NUR 208/NUR208 Exam 2 V3 | Mental Health
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client experiencing a panic attack. Which of the following nursing
interventions is the priority?
A. Instruct the client to use deep breathing exercises immediately.
B. Administer a prescribed PRN dose of an SSRI medication.
C. Stay with the client and remain calm while using short sentences.
D. Ask the client to explain the triggers for their current anxiety.
Correct Answer: C
Explanation: During a panic attack, the client’s ability to process information is severely
limited due to extreme physiological distress. Staying with the client provides a sense of
safety and prevents further escalation of panic symptoms. Short, simple sentences are
necessary because the client cannot focus on complex instructions or lengthy conversations
during this state.
2. A client with bipolar disorder is in the acute manic phase. Which meal choice is most
appropriate for the nurse to provide?
A. A bowl of vegetable soup and a slice of toasted bread.
B. Beef stew with a side of mashed potatoes and a dinner roll.
C. Spaghetti and meatballs with a side salad and a glass of water.
,D. A grilled cheese sandwich, an apple, and a carton of milk.
Correct Answer: D
Explanation: Clients in the manic phase have high energy levels and often cannot sit down
long enough to eat a full meal using utensils. Finger foods allow the client to maintain
nutritional intake while moving around the unit. This specific meal provides necessary
calories and protein in a format that accommodates the client’s hyperactivity.
3. A nurse is assessing a client taking Lithium Carbonate. The client reports blurred vision and
a coarse hand tremor. Which action should the nurse take first?
A. Advise the client to increase their fluid intake for the day.
B. Reassure the client that these are common side effects of the medication.
C. Request a stat ECG to check for cardiac arrhythmias.
D. Hold the medication and notify the healthcare provider.
Correct Answer: D
Explanation: Blurred vision and coarse hand tremors are classic signs of advanced lithium
toxicity, which can be life-threatening if not addressed. The nurse must immediately stop
administration to prevent further toxicity and contact the provider for a blood level check.
The therapeutic range for lithium is narrow, and symptoms of toxicity require urgent
medical intervention.
, 4. A client diagnosed with Obsessive-Compulsive Disorder (OCD) spends two hours daily
washing their hands. Which nursing action is most appropriate during the initial phase of
treatment?
A. Provide a set schedule that allows time for the ritual to be completed.
B. Lock the bathroom door to prevent the client from performing the ritual.
C. Confront the client about the irrational nature of the hand-washing.
D. Administer an antipsychotic medication to reduce the compulsion.
Correct Answer: A
Explanation: During the initial phase of care, the nurse should allow the client to perform
rituals to avoid a massive increase in anxiety. Forcing the client to stop a ritual abruptly
without teaching coping mechanisms can lead to severe panic or agitation. Over time, the
nurse will work with the client to gradually limit the time spent on rituals through
cognitive-behavioral techniques.
5. A nurse is teaching a client who is starting Phenelzine for depression. Which food should
the nurse instruct the client to avoid?
A. Fresh chicken breast and steamed rice.
B. Pepperoni pizza and aged cheddar cheese.
C. Canned green beans and boiled potatoes.
D. Whole grain bread and creamy peanut butter.
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client experiencing a panic attack. Which of the following nursing
interventions is the priority?
A. Instruct the client to use deep breathing exercises immediately.
B. Administer a prescribed PRN dose of an SSRI medication.
C. Stay with the client and remain calm while using short sentences.
D. Ask the client to explain the triggers for their current anxiety.
Correct Answer: C
Explanation: During a panic attack, the client’s ability to process information is severely
limited due to extreme physiological distress. Staying with the client provides a sense of
safety and prevents further escalation of panic symptoms. Short, simple sentences are
necessary because the client cannot focus on complex instructions or lengthy conversations
during this state.
2. A client with bipolar disorder is in the acute manic phase. Which meal choice is most
appropriate for the nurse to provide?
A. A bowl of vegetable soup and a slice of toasted bread.
B. Beef stew with a side of mashed potatoes and a dinner roll.
C. Spaghetti and meatballs with a side salad and a glass of water.
,D. A grilled cheese sandwich, an apple, and a carton of milk.
Correct Answer: D
Explanation: Clients in the manic phase have high energy levels and often cannot sit down
long enough to eat a full meal using utensils. Finger foods allow the client to maintain
nutritional intake while moving around the unit. This specific meal provides necessary
calories and protein in a format that accommodates the client’s hyperactivity.
3. A nurse is assessing a client taking Lithium Carbonate. The client reports blurred vision and
a coarse hand tremor. Which action should the nurse take first?
A. Advise the client to increase their fluid intake for the day.
B. Reassure the client that these are common side effects of the medication.
C. Request a stat ECG to check for cardiac arrhythmias.
D. Hold the medication and notify the healthcare provider.
Correct Answer: D
Explanation: Blurred vision and coarse hand tremors are classic signs of advanced lithium
toxicity, which can be life-threatening if not addressed. The nurse must immediately stop
administration to prevent further toxicity and contact the provider for a blood level check.
The therapeutic range for lithium is narrow, and symptoms of toxicity require urgent
medical intervention.
, 4. A client diagnosed with Obsessive-Compulsive Disorder (OCD) spends two hours daily
washing their hands. Which nursing action is most appropriate during the initial phase of
treatment?
A. Provide a set schedule that allows time for the ritual to be completed.
B. Lock the bathroom door to prevent the client from performing the ritual.
C. Confront the client about the irrational nature of the hand-washing.
D. Administer an antipsychotic medication to reduce the compulsion.
Correct Answer: A
Explanation: During the initial phase of care, the nurse should allow the client to perform
rituals to avoid a massive increase in anxiety. Forcing the client to stop a ritual abruptly
without teaching coping mechanisms can lead to severe panic or agitation. Over time, the
nurse will work with the client to gradually limit the time spent on rituals through
cognitive-behavioral techniques.
5. A nurse is teaching a client who is starting Phenelzine for depression. Which food should
the nurse instruct the client to avoid?
A. Fresh chicken breast and steamed rice.
B. Pepperoni pizza and aged cheddar cheese.
C. Canned green beans and boiled potatoes.
D. Whole grain bread and creamy peanut butter.
