NUR 208/NUR208 Exam 3 V1 | Mental Health
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client with Bipolar I Disorder who is experiencing a manic episode.
Which nutritional intervention is most appropriate?
A. Providing a high-calorie, high-protein meal in the dining room.
B. Encouraging the client to sit for 30 minutes to complete a standard meal.
C. Offering high-calorie finger foods and fluids to be consumed while walking.
D. Implementing a low-sodium diet to prevent lithium toxicity.
Correct Answer: C
Explanation: Clients in a manic state are often too hyperactive to sit down for a full meal.
Providing finger foods allows them to maintain nutritional intake while they are moving.
This intervention prevents weight loss and physical exhaustion during the manic phase.
2. A patient is prescribed Lithium Carbonate for the treatment of Bipolar Disorder. The nurse
should educate the patient that which of the following can increase the risk of lithium
toxicity?
A. Excessive sweating or dehydration.
B. Increasing dietary sodium intake.
C. Drinking 2 to 3 liters of water daily.
D. Avoiding caffeine-containing beverages.
,Correct Answer: A
Explanation: Lithium is a salt, and its levels are inversely related to sodium and fluid
balance in the body. Dehydration or low sodium intake causes the kidneys to reabsorb
lithium, leading to toxic levels. The patient must be taught to maintain consistent salt and
fluid intake to keep the therapeutic range between 0.6 and 1.2 mEq/L.
3. Which clinical finding is considered a ‘positive symptom’ of Schizophrenia?
A. Flat affect
B. Auditory hallucinations
C. Anhedonia
D. Avolition
Correct Answer: B
Explanation: Positive symptoms represent an excess or distortion of normal functions,
such as hallucinations or delusions. Negative symptoms, like flat affect or anhedonia,
involve a loss or decrease in normal functions. Distinguishing between these is vital for
determining the effectiveness of typical versus atypical antipsychotics.
4. A client diagnosed with Borderline Personality Disorder (BPD) is observed being very
friendly with one nurse while telling another nurse that they are ‘incompetent.’ This behavior
is known as:
A. Projection
B. Idealization
, C. Splitting
D. Transference
Correct Answer: C
Explanation: Splitting is a common defense mechanism in BPD where the individual views
people as either all good or all bad. This behavior often creates conflict among the
healthcare team members. Nurses must use a consistent, team-based approach to minimize
the impact of this behavior.
5. A nurse is assessing a client for potential suicide risk. Which statement by the client
indicates the highest level of lethality?
A. “I have a loaded gun in my bedside drawer at home.”
B. “I’ve been thinking about ending it all if things don’t get better.”
C. “I sometimes take too many of my sleeping pills to just forget.”
D. “I want to go to sleep and never wake up again.”
Correct Answer: A
Explanation: Lethality is determined by the specificity of the plan and the availability of
the means. A loaded gun is a highly lethal and immediate method, indicating an urgent risk.
The nurse must prioritize immediate safety interventions for this client.
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client with Bipolar I Disorder who is experiencing a manic episode.
Which nutritional intervention is most appropriate?
A. Providing a high-calorie, high-protein meal in the dining room.
B. Encouraging the client to sit for 30 minutes to complete a standard meal.
C. Offering high-calorie finger foods and fluids to be consumed while walking.
D. Implementing a low-sodium diet to prevent lithium toxicity.
Correct Answer: C
Explanation: Clients in a manic state are often too hyperactive to sit down for a full meal.
Providing finger foods allows them to maintain nutritional intake while they are moving.
This intervention prevents weight loss and physical exhaustion during the manic phase.
2. A patient is prescribed Lithium Carbonate for the treatment of Bipolar Disorder. The nurse
should educate the patient that which of the following can increase the risk of lithium
toxicity?
A. Excessive sweating or dehydration.
B. Increasing dietary sodium intake.
C. Drinking 2 to 3 liters of water daily.
D. Avoiding caffeine-containing beverages.
,Correct Answer: A
Explanation: Lithium is a salt, and its levels are inversely related to sodium and fluid
balance in the body. Dehydration or low sodium intake causes the kidneys to reabsorb
lithium, leading to toxic levels. The patient must be taught to maintain consistent salt and
fluid intake to keep the therapeutic range between 0.6 and 1.2 mEq/L.
3. Which clinical finding is considered a ‘positive symptom’ of Schizophrenia?
A. Flat affect
B. Auditory hallucinations
C. Anhedonia
D. Avolition
Correct Answer: B
Explanation: Positive symptoms represent an excess or distortion of normal functions,
such as hallucinations or delusions. Negative symptoms, like flat affect or anhedonia,
involve a loss or decrease in normal functions. Distinguishing between these is vital for
determining the effectiveness of typical versus atypical antipsychotics.
4. A client diagnosed with Borderline Personality Disorder (BPD) is observed being very
friendly with one nurse while telling another nurse that they are ‘incompetent.’ This behavior
is known as:
A. Projection
B. Idealization
, C. Splitting
D. Transference
Correct Answer: C
Explanation: Splitting is a common defense mechanism in BPD where the individual views
people as either all good or all bad. This behavior often creates conflict among the
healthcare team members. Nurses must use a consistent, team-based approach to minimize
the impact of this behavior.
5. A nurse is assessing a client for potential suicide risk. Which statement by the client
indicates the highest level of lethality?
A. “I have a loaded gun in my bedside drawer at home.”
B. “I’ve been thinking about ending it all if things don’t get better.”
C. “I sometimes take too many of my sleeping pills to just forget.”
D. “I want to go to sleep and never wake up again.”
Correct Answer: A
Explanation: Lethality is determined by the specificity of the plan and the availability of
the means. A loaded gun is a highly lethal and immediate method, indicating an urgent risk.
The nurse must prioritize immediate safety interventions for this client.
