PNR 200/PNR200 Exam 2 V1 | Mental Health
Nursing Q&A with Rationale | Fortis College
1. A patient diagnosed with bipolar disorder is in the manic phase and is moving rapidly
around the unit, talking loudly and interruptively. Which nursing intervention is most
appropriate?
A. Encourage the patient to discuss their feelings in a quiet area.
B. Ask the patient to sit down and participate in a group board game.
C. Provide a high-calorie finger food to the patient.
D. Administer a PRN sedative to ensure the safety of others.
Correct Answer: C
Explanation: During a manic episode, patients often have difficulty sitting still for meals
and expend high amounts of energy. Providing high-calorie finger foods allows the patient
to maintain nutrition while on the move. This intervention addresses physiological needs
without requiring the concentration needed for group activities.
2. A nurse is caring for a client who is taking lithium carbonate for mania. Which of the
following lab values should the nurse report to the provider immediately?
A. Serum lithium level of 0.8 mEq/L
B. Serum sodium level of 128 mEq/L
C. Serum potassium level of 4.0 mEq/L
,D. White blood cell count of 8,000/mm3
Correct Answer: B
Explanation: Lithium is a salt, and its excretion is closely tied to sodium levels in the body.
A low sodium level (hyponatremia) can lead to lithium retention and subsequent toxicity.
The nurse must monitor sodium levels closely to ensure the client stays within the
therapeutic range of 1.0 to 1.5 mEq/L for acute mania.
3. A client experiencing severe anxiety states, ‘I feel like I am going to die, my heart is racing,
and I can’t breathe.’ Which action should the nurse take first?
A. Ask the client to explain what triggered the anxiety.
B. Stay with the client and use simple, clear instructions.
C. Teach the client a new relaxation technique.
D. Leave the client alone to reduce environmental stimuli.
Correct Answer: B
Explanation: In severe to panic levels of anxiety, the nurse’s priority is safety and physical
presence. Staying with the client provides a sense of security and prevents injury. Using
simple words is necessary because the client’s ability to process information is severely
diminished during a panic attack.
4. A nurse is assessing a client with post-traumatic stress disorder (PTSD). Which of the
following findings is an expected clinical manifestation?
A. Excessive sleeping and lethargy
, B. Clear and detailed memory of the traumatic event
C. Increased interest in social activities
D. Hypervigilance and exaggerated startle response
Correct Answer: D
Explanation: Hypervigilance is a hallmark sign of PTSD, where the individual remains in a
constant state of high alert. This is often accompanied by an exaggerated startle response
and irritability. Clients may also experience dissociative amnesia or flashbacks regarding
the traumatic event.
5. A patient is prescribed phenelzine (Nardil) for depression. Which food choice indicates that
the patient understands the dietary restrictions?
A. Pepperoni pizza with extra cheese
B. Avocado salad with a glass of red wine
C. Smoked salmon and cream cheese bagel
D. Grilled chicken breast with steamed broccoli
Correct Answer: D
Explanation: Phenelzine is an MAOI, which requires a low-tyramine diet to prevent a
hypertensive crisis. Foods such as aged cheeses, cured meats, avocados, and red wine are
high in tyramine and must be avoided. Grilled chicken and fresh vegetables are safe options
that do not interact with the medication.
Nursing Q&A with Rationale | Fortis College
1. A patient diagnosed with bipolar disorder is in the manic phase and is moving rapidly
around the unit, talking loudly and interruptively. Which nursing intervention is most
appropriate?
A. Encourage the patient to discuss their feelings in a quiet area.
B. Ask the patient to sit down and participate in a group board game.
C. Provide a high-calorie finger food to the patient.
D. Administer a PRN sedative to ensure the safety of others.
Correct Answer: C
Explanation: During a manic episode, patients often have difficulty sitting still for meals
and expend high amounts of energy. Providing high-calorie finger foods allows the patient
to maintain nutrition while on the move. This intervention addresses physiological needs
without requiring the concentration needed for group activities.
2. A nurse is caring for a client who is taking lithium carbonate for mania. Which of the
following lab values should the nurse report to the provider immediately?
A. Serum lithium level of 0.8 mEq/L
B. Serum sodium level of 128 mEq/L
C. Serum potassium level of 4.0 mEq/L
,D. White blood cell count of 8,000/mm3
Correct Answer: B
Explanation: Lithium is a salt, and its excretion is closely tied to sodium levels in the body.
A low sodium level (hyponatremia) can lead to lithium retention and subsequent toxicity.
The nurse must monitor sodium levels closely to ensure the client stays within the
therapeutic range of 1.0 to 1.5 mEq/L for acute mania.
3. A client experiencing severe anxiety states, ‘I feel like I am going to die, my heart is racing,
and I can’t breathe.’ Which action should the nurse take first?
A. Ask the client to explain what triggered the anxiety.
B. Stay with the client and use simple, clear instructions.
C. Teach the client a new relaxation technique.
D. Leave the client alone to reduce environmental stimuli.
Correct Answer: B
Explanation: In severe to panic levels of anxiety, the nurse’s priority is safety and physical
presence. Staying with the client provides a sense of security and prevents injury. Using
simple words is necessary because the client’s ability to process information is severely
diminished during a panic attack.
4. A nurse is assessing a client with post-traumatic stress disorder (PTSD). Which of the
following findings is an expected clinical manifestation?
A. Excessive sleeping and lethargy
, B. Clear and detailed memory of the traumatic event
C. Increased interest in social activities
D. Hypervigilance and exaggerated startle response
Correct Answer: D
Explanation: Hypervigilance is a hallmark sign of PTSD, where the individual remains in a
constant state of high alert. This is often accompanied by an exaggerated startle response
and irritability. Clients may also experience dissociative amnesia or flashbacks regarding
the traumatic event.
5. A patient is prescribed phenelzine (Nardil) for depression. Which food choice indicates that
the patient understands the dietary restrictions?
A. Pepperoni pizza with extra cheese
B. Avocado salad with a glass of red wine
C. Smoked salmon and cream cheese bagel
D. Grilled chicken breast with steamed broccoli
Correct Answer: D
Explanation: Phenelzine is an MAOI, which requires a low-tyramine diet to prevent a
hypertensive crisis. Foods such as aged cheeses, cured meats, avocados, and red wine are
high in tyramine and must be avoided. Grilled chicken and fresh vegetables are safe options
that do not interact with the medication.
