NUR 208/NUR208 Exam 1 V3 | Mental Health
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client who is experiencing severe anxiety. Which of the following
actions should the nurse take first?
A. Instruct the client to use progressive muscle relaxation techniques.
B. Encourage the client to describe the feelings they are experiencing.
C. Administer an as-needed dose of lorazepam.
D. Remain with the client and provide a calm, quiet environment.
Correct Answer: D
Explanation: Safety and stabilization are the priorities when a client is in a state of severe
anxiety or panic. Remaining with the client provides a sense of security and prevents the
client from feeling abandoned during a crisis. A quiet environment helps reduce external
stimuli that could further exacerbate the client’s anxiety levels.
2. A client is being admitted involuntarily to a psychiatric unit. The nurse understands that
this type of admission is based on which of the following criteria?
A. The client refuses to take prescribed psychotropic medications.
B. The client is unable to manage their financial affairs.
C. The client is a danger to themselves or others due to mental illness.
D. The client has a history of multiple voluntary admissions.
,Correct Answer: C
Explanation: Involuntary admission is legally reserved for individuals who pose a
significant risk of harm to themselves or others. This process is intended to ensure safety
when the individual’s judgment is impaired by mental illness. The nurse must document
specific behaviors that meet the legal criteria for this emergency commitment.
3. A nurse is practicing therapeutic communication with a client. The client states, ‘I don’t
think I can handle this anymore.’ The nurse responds, ‘It sounds like you are feeling
overwhelmed.’ Which technique is the nurse using?
A. Exploring
B. Restating
C. Reflecting
D. Focusing
Correct Answer: C
Explanation: Reflecting involves directing back the client’s feelings or ideas so they can be
recognized and accepted. In this scenario, the nurse identifies the underlying emotion of
feeling overwhelmed and presents it back to the client. This technique encourages the
client to continue expressing their feelings in a supportive environment.
4. A nurse is assessing a client for lithium toxicity. Which of the following findings should the
nurse identify as an early sign of toxicity?
A. Fine hand tremors and nausea
, B. Coarse tremors and ataxia
C. Seizures and hypotension
D. Oliguria and blurred vision
Correct Answer: A
Explanation: Lithium has a narrow therapeutic index, making monitoring for toxicity
essential. Early signs of toxicity typically include gastrointestinal upset, such as nausea, and
fine hand tremors. As levels rise, these symptoms progress to more severe neurological and
systemic manifestations like coarse tremors and ataxia.
5. According to Erikson’s stages of psychosocial development, a 75-year-old client who feels
their life has been meaningful is demonstrating which of the following?
A. Generativity
B. Integrity
C. Intimacy
D. Autonomy
Correct Answer: B
Explanation: The stage of Integrity vs. Despair occurs during late adulthood. Individuals
who look back on their lives with a sense of fulfillment and pride achieve integrity. This
sense of peace allows the individual to face the end of life without significant regret or
despair.
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client who is experiencing severe anxiety. Which of the following
actions should the nurse take first?
A. Instruct the client to use progressive muscle relaxation techniques.
B. Encourage the client to describe the feelings they are experiencing.
C. Administer an as-needed dose of lorazepam.
D. Remain with the client and provide a calm, quiet environment.
Correct Answer: D
Explanation: Safety and stabilization are the priorities when a client is in a state of severe
anxiety or panic. Remaining with the client provides a sense of security and prevents the
client from feeling abandoned during a crisis. A quiet environment helps reduce external
stimuli that could further exacerbate the client’s anxiety levels.
2. A client is being admitted involuntarily to a psychiatric unit. The nurse understands that
this type of admission is based on which of the following criteria?
A. The client refuses to take prescribed psychotropic medications.
B. The client is unable to manage their financial affairs.
C. The client is a danger to themselves or others due to mental illness.
D. The client has a history of multiple voluntary admissions.
,Correct Answer: C
Explanation: Involuntary admission is legally reserved for individuals who pose a
significant risk of harm to themselves or others. This process is intended to ensure safety
when the individual’s judgment is impaired by mental illness. The nurse must document
specific behaviors that meet the legal criteria for this emergency commitment.
3. A nurse is practicing therapeutic communication with a client. The client states, ‘I don’t
think I can handle this anymore.’ The nurse responds, ‘It sounds like you are feeling
overwhelmed.’ Which technique is the nurse using?
A. Exploring
B. Restating
C. Reflecting
D. Focusing
Correct Answer: C
Explanation: Reflecting involves directing back the client’s feelings or ideas so they can be
recognized and accepted. In this scenario, the nurse identifies the underlying emotion of
feeling overwhelmed and presents it back to the client. This technique encourages the
client to continue expressing their feelings in a supportive environment.
4. A nurse is assessing a client for lithium toxicity. Which of the following findings should the
nurse identify as an early sign of toxicity?
A. Fine hand tremors and nausea
, B. Coarse tremors and ataxia
C. Seizures and hypotension
D. Oliguria and blurred vision
Correct Answer: A
Explanation: Lithium has a narrow therapeutic index, making monitoring for toxicity
essential. Early signs of toxicity typically include gastrointestinal upset, such as nausea, and
fine hand tremors. As levels rise, these symptoms progress to more severe neurological and
systemic manifestations like coarse tremors and ataxia.
5. According to Erikson’s stages of psychosocial development, a 75-year-old client who feels
their life has been meaningful is demonstrating which of the following?
A. Generativity
B. Integrity
C. Intimacy
D. Autonomy
Correct Answer: B
Explanation: The stage of Integrity vs. Despair occurs during late adulthood. Individuals
who look back on their lives with a sense of fulfillment and pride achieve integrity. This
sense of peace allows the individual to face the end of life without significant regret or
despair.
