ritual to explain its inefficiency
B. Redirect the client to a different task immediately
C. Administer a PRN dose of an antianxiety medication
D. Allow the client to complete the ritual
,Correct Answer: D
Explanation: In the initial phase of treatment for OCD, the nurse should allow the client to
complete the ritual to prevent a panic-level increase in anxiety. Forcing the client to stop
before they are emotionally ready can be counterproductive and damaging to the
therapeutic relationship. Later in therapy, the treatment plan will involve gradually
limiting the time spent on rituals.
3. Which of the following defense mechanisms is a client using when they state, ‘I only drink
because my spouse is so demanding’?
A. Rationalization
B. Projection
C. Displacement
D. Sublimation
Correct Answer: A
Explanation: Rationalization involves justifying behavior or feelings by developing a
seemingly logical explanation to avoid the true reason. In this case, the client is blaming
their spouse’s behavior for their own choice to consume alcohol. This allows the client to
avoid taking personal responsibility for their substance use.
, 4. A nurse is reviewing the medical record of a client who has a prescription for clozapine.
Which of the following laboratory results should the nurse report to the provider
immediately?
A. Sodium 138 mEq/L
B. Hemoglobin 14 g/dL
C. Platelets 200,000/mm3
D. WBC count 2,500/mm3
Correct Answer: D
Explanation: Clozapine is an atypical antipsychotic that carries a significant risk for
agranulocytosis, which is a severe depletion of white blood cells. A WBC count below
3,000/mm3 indicates a dangerous level of neutropenia that requires immediate cessation
of the drug. The nurse must monitor weekly or bi-weekly blood counts as mandated by the
FDA.
5. During an intake assessment, a client with depression tells the nurse, ‘Everything is useless.
I don’t think I can go on.’ Which of the following responses by the nurse is the priority?
A. ‘Are you thinking about harming yourself?’
B. ‘Why do you feel that way today?’
C. ‘I understand; many people feel this way when they are depressed.’
D. ‘Let’s focus on the positive aspects of your life.’
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client who has a prescription for lithium carbonate. Which of the
following findings should the nurse identify as an early sign of lithium toxicity?
A. Coarse hand tremors
B. Constipation
C. Slurred speech
D. Muscle weakness
Correct Answer: D
Explanation: Early signs of lithium toxicity include muscle weakness, fine hand tremors,
and gastrointestinal distress such as nausea or diarrhea. Coarse tremors and slurred
speech are associated with advanced toxicity levels. The nurse must monitor these early
indicators to prevent progression to more severe neurological or systemic damage.
2. A client is admitted to the psychiatric unit for treatment of obsessive-compulsive disorder
(OCD). Which action should the nurse take first when the client begins a repetitive ritual?
A. Interrupt the ritual to explain its inefficiency
B. Redirect the client to a different task immediately
C. Administer a PRN dose of an antianxiety medication
D. Allow the client to complete the ritual
,Correct Answer: D
Explanation: In the initial phase of treatment for OCD, the nurse should allow the client to
complete the ritual to prevent a panic-level increase in anxiety. Forcing the client to stop
before they are emotionally ready can be counterproductive and damaging to the
therapeutic relationship. Later in therapy, the treatment plan will involve gradually
limiting the time spent on rituals.
3. Which of the following defense mechanisms is a client using when they state, ‘I only drink
because my spouse is so demanding’?
A. Rationalization
B. Projection
C. Displacement
D. Sublimation
Correct Answer: A
Explanation: Rationalization involves justifying behavior or feelings by developing a
seemingly logical explanation to avoid the true reason. In this case, the client is blaming
their spouse’s behavior for their own choice to consume alcohol. This allows the client to
avoid taking personal responsibility for their substance use.
, 4. A nurse is reviewing the medical record of a client who has a prescription for clozapine.
Which of the following laboratory results should the nurse report to the provider
immediately?
A. Sodium 138 mEq/L
B. Hemoglobin 14 g/dL
C. Platelets 200,000/mm3
D. WBC count 2,500/mm3
Correct Answer: D
Explanation: Clozapine is an atypical antipsychotic that carries a significant risk for
agranulocytosis, which is a severe depletion of white blood cells. A WBC count below
3,000/mm3 indicates a dangerous level of neutropenia that requires immediate cessation
of the drug. The nurse must monitor weekly or bi-weekly blood counts as mandated by the
FDA.
5. During an intake assessment, a client with depression tells the nurse, ‘Everything is useless.
I don’t think I can go on.’ Which of the following responses by the nurse is the priority?
A. ‘Are you thinking about harming yourself?’
B. ‘Why do you feel that way today?’
C. ‘I understand; many people feel this way when they are depressed.’
D. ‘Let’s focus on the positive aspects of your life.’
