NUR 208/NUR208 Final Exam V2 | Mental Health
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client who states, “I feel like my life is a total failure and nothing
matters anymore.” Which of the following is the most therapeutic response?
A. “Why do you feel that way today?”
B. “I’m sure things aren’t as bad as they seem.”
C. “You feel as though your life has no meaning right now?”
D. “You should focus on the positive aspects of your life.”
Correct Answer: C
Explanation: This response uses the therapeutic technique of restating or reflecting, which
encourages the client to explore their feelings further. It avoids asking ‘why’ questions,
which can be perceived as accusatory and may cause the client to become defensive. By
validating the client’s current emotional state, the nurse builds a rapport that is essential
for effective mental health nursing care.
2. A client diagnosed with Bipolar Disorder is in the manic phase and is moving rapidly around
the unit. Which of the following nutritional interventions is most appropriate?
A. Offer high-calorie, high-protein finger foods that can be eaten while walking.
B. Provide a quiet place for the client to sit and eat a three-course meal.
C. Restrict fluid intake to prevent electrolyte imbalances during activity.
,D. Allow the client to skip meals until they are in a calmer state.
Correct Answer: A
Explanation: Clients in a manic state often have difficulty sitting still long enough to
consume adequate calories. Providing high-calorie finger foods allows the client to
maintain nutrition while remaining active on the unit. This intervention addresses the
physiological need for energy and prevents exhaustion or weight loss during the manic
episode.
3. Which of the following assessments is the priority for a client who was started on
Clozapine (Clozaril) two weeks ago?
A. Monitoring for fine hand tremors.
B. Reviewing the weekly White Blood Cell (WBC) count.
C. Checking the client’s weight and BMI.
D. Assessing for dry mouth and urinary retention.
Correct Answer: B
Explanation: Clozapine carries a significant risk of agranulocytosis, which is a severe and
potentially fatal decrease in the white blood cell count. Regular monitoring of the absolute
neutrophil count and WBC is a mandatory safety requirement for this medication. If the
WBC drops too low, the medication must be discontinued immediately to prevent life-
threatening infections.
,4. A nurse is assessing a client for suspected Lithium toxicity. Which of the following findings
should the nurse identify as an early sign of toxicity?
A. Severe hypotension and cardiac arrhythmias.
B. Coarse hand tremors and gastrointestinal upset.
C. Seizures and a decreased level of consciousness.
D. Polyuria and mild thirst.
Correct Answer: B
Explanation: Early signs of lithium toxicity typically include coarse hand tremors, nausea,
vomiting, and diarrhea. These symptoms usually occur when lithium levels exceed 1.5
mEq/L. The nurse must recognize these early indicators to prevent the progression to
severe toxicity, which can result in permanent neurological damage or death.
5. A client is being admitted involuntarily to a psychiatric unit. The nurse understands that
this type of admission is primarily based on which of the following criteria?
A. The client’s refusal to take prescribed psychiatric medications.
B. A diagnosis of a severe mental illness such as Schizophrenia.
C. The client’s inability to provide for their own basic needs or being a danger to self or
others.
D. The client’s family requesting that the client be hospitalized for treatment.
Correct Answer: C
, Explanation: Involuntary admission is legally reserved for individuals who pose a clear
danger to themselves or others, or who are so gravely disabled they cannot care for basic
needs. This process is governed by state laws to protect the individual’s civil liberties while
ensuring safety. The nurse must document the specific behaviors that justify the need for
involuntary commitment throughout the stay.
6. A nurse is providing teaching to a client starting Phenelzine (Nardil). Which food choice by
the client indicates an understanding of the dietary restrictions?
A. Pepperoni pizza with extra cheese.
B. Avocado toast with smoked salmon.
C. A glass of red wine with aged cheddar cheese.
D. Grilled chicken breast with steamed broccoli.
Correct Answer: D
Explanation: Phenelzine is a Monoamine Oxidase Inhibitor (MAOI) that requires a low-
tyramine diet to prevent a hypertensive crisis. Foods such as aged cheeses, cured meats,
red wine, and overripe fruits (like avocados) are high in tyramine and must be avoided.
Grilled chicken and steamed broccoli are safe options that do not contain significant
amounts of tyramine.
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client who states, “I feel like my life is a total failure and nothing
matters anymore.” Which of the following is the most therapeutic response?
A. “Why do you feel that way today?”
B. “I’m sure things aren’t as bad as they seem.”
C. “You feel as though your life has no meaning right now?”
D. “You should focus on the positive aspects of your life.”
Correct Answer: C
Explanation: This response uses the therapeutic technique of restating or reflecting, which
encourages the client to explore their feelings further. It avoids asking ‘why’ questions,
which can be perceived as accusatory and may cause the client to become defensive. By
validating the client’s current emotional state, the nurse builds a rapport that is essential
for effective mental health nursing care.
2. A client diagnosed with Bipolar Disorder is in the manic phase and is moving rapidly around
the unit. Which of the following nutritional interventions is most appropriate?
A. Offer high-calorie, high-protein finger foods that can be eaten while walking.
B. Provide a quiet place for the client to sit and eat a three-course meal.
C. Restrict fluid intake to prevent electrolyte imbalances during activity.
,D. Allow the client to skip meals until they are in a calmer state.
Correct Answer: A
Explanation: Clients in a manic state often have difficulty sitting still long enough to
consume adequate calories. Providing high-calorie finger foods allows the client to
maintain nutrition while remaining active on the unit. This intervention addresses the
physiological need for energy and prevents exhaustion or weight loss during the manic
episode.
3. Which of the following assessments is the priority for a client who was started on
Clozapine (Clozaril) two weeks ago?
A. Monitoring for fine hand tremors.
B. Reviewing the weekly White Blood Cell (WBC) count.
C. Checking the client’s weight and BMI.
D. Assessing for dry mouth and urinary retention.
Correct Answer: B
Explanation: Clozapine carries a significant risk of agranulocytosis, which is a severe and
potentially fatal decrease in the white blood cell count. Regular monitoring of the absolute
neutrophil count and WBC is a mandatory safety requirement for this medication. If the
WBC drops too low, the medication must be discontinued immediately to prevent life-
threatening infections.
,4. A nurse is assessing a client for suspected Lithium toxicity. Which of the following findings
should the nurse identify as an early sign of toxicity?
A. Severe hypotension and cardiac arrhythmias.
B. Coarse hand tremors and gastrointestinal upset.
C. Seizures and a decreased level of consciousness.
D. Polyuria and mild thirst.
Correct Answer: B
Explanation: Early signs of lithium toxicity typically include coarse hand tremors, nausea,
vomiting, and diarrhea. These symptoms usually occur when lithium levels exceed 1.5
mEq/L. The nurse must recognize these early indicators to prevent the progression to
severe toxicity, which can result in permanent neurological damage or death.
5. A client is being admitted involuntarily to a psychiatric unit. The nurse understands that
this type of admission is primarily based on which of the following criteria?
A. The client’s refusal to take prescribed psychiatric medications.
B. A diagnosis of a severe mental illness such as Schizophrenia.
C. The client’s inability to provide for their own basic needs or being a danger to self or
others.
D. The client’s family requesting that the client be hospitalized for treatment.
Correct Answer: C
, Explanation: Involuntary admission is legally reserved for individuals who pose a clear
danger to themselves or others, or who are so gravely disabled they cannot care for basic
needs. This process is governed by state laws to protect the individual’s civil liberties while
ensuring safety. The nurse must document the specific behaviors that justify the need for
involuntary commitment throughout the stay.
6. A nurse is providing teaching to a client starting Phenelzine (Nardil). Which food choice by
the client indicates an understanding of the dietary restrictions?
A. Pepperoni pizza with extra cheese.
B. Avocado toast with smoked salmon.
C. A glass of red wine with aged cheddar cheese.
D. Grilled chicken breast with steamed broccoli.
Correct Answer: D
Explanation: Phenelzine is a Monoamine Oxidase Inhibitor (MAOI) that requires a low-
tyramine diet to prevent a hypertensive crisis. Foods such as aged cheeses, cured meats,
red wine, and overripe fruits (like avocados) are high in tyramine and must be avoided.
Grilled chicken and steamed broccoli are safe options that do not contain significant
amounts of tyramine.
