NUR 208/NUR208 Final Exam V3 | Mental Health
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client who has schizophrenia and is experiencing auditory
hallucinations. Which of the following responses should the nurse make?
A. “Why do you think the voices are talking to you right now?”
B. “I understand the voices are real to you, but I do not hear them.”
C. “The voices are just a part of your imagination and will go away soon.”
D. “Tell the voices to leave you alone so we can finish our talk.”
Correct Answer: B
Explanation: The nurse must acknowledge the client’s perception of the hallucinations
while maintaining reality. By stating that they do not hear the voices, the nurse avoids
reinforcing the hallucination. This therapeutic approach focuses on the client’s feelings and
provides a bridge to reality without being dismissive.
2. A client is prescribed lithium carbonate for bipolar disorder. Which of the following
findings should the nurse identify as an early sign of lithium toxicity?
A. Fine hand tremors and mild thirst
B. Blurred vision and muscle irritability
C. Diarrhea and vomiting
D. Severe hypotension and seizures
,Correct Answer: C
Explanation: Gastrointestinal distress, such as diarrhea, vomiting, and nausea, are early
indicators of lithium toxicity. The nurse should monitor these symptoms closely as they can
lead to electrolyte imbalances. Recognizing these early signs is critical to preventing
advanced toxicity and multi-organ failure.
3. A nurse is assessing a client with major depressive disorder. Which of the following should
the nurse identify as the priority assessment?
A. The client’s risk for self-harm or suicide.
B. The client’s history of substance abuse.
C. The client’s current support system at home.
D. The client’s ability to perform activities of daily living.
Correct Answer: A
Explanation: Safety is the highest priority in mental health nursing for clients with major
depressive disorder. Assessing for suicidal ideation, plan, and means ensures the
immediate safety of the client. Other assessments like ADLs and support systems are
important but secondary to the prevention of self-harm.
4. A client with a history of alcohol use disorder is admitted and shows signs of tremors,
tachycardia, and diaphoresis. Which medication should the nurse expect to administer?
A. Disulfiram
B. Lorazepam
, C. Methadone
D. Naloxone
Correct Answer: B
Explanation: Benzodiazepines like lorazepam are the first-line treatment for managing
alcohol withdrawal symptoms. They help stabilize vital signs and prevent the progression
to seizures or delirium tremens. The nurse must titrate the dose based on the client’s
Withdrawal Assessment (CIWA) scores.
5. A nurse is caring for a client with borderline personality disorder. The client says, ‘You are
the only nurse who understands me; the others are mean.’ Which defense mechanism is the
client using?
A. Splitting
B. Projection
C. Reaction formation
D. Displacement
Correct Answer: A
Explanation: Splitting is a common defense mechanism in borderline personality disorder
where the client views others as all good or all bad. This behavior often creates conflict
among the nursing staff and is a way for the client to cope with emotional instability. The
nurse should maintain consistent boundaries and communicate with the treatment team to
prevent manipulation.
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client who has schizophrenia and is experiencing auditory
hallucinations. Which of the following responses should the nurse make?
A. “Why do you think the voices are talking to you right now?”
B. “I understand the voices are real to you, but I do not hear them.”
C. “The voices are just a part of your imagination and will go away soon.”
D. “Tell the voices to leave you alone so we can finish our talk.”
Correct Answer: B
Explanation: The nurse must acknowledge the client’s perception of the hallucinations
while maintaining reality. By stating that they do not hear the voices, the nurse avoids
reinforcing the hallucination. This therapeutic approach focuses on the client’s feelings and
provides a bridge to reality without being dismissive.
2. A client is prescribed lithium carbonate for bipolar disorder. Which of the following
findings should the nurse identify as an early sign of lithium toxicity?
A. Fine hand tremors and mild thirst
B. Blurred vision and muscle irritability
C. Diarrhea and vomiting
D. Severe hypotension and seizures
,Correct Answer: C
Explanation: Gastrointestinal distress, such as diarrhea, vomiting, and nausea, are early
indicators of lithium toxicity. The nurse should monitor these symptoms closely as they can
lead to electrolyte imbalances. Recognizing these early signs is critical to preventing
advanced toxicity and multi-organ failure.
3. A nurse is assessing a client with major depressive disorder. Which of the following should
the nurse identify as the priority assessment?
A. The client’s risk for self-harm or suicide.
B. The client’s history of substance abuse.
C. The client’s current support system at home.
D. The client’s ability to perform activities of daily living.
Correct Answer: A
Explanation: Safety is the highest priority in mental health nursing for clients with major
depressive disorder. Assessing for suicidal ideation, plan, and means ensures the
immediate safety of the client. Other assessments like ADLs and support systems are
important but secondary to the prevention of self-harm.
4. A client with a history of alcohol use disorder is admitted and shows signs of tremors,
tachycardia, and diaphoresis. Which medication should the nurse expect to administer?
A. Disulfiram
B. Lorazepam
, C. Methadone
D. Naloxone
Correct Answer: B
Explanation: Benzodiazepines like lorazepam are the first-line treatment for managing
alcohol withdrawal symptoms. They help stabilize vital signs and prevent the progression
to seizures or delirium tremens. The nurse must titrate the dose based on the client’s
Withdrawal Assessment (CIWA) scores.
5. A nurse is caring for a client with borderline personality disorder. The client says, ‘You are
the only nurse who understands me; the others are mean.’ Which defense mechanism is the
client using?
A. Splitting
B. Projection
C. Reaction formation
D. Displacement
Correct Answer: A
Explanation: Splitting is a common defense mechanism in borderline personality disorder
where the client views others as all good or all bad. This behavior often creates conflict
among the nursing staff and is a way for the client to cope with emotional instability. The
nurse should maintain consistent boundaries and communicate with the treatment team to
prevent manipulation.
