HESI PNR 200/PNR200 Mental Health Nursing V1 |
Exit Exam Q&A with Rationale | Fortis College
1. A nurse is caring for a client with a history of alcohol use disorder who is experiencing
tremors, tachycardia, and diaphoresis. Which medication should the nurse expect to
administer first?
A. Disulfiram
B. Methadone
C. Lorazepam
D. Fluoxetine
Correct Answer: C
Explanation: The client is exhibiting signs of acute alcohol withdrawal, which can lead to
life-threatening seizures or delirium tremens. Benzodiazepines like lorazepam are the first-
line treatment to stabilize vital signs and prevent progression. Disulfiram is used for
maintenance of sobriety, not acute withdrawal management.
2. Which assessment finding should a nurse prioritize for a client newly prescribed clozapine
for treatment-resistant schizophrenia?
A. Body mass index of 28
B. Blood pressure of 140/90 mmHg
C. Fast blood glucose of 110 mg/dL
,D. White blood cell count of 2,500/mm3
Correct Answer: D
Explanation: Clozapine carries a black box warning for agranulocytosis, which is a
dangerously low white blood cell count. A WBC count of 2,500/mm3 is significantly below
the normal range and requires immediate notification of the provider. Frequent blood
monitoring is mandatory for any patient taking this medication.
3. A client diagnosed with borderline personality disorder is observed praising one nurse
while telling another nurse that they are ‘incompetent.’ This behavior is known as:
A. Projection
B. Rationalization
C. Sublimation
D. Splitting
Correct Answer: D
Explanation: Splitting is a common defense mechanism in borderline personality disorder
where the individual views others as either all good or all bad. This behavior serves to
protect the individual’s ego but often creates conflict among the healthcare team.
Consistent limits and team communication are essential to manage splitting effectively.
4. What is the therapeutic serum lithium level for a client in the acute manic phase of bipolar
disorder?
A. 0.1 to 0.5 mEq/L
, B. 1.5 to 2.0 mEq/L
C. 0.8 to 1.4 mEq/L
D. 2.5 to 3.0 mEq/L
Correct Answer: C
Explanation: The therapeutic range for lithium in acute mania is typically 0.8 to 1.4
mEq/L, while maintenance levels are slightly lower. Levels above 1.5 mEq/L are
considered toxic and require immediate intervention. Nurses must monitor renal function
and sodium levels as they directly impact lithium clearance.
5. A client is admitted to the unit following a suicide attempt. Which nursing action is the
highest priority?
A. Administering antidepressant medication
B. Implementing one-on-one observation
C. Encouraging the client to attend group therapy
D. Assessing the client’s past coping mechanisms
Correct Answer: B
Explanation: Safety is the absolute priority for a client who has recently attempted suicide.
Continuous one-on-one observation ensures the client remains in sight at all times to
prevent further self-harm. Other interventions are important for long-term recovery but do
not address the immediate safety risk.
Exit Exam Q&A with Rationale | Fortis College
1. A nurse is caring for a client with a history of alcohol use disorder who is experiencing
tremors, tachycardia, and diaphoresis. Which medication should the nurse expect to
administer first?
A. Disulfiram
B. Methadone
C. Lorazepam
D. Fluoxetine
Correct Answer: C
Explanation: The client is exhibiting signs of acute alcohol withdrawal, which can lead to
life-threatening seizures or delirium tremens. Benzodiazepines like lorazepam are the first-
line treatment to stabilize vital signs and prevent progression. Disulfiram is used for
maintenance of sobriety, not acute withdrawal management.
2. Which assessment finding should a nurse prioritize for a client newly prescribed clozapine
for treatment-resistant schizophrenia?
A. Body mass index of 28
B. Blood pressure of 140/90 mmHg
C. Fast blood glucose of 110 mg/dL
,D. White blood cell count of 2,500/mm3
Correct Answer: D
Explanation: Clozapine carries a black box warning for agranulocytosis, which is a
dangerously low white blood cell count. A WBC count of 2,500/mm3 is significantly below
the normal range and requires immediate notification of the provider. Frequent blood
monitoring is mandatory for any patient taking this medication.
3. A client diagnosed with borderline personality disorder is observed praising one nurse
while telling another nurse that they are ‘incompetent.’ This behavior is known as:
A. Projection
B. Rationalization
C. Sublimation
D. Splitting
Correct Answer: D
Explanation: Splitting is a common defense mechanism in borderline personality disorder
where the individual views others as either all good or all bad. This behavior serves to
protect the individual’s ego but often creates conflict among the healthcare team.
Consistent limits and team communication are essential to manage splitting effectively.
4. What is the therapeutic serum lithium level for a client in the acute manic phase of bipolar
disorder?
A. 0.1 to 0.5 mEq/L
, B. 1.5 to 2.0 mEq/L
C. 0.8 to 1.4 mEq/L
D. 2.5 to 3.0 mEq/L
Correct Answer: C
Explanation: The therapeutic range for lithium in acute mania is typically 0.8 to 1.4
mEq/L, while maintenance levels are slightly lower. Levels above 1.5 mEq/L are
considered toxic and require immediate intervention. Nurses must monitor renal function
and sodium levels as they directly impact lithium clearance.
5. A client is admitted to the unit following a suicide attempt. Which nursing action is the
highest priority?
A. Administering antidepressant medication
B. Implementing one-on-one observation
C. Encouraging the client to attend group therapy
D. Assessing the client’s past coping mechanisms
Correct Answer: B
Explanation: Safety is the absolute priority for a client who has recently attempted suicide.
Continuous one-on-one observation ensures the client remains in sight at all times to
prevent further self-harm. Other interventions are important for long-term recovery but do
not address the immediate safety risk.
