NUR 208/NUR208 Exam 1 V2 | Mental Health
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a client who has major depressive disorder. Which of the following
findings should the nurse identify as a manifestation of the cognitive triad of depression?
A. Weight loss, insomnia, and fatigue.
B. Psychomotor agitation, pressured speech, and flight of ideas.
C. Feelings of hopelessness, a negative view of self, and a negative view of the future.
D. Hallucinations, delusions, and disorganized thinking.
Correct Answer: C
Explanation: The cognitive triad involves a negative view of self, the world, and the future.
This theory suggests that depressed individuals process information in a biased way.
Recognizing these cognitive patterns is essential for planning Cognitive Behavioral Therapy
interventions.
2. A nurse is caring for a client who is experiencing a severe panic attack. Which of the
following actions should the nurse take first?
A. Encourage the client to explore the cause of the anxiety.
B. Teach the client deep-breathing exercises.
C. Administer a dose of alprazolam.
D. Stay with the client and remain quiet.
,Correct Answer: D
Explanation: Staying with a client during a panic attack provides a sense of safety and
reduces the fear of being alone. During severe or panic levels of anxiety, the client is unable
to learn new information or process complex instructions. Safety and physical presence are
the immediate priorities before any educational or pharmacological interventions are fully
effective.
3. A nurse is reviewing the laboratory results for a client who has been taking lithium
carbonate for one week. The client’s lithium level is 0.8 mEq/L. Which of the following actions
should the nurse take?
A. Withhold the next dose and notify the provider.
B. Instruct the client to increase their salt intake.
C. Prepare for emergency hemodialysis.
D. Administer the next dose as scheduled.
Correct Answer: D
Explanation: A therapeutic lithium level for acute mania is generally 0.8 to 1.2 mEq/L, and
for maintenance, it is 0.6 to 1.2 mEq/L. The result of 0.8 mEq/L is within the therapeutic
range, so the nurse should continue the treatment. Monitoring for signs of toxicity remains
a priority, but no intervention is required for this normal lab value.
, 4. A nurse is providing teaching to a client who has a new prescription for phenelzine. Which
of the following foods should the nurse instruct the client to avoid?
A. Smoked salmon
B. Fresh green beans
C. Cottage cheese
D. Whole grain bread
Correct Answer: A
Explanation: Phenelzine is an MAOI, which requires a tyramine-restricted diet to prevent
hypertensive crisis. Smoked, aged, cured, or fermented foods like smoked salmon are high
in tyramine and must be avoided. The other options do not contain significant amounts of
tyramine and are safe to consume.
5. A client states, ‘I think my wife is cheating on me because she’s been working late every
night.’ The nurse knows the client is the one actually having an affair. Which defense
mechanism is the client using?
A. Reaction Formation
B. Sublimation
C. Displacement
D. Projection
Correct Answer: D
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a client who has major depressive disorder. Which of the following
findings should the nurse identify as a manifestation of the cognitive triad of depression?
A. Weight loss, insomnia, and fatigue.
B. Psychomotor agitation, pressured speech, and flight of ideas.
C. Feelings of hopelessness, a negative view of self, and a negative view of the future.
D. Hallucinations, delusions, and disorganized thinking.
Correct Answer: C
Explanation: The cognitive triad involves a negative view of self, the world, and the future.
This theory suggests that depressed individuals process information in a biased way.
Recognizing these cognitive patterns is essential for planning Cognitive Behavioral Therapy
interventions.
2. A nurse is caring for a client who is experiencing a severe panic attack. Which of the
following actions should the nurse take first?
A. Encourage the client to explore the cause of the anxiety.
B. Teach the client deep-breathing exercises.
C. Administer a dose of alprazolam.
D. Stay with the client and remain quiet.
,Correct Answer: D
Explanation: Staying with a client during a panic attack provides a sense of safety and
reduces the fear of being alone. During severe or panic levels of anxiety, the client is unable
to learn new information or process complex instructions. Safety and physical presence are
the immediate priorities before any educational or pharmacological interventions are fully
effective.
3. A nurse is reviewing the laboratory results for a client who has been taking lithium
carbonate for one week. The client’s lithium level is 0.8 mEq/L. Which of the following actions
should the nurse take?
A. Withhold the next dose and notify the provider.
B. Instruct the client to increase their salt intake.
C. Prepare for emergency hemodialysis.
D. Administer the next dose as scheduled.
Correct Answer: D
Explanation: A therapeutic lithium level for acute mania is generally 0.8 to 1.2 mEq/L, and
for maintenance, it is 0.6 to 1.2 mEq/L. The result of 0.8 mEq/L is within the therapeutic
range, so the nurse should continue the treatment. Monitoring for signs of toxicity remains
a priority, but no intervention is required for this normal lab value.
, 4. A nurse is providing teaching to a client who has a new prescription for phenelzine. Which
of the following foods should the nurse instruct the client to avoid?
A. Smoked salmon
B. Fresh green beans
C. Cottage cheese
D. Whole grain bread
Correct Answer: A
Explanation: Phenelzine is an MAOI, which requires a tyramine-restricted diet to prevent
hypertensive crisis. Smoked, aged, cured, or fermented foods like smoked salmon are high
in tyramine and must be avoided. The other options do not contain significant amounts of
tyramine and are safe to consume.
5. A client states, ‘I think my wife is cheating on me because she’s been working late every
night.’ The nurse knows the client is the one actually having an affair. Which defense
mechanism is the client using?
A. Reaction Formation
B. Sublimation
C. Displacement
D. Projection
Correct Answer: D
