NUR 208/NUR208 Final Exam V1 | Mental Health
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client with schizophrenia who is experiencing auditory
hallucinations. Which is the most therapeutic response by the nurse?
A. “I don’t hear the voices, but I can see that you are frightened.”
B. “The voices are not real; they are just part of your illness.”
C. “What are the voices telling you to do right now?”
D. “Try to ignore the voices and focus on the group activity.”
Correct Answer: A
Explanation: Acknowledging the client’s feelings while presenting reality is a fundamental
therapeutic technique in psychosis management. This approach validates the client’s
experience without agreeing with the hallucination, which helps build trust. By addressing
the emotional impact, the nurse provides comfort and safety in a non-judgmental manner.
2. A client is prescribed Lithium Carbonate for Bipolar I Disorder. Which laboratory value
should the nurse prioritize for review?
A. Serum Creatinine and BUN
B. Complete Blood Count
C. Liver function tests
D. Amylase and lipase levels
,Correct Answer: A
Explanation: Lithium is excreted primarily by the kidneys, making renal function
monitoring essential to prevent toxicity. Elevated creatinine or BUN levels indicate
impaired clearance, which could lead to dangerously high lithium levels in the blood.
Regular monitoring of these values ensures the medication remains within the narrow
therapeutic range of 0.6 to 1.2 mEq/L.
3. A client with Borderline Personality Disorder is being manipulative and trying to pit staff
members against each other. What is this behavior called?
A. Projective identification
B. Rationalization
C. Dissociation
D. Splitting
Correct Answer: D
Explanation: Splitting is a common defense mechanism in Borderline Personality Disorder
where the client views individuals as either all good or all bad. This behavior often creates
conflict among the healthcare team as the client attempts to divide staff. Consistent limit
setting and clear communication among team members are necessary to manage this
behavior effectively.
4. Which assessment finding is most characteristic of a client experiencing Delirium?
A. Gradual onset of memory loss over several years
, B. Sudden onset of fluctuating levels of consciousness
C. Stable vital signs despite cognitive impairment
D. Irreversible decline in executive functioning
Correct Answer: B
Explanation: Delirium is characterized by a rapid, acute onset of confusion and changes in
consciousness that typically fluctuate throughout the day. Unlike dementia, delirium is
often secondary to an underlying medical condition like infection or dehydration and is
potentially reversible. Nurses must prioritize identifying the physiological cause to prevent
permanent damage or death.
5. A nurse is providing education to a client starting a Monoamine Oxidase Inhibitor (MAOI).
Which food must be avoided?
A. Aged cheddar cheese
B. Fresh green leafy vegetables
C. Whole grain bread
D. Grilled chicken breast
Correct Answer: A
Explanation: Clients taking MAOIs must adhere to a low-tyramine diet to prevent a
hypertensive crisis, a life-threatening complication. Aged cheeses, cured meats, and
fermented products contain high levels of tyramine which can cause a massive release of
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client with schizophrenia who is experiencing auditory
hallucinations. Which is the most therapeutic response by the nurse?
A. “I don’t hear the voices, but I can see that you are frightened.”
B. “The voices are not real; they are just part of your illness.”
C. “What are the voices telling you to do right now?”
D. “Try to ignore the voices and focus on the group activity.”
Correct Answer: A
Explanation: Acknowledging the client’s feelings while presenting reality is a fundamental
therapeutic technique in psychosis management. This approach validates the client’s
experience without agreeing with the hallucination, which helps build trust. By addressing
the emotional impact, the nurse provides comfort and safety in a non-judgmental manner.
2. A client is prescribed Lithium Carbonate for Bipolar I Disorder. Which laboratory value
should the nurse prioritize for review?
A. Serum Creatinine and BUN
B. Complete Blood Count
C. Liver function tests
D. Amylase and lipase levels
,Correct Answer: A
Explanation: Lithium is excreted primarily by the kidneys, making renal function
monitoring essential to prevent toxicity. Elevated creatinine or BUN levels indicate
impaired clearance, which could lead to dangerously high lithium levels in the blood.
Regular monitoring of these values ensures the medication remains within the narrow
therapeutic range of 0.6 to 1.2 mEq/L.
3. A client with Borderline Personality Disorder is being manipulative and trying to pit staff
members against each other. What is this behavior called?
A. Projective identification
B. Rationalization
C. Dissociation
D. Splitting
Correct Answer: D
Explanation: Splitting is a common defense mechanism in Borderline Personality Disorder
where the client views individuals as either all good or all bad. This behavior often creates
conflict among the healthcare team as the client attempts to divide staff. Consistent limit
setting and clear communication among team members are necessary to manage this
behavior effectively.
4. Which assessment finding is most characteristic of a client experiencing Delirium?
A. Gradual onset of memory loss over several years
, B. Sudden onset of fluctuating levels of consciousness
C. Stable vital signs despite cognitive impairment
D. Irreversible decline in executive functioning
Correct Answer: B
Explanation: Delirium is characterized by a rapid, acute onset of confusion and changes in
consciousness that typically fluctuate throughout the day. Unlike dementia, delirium is
often secondary to an underlying medical condition like infection or dehydration and is
potentially reversible. Nurses must prioritize identifying the physiological cause to prevent
permanent damage or death.
5. A nurse is providing education to a client starting a Monoamine Oxidase Inhibitor (MAOI).
Which food must be avoided?
A. Aged cheddar cheese
B. Fresh green leafy vegetables
C. Whole grain bread
D. Grilled chicken breast
Correct Answer: A
Explanation: Clients taking MAOIs must adhere to a low-tyramine diet to prevent a
hypertensive crisis, a life-threatening complication. Aged cheeses, cured meats, and
fermented products contain high levels of tyramine which can cause a massive release of
