MENTAL HEALTH NURSING
60 Updated Actual Exam Questions and Correct Answers • Verified Solutions
1. A client admitted with major depressive disorder states, "I am a burden to my family
and everyone would be better off without me." What is the nurse's priority response?
A) "You shouldn't say that; your family loves you very much."
B) "Are you currently having thoughts of harming or killing yourself?"
C) "Let's focus on positive things that happened in your life today."
D) "I will notify your physician so your medication can be increased."
Rationale: Expressing feelings of being a burden strongly indicates suicidal ideation. Asking directly
about explicit suicidal intent and plans is necessary to establish immediate safety protocols.
2. A patient with schizophrenia reports, "The voices are telling me that the food in this
clinic is poisoned!" How should the nurse respond therapeutic ally?
A) "I know the voices feel real to you, but I do not hear them, and your food is safe."
B) "Nobody is trying to poison you, so please eat your meal."
C) "Why do you think someone would want to put poison in your food?"
D) "If you don't eat, we will have to place you on a feeding tube."
Rationale: Validating the client's feelings while presenting reality without directly validating or arguing
with the hallucination establishes trust while grounding the client in reality.
3. What is the therapeutic serum level range for a client receiving lithium carbonate for
bipolar I disorder maintenance?
A) 0.1 to 0.4 mEq/L
B) 0.6 to 1.2 mEq/L
C) 1.5 to 2.5 mEq/L
D) 3.0 to 4.5 mEq/L
Rationale: The therapeutic range for lithium maintenance is 0.6 to 1.2 mEq/L. Levels above 1.5
mEq/L lead to early toxicity symptoms, while levels above 2.0 mEq/L are life-threatening.
4. A client taking haloperidol develops high fever, muscle rigidity, altered consciousness,
,and autonomic instability. What emergency condition is suspected?
A) Tardive dyskinesia
B) Neuroleptic Malignant Syndrome (NMS)
C) Serotonin syndrome
D) Acute dystonic reaction
Rationale: Neuroleptic Malignant Syndrome is a severe, life-threatening reaction to antipsychotics
characterized by hyperpyrexia, severe muscle rigidity, diaphoresis, labile blood pressure, and
confusion.
5. Which drug is administered as a muscle relaxant during Electroconvulsive Therapy
(ECT) to prevent bone fractures?
A) Atropine sulfate
B) Succinylcholine
C) Methohexital
D) Lorazepam
Rationale: Succinylcholine is a short-acting depolarizing neuromuscular blocker given during ECT to
prevent major physical movements and muscle contractions during the induced seizure.
6. What is the primary focus during the orientation phase of the nurse-client therapeutic
relationship?
A) Establishing trust, boundaries, and setting mutual goals
B) Performing deep problem-solving and behavioral modification
C) Evaluating goal achievement and handling separation anxiety
D) Promoting independent client decision-making without nurse guidance
Rationale: The orientation phase centers on building rapport, establishing parameters of the
relationship, clarifying roles, establishing confidentiality, and setting mutual goals.
7. A client with obsessive-compulsive disorder spends two hours washing hands
repeatedly before meals. What intervention is best initially?
A) Lock the bathroom door so handwashing is impossible
B) Allow time for the ritual initially, then gradually structure limits on the time spent
C) Inform the client that handwashing is illogical and clean hands are already safe
D) Administer high-dose antipsychotics immediately
, Rationale: Suddenly stopping compulsive rituals increases severe anxiety. The nurse should allow
adequate time initially while gradually negotiating limits to reduce ritual time.
8. Which defense mechanism is demonstrated when a client who is furious at their
supervisor comes home and kicks the family pet?
A) Projection
B) Displacement
C) Sublimation
D) Reaction formation
Rationale: Displacement involves transferring emotional feelings or impulses from a threatening
target to a neutral or less threatening person or object.
9. What severe adverse effect is associated with clozapine, requiring weekly complete
blood count (CBC) monitoring?
A) Agranulocytosis
B) Hepatic necrosis
C) Nephrogenic diabetes insipidus
D) Pulmonary embolism
Rationale: Clozapine carries a high risk for agranulocytosis (severe drop in absolute neutrophil
count), exposing clients to opportunistic infections. Monitoring baseline and ongoing ANC is
mandatory.
10. A client experiencing severe panic level anxiety reports feeling disconnected from
their body. What is the nurse's priority action?
A) Teach detailed coping mechanisms and lifestyle adjustments
B) Stay with the client, speak in short simple sentences, and maintain a quiet
environment
C) Leave the room to give the client private time to calm down
D) Encourage the client to join a group therapy session
Rationale: During panic-level anxiety, cognitive processing is disrupted. Presence, reassurance,
simple commands, and low environmental stimuli provide safety until anxiety subsides.
11. What extrapyramidal side effect (EPS) involves intense motor restlessness and an
inability to sit still?
60 Updated Actual Exam Questions and Correct Answers • Verified Solutions
1. A client admitted with major depressive disorder states, "I am a burden to my family
and everyone would be better off without me." What is the nurse's priority response?
A) "You shouldn't say that; your family loves you very much."
B) "Are you currently having thoughts of harming or killing yourself?"
C) "Let's focus on positive things that happened in your life today."
D) "I will notify your physician so your medication can be increased."
Rationale: Expressing feelings of being a burden strongly indicates suicidal ideation. Asking directly
about explicit suicidal intent and plans is necessary to establish immediate safety protocols.
2. A patient with schizophrenia reports, "The voices are telling me that the food in this
clinic is poisoned!" How should the nurse respond therapeutic ally?
A) "I know the voices feel real to you, but I do not hear them, and your food is safe."
B) "Nobody is trying to poison you, so please eat your meal."
C) "Why do you think someone would want to put poison in your food?"
D) "If you don't eat, we will have to place you on a feeding tube."
Rationale: Validating the client's feelings while presenting reality without directly validating or arguing
with the hallucination establishes trust while grounding the client in reality.
3. What is the therapeutic serum level range for a client receiving lithium carbonate for
bipolar I disorder maintenance?
A) 0.1 to 0.4 mEq/L
B) 0.6 to 1.2 mEq/L
C) 1.5 to 2.5 mEq/L
D) 3.0 to 4.5 mEq/L
Rationale: The therapeutic range for lithium maintenance is 0.6 to 1.2 mEq/L. Levels above 1.5
mEq/L lead to early toxicity symptoms, while levels above 2.0 mEq/L are life-threatening.
4. A client taking haloperidol develops high fever, muscle rigidity, altered consciousness,
,and autonomic instability. What emergency condition is suspected?
A) Tardive dyskinesia
B) Neuroleptic Malignant Syndrome (NMS)
C) Serotonin syndrome
D) Acute dystonic reaction
Rationale: Neuroleptic Malignant Syndrome is a severe, life-threatening reaction to antipsychotics
characterized by hyperpyrexia, severe muscle rigidity, diaphoresis, labile blood pressure, and
confusion.
5. Which drug is administered as a muscle relaxant during Electroconvulsive Therapy
(ECT) to prevent bone fractures?
A) Atropine sulfate
B) Succinylcholine
C) Methohexital
D) Lorazepam
Rationale: Succinylcholine is a short-acting depolarizing neuromuscular blocker given during ECT to
prevent major physical movements and muscle contractions during the induced seizure.
6. What is the primary focus during the orientation phase of the nurse-client therapeutic
relationship?
A) Establishing trust, boundaries, and setting mutual goals
B) Performing deep problem-solving and behavioral modification
C) Evaluating goal achievement and handling separation anxiety
D) Promoting independent client decision-making without nurse guidance
Rationale: The orientation phase centers on building rapport, establishing parameters of the
relationship, clarifying roles, establishing confidentiality, and setting mutual goals.
7. A client with obsessive-compulsive disorder spends two hours washing hands
repeatedly before meals. What intervention is best initially?
A) Lock the bathroom door so handwashing is impossible
B) Allow time for the ritual initially, then gradually structure limits on the time spent
C) Inform the client that handwashing is illogical and clean hands are already safe
D) Administer high-dose antipsychotics immediately
, Rationale: Suddenly stopping compulsive rituals increases severe anxiety. The nurse should allow
adequate time initially while gradually negotiating limits to reduce ritual time.
8. Which defense mechanism is demonstrated when a client who is furious at their
supervisor comes home and kicks the family pet?
A) Projection
B) Displacement
C) Sublimation
D) Reaction formation
Rationale: Displacement involves transferring emotional feelings or impulses from a threatening
target to a neutral or less threatening person or object.
9. What severe adverse effect is associated with clozapine, requiring weekly complete
blood count (CBC) monitoring?
A) Agranulocytosis
B) Hepatic necrosis
C) Nephrogenic diabetes insipidus
D) Pulmonary embolism
Rationale: Clozapine carries a high risk for agranulocytosis (severe drop in absolute neutrophil
count), exposing clients to opportunistic infections. Monitoring baseline and ongoing ANC is
mandatory.
10. A client experiencing severe panic level anxiety reports feeling disconnected from
their body. What is the nurse's priority action?
A) Teach detailed coping mechanisms and lifestyle adjustments
B) Stay with the client, speak in short simple sentences, and maintain a quiet
environment
C) Leave the room to give the client private time to calm down
D) Encourage the client to join a group therapy session
Rationale: During panic-level anxiety, cognitive processing is disrupted. Presence, reassurance,
simple commands, and low environmental stimuli provide safety until anxiety subsides.
11. What extrapyramidal side effect (EPS) involves intense motor restlessness and an
inability to sit still?
