NUR 208/NUR208 Exam 3 V3 | Mental Health
Nursing Q&A with Rationale | Fortis College
1. A client diagnosed with Bipolar I Disorder is in the midst of a manic episode. The client is
pacing the hallway, speaking loudly and rapidly, and has not eaten in 24 hours. Which nursing
intervention is the priority?
A. Encourage the client to join a group therapy session to improve social skills.
B. Administer a PRN sedative and place the client in a seclusion room.
C. Ask the client to sit in the dayroom and watch a relaxing movie.
D. Provide the client with high-calorie, nutritious finger foods and fluids.
Correct Answer: D
Explanation: Clients in a manic state often have difficulty sitting still long enough to
consume adequate nutrition. Providing finger foods allows the client to satisfy nutritional
needs while remaining mobile. This intervention addresses physical safety and
physiological needs, which are prioritized in the acute phase of mania.
2. A nurse is caring for a client who has been taking Lithium Carbonate for three months. The
client reports blurred vision, a coarse hand tremor, and severe diarrhea. What action should
the nurse take first?
A. Administer the next scheduled dose of Lithium as prescribed.
B. Hold the medication and request a serum Lithium level.
,C. Advise the client to increase their sodium intake immediately.
D. Reassure the client that these are common, expected side effects.
Correct Answer: B
Explanation: The symptoms of blurred vision, coarse tremors, and severe diarrhea are
indicative of Lithium toxicity. The nurse must immediately stop the medication to prevent
further toxicity and potential permanent organ damage. Obtaining a serum level is the
definitive method to determine the extent of toxicity and guide treatment.
3. Which assessment finding in a client diagnosed with Major Depressive Disorder (MDD)
requires the most immediate intervention by the nurse?
A. The client reports sleeping 12 hours a day and feeling fatigued.
B. The client states they have no appetite and have lost 5 pounds.
C. The client refuses to participate in the morning hygiene routine.
D. The client gives away a prized possession and expresses a sense of relief.
Correct Answer: D
Explanation: Giving away possessions and expressing sudden relief are classic warning
signs of impending suicide, as the client may have finalized a plan. This behavioral change
indicates a significantly increased risk to the client’s safety. The nurse must prioritize a
suicide assessment and implement safety precautions immediately.
,4. A client is admitted with a diagnosis of Schizophrenia, Paranoid Type. The client tells the
nurse, ‘The FBI has planted a listening device in my tooth to monitor my thoughts.’ How
should the nurse respond?
A. ‘I understand you believe this, but I do not see any evidence of a device.’
B. ‘That is impossible; the FBI does not have the technology to do that.’
C. ‘Why would the FBI want to monitor your thoughts specifically?’
D. ‘I will call the dentist to have your tooth checked for any devices.’
Correct Answer: A
Explanation: This response acknowledges the client’s perception without validating the
delusion, which helps maintain a therapeutic relationship while presenting reality. Arguing
with the client or asking ‘why’ can increase defensiveness or reinforce the delusional
system. Presenting reality gently is the standard approach for managing delusional
thinking in psychotic disorders.
5. A nurse is teaching a client about a newly prescribed Monoamine Oxidase Inhibitor
(MAOI). Which food choice by the client indicates a need for further teaching?
A. Grilled chicken with steamed broccoli
B. Fresh apple slices and peanut butter
C. A pepperoni pizza with aged cheddar cheese
D. Scrambled eggs and whole-wheat toast
, Correct Answer: C
Explanation: Foods containing high levels of tyramine, such as aged cheeses and processed
meats like pepperoni, must be avoided while taking MAOIs. Consuming tyramine while on
an MAOI can trigger a hypertensive crisis, which is a medical emergency. The nurse must
ensure the client understands the strict dietary restrictions required for safety.
6. A client diagnosed with Borderline Personality Disorder is observed being very friendly
with one nurse while being hostile and demeaning toward another nurse. What is the nurse’s
best understanding of this behavior?
A. The client is experiencing a manic episode and needs stabilization.
B. The client has a preference for certain personality types among staff.
C. The client is using ‘splitting’ as a defense mechanism.
D. The client is showing signs of early-onset dementia.
Correct Answer: C
Explanation: Splitting is a common defense mechanism in Borderline Personality Disorder
where the individual views people or situations as either ‘all good’ or ‘all bad.’ This
behavior often leads to staff conflict and requires a consistent, unified team approach to
care. Recognizing this behavior allows the nursing team to set firm boundaries and prevent
manipulation.
Nursing Q&A with Rationale | Fortis College
1. A client diagnosed with Bipolar I Disorder is in the midst of a manic episode. The client is
pacing the hallway, speaking loudly and rapidly, and has not eaten in 24 hours. Which nursing
intervention is the priority?
A. Encourage the client to join a group therapy session to improve social skills.
B. Administer a PRN sedative and place the client in a seclusion room.
C. Ask the client to sit in the dayroom and watch a relaxing movie.
D. Provide the client with high-calorie, nutritious finger foods and fluids.
Correct Answer: D
Explanation: Clients in a manic state often have difficulty sitting still long enough to
consume adequate nutrition. Providing finger foods allows the client to satisfy nutritional
needs while remaining mobile. This intervention addresses physical safety and
physiological needs, which are prioritized in the acute phase of mania.
2. A nurse is caring for a client who has been taking Lithium Carbonate for three months. The
client reports blurred vision, a coarse hand tremor, and severe diarrhea. What action should
the nurse take first?
A. Administer the next scheduled dose of Lithium as prescribed.
B. Hold the medication and request a serum Lithium level.
,C. Advise the client to increase their sodium intake immediately.
D. Reassure the client that these are common, expected side effects.
Correct Answer: B
Explanation: The symptoms of blurred vision, coarse tremors, and severe diarrhea are
indicative of Lithium toxicity. The nurse must immediately stop the medication to prevent
further toxicity and potential permanent organ damage. Obtaining a serum level is the
definitive method to determine the extent of toxicity and guide treatment.
3. Which assessment finding in a client diagnosed with Major Depressive Disorder (MDD)
requires the most immediate intervention by the nurse?
A. The client reports sleeping 12 hours a day and feeling fatigued.
B. The client states they have no appetite and have lost 5 pounds.
C. The client refuses to participate in the morning hygiene routine.
D. The client gives away a prized possession and expresses a sense of relief.
Correct Answer: D
Explanation: Giving away possessions and expressing sudden relief are classic warning
signs of impending suicide, as the client may have finalized a plan. This behavioral change
indicates a significantly increased risk to the client’s safety. The nurse must prioritize a
suicide assessment and implement safety precautions immediately.
,4. A client is admitted with a diagnosis of Schizophrenia, Paranoid Type. The client tells the
nurse, ‘The FBI has planted a listening device in my tooth to monitor my thoughts.’ How
should the nurse respond?
A. ‘I understand you believe this, but I do not see any evidence of a device.’
B. ‘That is impossible; the FBI does not have the technology to do that.’
C. ‘Why would the FBI want to monitor your thoughts specifically?’
D. ‘I will call the dentist to have your tooth checked for any devices.’
Correct Answer: A
Explanation: This response acknowledges the client’s perception without validating the
delusion, which helps maintain a therapeutic relationship while presenting reality. Arguing
with the client or asking ‘why’ can increase defensiveness or reinforce the delusional
system. Presenting reality gently is the standard approach for managing delusional
thinking in psychotic disorders.
5. A nurse is teaching a client about a newly prescribed Monoamine Oxidase Inhibitor
(MAOI). Which food choice by the client indicates a need for further teaching?
A. Grilled chicken with steamed broccoli
B. Fresh apple slices and peanut butter
C. A pepperoni pizza with aged cheddar cheese
D. Scrambled eggs and whole-wheat toast
, Correct Answer: C
Explanation: Foods containing high levels of tyramine, such as aged cheeses and processed
meats like pepperoni, must be avoided while taking MAOIs. Consuming tyramine while on
an MAOI can trigger a hypertensive crisis, which is a medical emergency. The nurse must
ensure the client understands the strict dietary restrictions required for safety.
6. A client diagnosed with Borderline Personality Disorder is observed being very friendly
with one nurse while being hostile and demeaning toward another nurse. What is the nurse’s
best understanding of this behavior?
A. The client is experiencing a manic episode and needs stabilization.
B. The client has a preference for certain personality types among staff.
C. The client is using ‘splitting’ as a defense mechanism.
D. The client is showing signs of early-onset dementia.
Correct Answer: C
Explanation: Splitting is a common defense mechanism in Borderline Personality Disorder
where the individual views people or situations as either ‘all good’ or ‘all bad.’ This
behavior often leads to staff conflict and requires a consistent, unified team approach to
care. Recognizing this behavior allows the nursing team to set firm boundaries and prevent
manipulation.
