EXAM 2 V2: NR326 / NR 326 MENTAL HEALTH
(LATEST UPDATE) | ALL POSSIBLE AND
CURRENTLY MOST TESTED 100 PRACTICE
QUESTIONS AND 100% CORRECT VERIFIED
ANSWERS WITH DETAILED RATIONALES PLUS
ANSWER KEY ALREADY A+ GRADED MOST
RECENT!!!
1. A client diagnosed with schizophrenia tells the nurse, "The CIA is using
satellites to read my thoughts." Which is the most appropriate therapeutic
response by the nurse?
a. "That sounds frightening. Tell me more about what you are experiencing."
b. "You know that isn't true. The CIA doesn't monitor private citizens."
c. "Why do you think the CIA would be interested in you?"
d. "Let's talk about something else to take your mind off of it."
Correct Answer: a
Rationale: This response validates the client's feelings without endorsing the
delusion. It uses the therapeutic technique of exploring and focuses on the client's
emotional experience. Option b is confrontational and dismissive. Option c asks
"why," which can be challenging and may increase paranoia. Option d ignores the
client's distress and avoids the issue.
2. A nurse is planning care for a client with major depressive disorder. Which
nursing intervention is the priority during the first 24 hours of admission?
a. Encourage participation in group therapy.
b. Observe and monitor for suicide risk.
c. Teach about antidepressant medications.
,d. Establish a structured daily routine.
Correct Answer: b
Rationale: Client safety is the priority in psychiatric nursing. The highest risk for a
client with major depressive disorder is self-harm or suicide. Therefore, continuous
observation and suicide risk assessment are the initial priorities. While the other
options are important aspects of care, they are not the immediate priority.
3. The nurse is caring for a client who is exhibiting signs of alcohol withdrawal.
Which assessment finding requires immediate intervention?
a. Fine tremors of the hands.
b. Nausea and vomiting.
c. Heart rate of 100 bpm.
d. Seizure activity.
Correct Answer: d
Rationale: Seizures are a life-threatening complication of alcohol withdrawal that
can progress to status epilepticus. This is a medical emergency requiring
immediate intervention. The other symptoms (tremors, nausea, tachycardia) are
common withdrawal symptoms but do not pose the immediate life-threatening
risk of a seizure.
4. A client with bipolar disorder in the manic phase is pacing the hallways and
talking rapidly. The client interrupts the nurse and demands, "Get me out of
here now!" Which is the most appropriate nursing response?
a. "You need to calm down and stop pacing."
b. "If you continue to be disruptive, you will be put in seclusion."
c. "I understand you are upset. Let's walk together for a few minutes."
d. "You will be discharged when your behavior is under control."
Correct Answer: c
Rationale: This response uses a calm, non-confrontational approach and offers a
safe, controlled activity that can help channel the client's excess energy. It also
acknowledges the client's feelings. Options a and d are authoritarian and can
escalate agitation. Option b is a threat that can increase aggression and is not a
therapeutic intervention.
5. Which medication is most likely to be prescribed to a client for the acute
management of extrapyramidal symptoms (EPS) like dystonia?
,a. Lorazepam (Ativan)
b. Diphenhydramine (Benadryl)
c. Clozapine (Clozaril)
d. Fluoxetine (Prozac)
Correct Answer: b
Rationale: Diphenhydramine is an anticholinergic medication often used to treat
acute dystonic reactions and other EPS. It works by blocking acetylcholine in the
brain. Lorazepam can be used for anxiety or agitation, but not as a primary
treatment for EPS. Clozapine is an antipsychotic that can cause EPS, not treat it.
Fluoxetine is an antidepressant.
6. A client is being treated with a monoamine oxidase inhibitor (MAOI) for
depression. The nurse should instruct the client to avoid which food?
a. Apples
b. Grilled chicken
c. Aged cheddar cheese
d. White rice
Correct Answer: c
Rationale: Aged cheeses contain high levels of tyramine. When combined with an
MAOI, tyramine can cause a hypertensive crisis, a potentially fatal surge in blood
pressure. The other foods listed are low in tyramine and are safe to consume.
7. A client diagnosed with post-traumatic stress disorder (PTSD) reports having
recurrent nightmares and flashbacks. The nurse understands these symptoms
are most characteristic of which type of response?
a. Avoidance
b. Intrusion
c. Hyperarousal
d. Negative alterations in cognition and mood
Correct Answer: b
Rationale: Intrusion symptoms involve the involuntary and distressing re-
experiencing of the traumatic event through flashbacks, nightmares, and intense
psychological or physiological distress. Avoidance is staying away from reminders.
Hyperarousal includes hypervigilance and an exaggerated startle response.
Negative alterations include persistent negative beliefs and emotions.
, 8. The nurse is performing a mental status examination (MSE) on a new client.
To assess the client's abstract thinking, which question should the nurse ask?
a. "What is the name of the current president?"
b. "Can you spell 'world' backwards?"
c. "What do a dog and a cat have in common?"
d. "How are you feeling today?"
Correct Answer: c
Rationale: Abstract thinking is the ability to understand concepts beyond the
concrete. Asking for similarities requires the client to identify the abstract
relationship (e.g., both are animals or pets). Options a assesses orientation, b
assesses attention/concentration, and d assesses mood/affect.
9. A client is brought to the emergency department by police. The client is
aggressive, confused, and has extreme psychomotor agitation. The client's
pupils are dilated, and vital signs show hypertension, tachycardia, and
hyperthermia. Which substance intoxication is most likely?
a. Alcohol
b. Opioids
c. Cannabis
d. Stimulants (e.g., cocaine, methamphetamine)
Correct Answer: d
Rationale: Stimulant intoxication presents with signs of sympathetic nervous
system overdrive, including hypertension, tachycardia, hyperthermia, dilated
pupils, agitation, and confusion. Alcohol typically causes CNS depression. Opioids
cause miosis (constricted pupils) and respiratory depression. Cannabis can cause
tachycardia but not typically this level of extreme agitation or hyperthermia.
10. A nurse is using cognitive-behavioral therapy (CBT) techniques with a client
who has generalized anxiety disorder. The client states, "I know I'm going to fail
my exam, I'm a failure." Which intervention is most consistent with CBT?
a. "Tell me more about your feelings of being a failure."
b. "Let's examine the evidence for and against that belief."
c. "It's okay, you studied hard and you'll do fine."
d. "We should focus on your breathing to reduce anxiety."
Correct Answer: b
Rationale: CBT focuses on identifying and challenging cognitive distortions (like
(LATEST UPDATE) | ALL POSSIBLE AND
CURRENTLY MOST TESTED 100 PRACTICE
QUESTIONS AND 100% CORRECT VERIFIED
ANSWERS WITH DETAILED RATIONALES PLUS
ANSWER KEY ALREADY A+ GRADED MOST
RECENT!!!
1. A client diagnosed with schizophrenia tells the nurse, "The CIA is using
satellites to read my thoughts." Which is the most appropriate therapeutic
response by the nurse?
a. "That sounds frightening. Tell me more about what you are experiencing."
b. "You know that isn't true. The CIA doesn't monitor private citizens."
c. "Why do you think the CIA would be interested in you?"
d. "Let's talk about something else to take your mind off of it."
Correct Answer: a
Rationale: This response validates the client's feelings without endorsing the
delusion. It uses the therapeutic technique of exploring and focuses on the client's
emotional experience. Option b is confrontational and dismissive. Option c asks
"why," which can be challenging and may increase paranoia. Option d ignores the
client's distress and avoids the issue.
2. A nurse is planning care for a client with major depressive disorder. Which
nursing intervention is the priority during the first 24 hours of admission?
a. Encourage participation in group therapy.
b. Observe and monitor for suicide risk.
c. Teach about antidepressant medications.
,d. Establish a structured daily routine.
Correct Answer: b
Rationale: Client safety is the priority in psychiatric nursing. The highest risk for a
client with major depressive disorder is self-harm or suicide. Therefore, continuous
observation and suicide risk assessment are the initial priorities. While the other
options are important aspects of care, they are not the immediate priority.
3. The nurse is caring for a client who is exhibiting signs of alcohol withdrawal.
Which assessment finding requires immediate intervention?
a. Fine tremors of the hands.
b. Nausea and vomiting.
c. Heart rate of 100 bpm.
d. Seizure activity.
Correct Answer: d
Rationale: Seizures are a life-threatening complication of alcohol withdrawal that
can progress to status epilepticus. This is a medical emergency requiring
immediate intervention. The other symptoms (tremors, nausea, tachycardia) are
common withdrawal symptoms but do not pose the immediate life-threatening
risk of a seizure.
4. A client with bipolar disorder in the manic phase is pacing the hallways and
talking rapidly. The client interrupts the nurse and demands, "Get me out of
here now!" Which is the most appropriate nursing response?
a. "You need to calm down and stop pacing."
b. "If you continue to be disruptive, you will be put in seclusion."
c. "I understand you are upset. Let's walk together for a few minutes."
d. "You will be discharged when your behavior is under control."
Correct Answer: c
Rationale: This response uses a calm, non-confrontational approach and offers a
safe, controlled activity that can help channel the client's excess energy. It also
acknowledges the client's feelings. Options a and d are authoritarian and can
escalate agitation. Option b is a threat that can increase aggression and is not a
therapeutic intervention.
5. Which medication is most likely to be prescribed to a client for the acute
management of extrapyramidal symptoms (EPS) like dystonia?
,a. Lorazepam (Ativan)
b. Diphenhydramine (Benadryl)
c. Clozapine (Clozaril)
d. Fluoxetine (Prozac)
Correct Answer: b
Rationale: Diphenhydramine is an anticholinergic medication often used to treat
acute dystonic reactions and other EPS. It works by blocking acetylcholine in the
brain. Lorazepam can be used for anxiety or agitation, but not as a primary
treatment for EPS. Clozapine is an antipsychotic that can cause EPS, not treat it.
Fluoxetine is an antidepressant.
6. A client is being treated with a monoamine oxidase inhibitor (MAOI) for
depression. The nurse should instruct the client to avoid which food?
a. Apples
b. Grilled chicken
c. Aged cheddar cheese
d. White rice
Correct Answer: c
Rationale: Aged cheeses contain high levels of tyramine. When combined with an
MAOI, tyramine can cause a hypertensive crisis, a potentially fatal surge in blood
pressure. The other foods listed are low in tyramine and are safe to consume.
7. A client diagnosed with post-traumatic stress disorder (PTSD) reports having
recurrent nightmares and flashbacks. The nurse understands these symptoms
are most characteristic of which type of response?
a. Avoidance
b. Intrusion
c. Hyperarousal
d. Negative alterations in cognition and mood
Correct Answer: b
Rationale: Intrusion symptoms involve the involuntary and distressing re-
experiencing of the traumatic event through flashbacks, nightmares, and intense
psychological or physiological distress. Avoidance is staying away from reminders.
Hyperarousal includes hypervigilance and an exaggerated startle response.
Negative alterations include persistent negative beliefs and emotions.
, 8. The nurse is performing a mental status examination (MSE) on a new client.
To assess the client's abstract thinking, which question should the nurse ask?
a. "What is the name of the current president?"
b. "Can you spell 'world' backwards?"
c. "What do a dog and a cat have in common?"
d. "How are you feeling today?"
Correct Answer: c
Rationale: Abstract thinking is the ability to understand concepts beyond the
concrete. Asking for similarities requires the client to identify the abstract
relationship (e.g., both are animals or pets). Options a assesses orientation, b
assesses attention/concentration, and d assesses mood/affect.
9. A client is brought to the emergency department by police. The client is
aggressive, confused, and has extreme psychomotor agitation. The client's
pupils are dilated, and vital signs show hypertension, tachycardia, and
hyperthermia. Which substance intoxication is most likely?
a. Alcohol
b. Opioids
c. Cannabis
d. Stimulants (e.g., cocaine, methamphetamine)
Correct Answer: d
Rationale: Stimulant intoxication presents with signs of sympathetic nervous
system overdrive, including hypertension, tachycardia, hyperthermia, dilated
pupils, agitation, and confusion. Alcohol typically causes CNS depression. Opioids
cause miosis (constricted pupils) and respiratory depression. Cannabis can cause
tachycardia but not typically this level of extreme agitation or hyperthermia.
10. A nurse is using cognitive-behavioral therapy (CBT) techniques with a client
who has generalized anxiety disorder. The client states, "I know I'm going to fail
my exam, I'm a failure." Which intervention is most consistent with CBT?
a. "Tell me more about your feelings of being a failure."
b. "Let's examine the evidence for and against that belief."
c. "It's okay, you studied hard and you'll do fine."
d. "We should focus on your breathing to reduce anxiety."
Correct Answer: b
Rationale: CBT focuses on identifying and challenging cognitive distortions (like
