,NSG 221 Mental Health Exam 3 | Herzing
University | Latest 2026/2027 Updated (PDF)
1. A client diagnosed with Bipolar I Disorder is prescribed Lithium Carbonate. Which serum lithium
level should the nurse identify as being within the therapeutic range for maintenance therapy?
A) 0.4 to 0.8 mEq/L
B) 0.6 to 1.2 mEq/L
C) 1.5 to 2.0 mEq/L
D) 2.1 to 3.0 mEq/L
Correct Answer: 0.6 to 1.2 mEq/L
Rationale: The therapeutic serum lithium level for maintenance therapy is generally 0.6 to 1.2 mEq/L.
Levels above 1.5 mEq/L are associated with toxicity, manifesting as tremors, confusion, and ataxia.
Regular blood monitoring is essential for safety and efficacy. The other ranges are either
subtherapeutic or indicate toxicity.
2. A nurse is caring for a client with Schizophrenia who is experiencing auditory hallucinations. Which
is the most appropriate initial nursing intervention?
A) Tell the client that the voices are not real
B) Leave the client alone to reduce environmental stimuli
C) Ask the client, "What are the voices telling you?"
D) Argue with the client about the validity of the hallucinations
Correct Answer: Ask the client, "What are the voices telling you?"
Rationale: Asking what the voices are saying is critical for assessing safety and identifying command
hallucinations. The nurse should acknowledge the client's experience without validating the
hallucination as reality. Telling the client the voices are not real or arguing is confrontational and
damages rapport; leaving the client alone neglects safety assessment.
3. Which clinical manifestation is considered a negative symptom of Schizophrenia?
,A) Delusions
B) Echolalia
C) Flat affect
D) Hallucinations
Correct Answer: Flat affect
Rationale: Negative symptoms represent a loss of normal function, such as flat affect, alogia, and
avolition. Delusions and hallucinations are positive symptoms because they involve an excess of
normal functions. Understanding this distinction is vital for determining appropriate pharmacological
treatment.
4. A client is admitted to the psychiatric unit with a diagnosis of Borderline Personality Disorder. The
nurse observes the client praising one nurse while demeaning another. This behavior is known as:
A) Sublimation
B) Projection
C) Splitting
D) Reaction Formation
Correct Answer: Splitting
Rationale: Splitting is a common defense mechanism in Borderline Personality Disorder where
individuals view things as all good or all bad. This behavior often creates conflict among staff
members. Sublimation involves channeling unacceptable impulses into acceptable activities,
projection involves attributing one's own feelings to others, and reaction formation involves
expressing the opposite of true feelings.
5. A nurse is assessing a client for alcohol withdrawal. Which symptom should the nurse expect to find
within 6 to 12 hours after the last drink?
A) Visual hallucinations
B) Severe hypotension
C) Tremors and tachycardia
, D) Deep sleep and bradycardia
Correct Answer: Tremors and tachycardia
Rationale: Within 6 to 12 hours after the last drink, the client may experience tremors, tachycardia,
diaphoresis, and anxiety. Visual hallucinations typically occur later (24-72 hours). Hypotension is not
characteristic of alcohol withdrawal; hypertension is more common. Deep sleep and bradycardia are
not withdrawal symptoms.
6. A client experiencing a panic attack reports palpitations, shortness of breath, and a fear of dying.
Which nursing intervention should the nurse implement first?
A) Administer a PRN benzodiazepine as ordered
B) Ask the client to describe the trigger for the panic
C) Help the client use grounding and breathing techniques
D) Explain the physiological basis of the panic response
Correct Answer: Help the client use grounding and breathing techniques
Rationale: During a panic attack, the priority is to help the client regain control through grounding and
focused breathing techniques. These interventions address the immediate physiological and
emotional distress. Administering medication may be appropriate but is not the first intervention;
exploring triggers and providing explanations are ineffective during the acute episode as cognitive
processing is impaired.
7. A client with Major Depressive Disorder (MDD) tells the nurse, "I don't see the point in anything
anymore. Everyone would be better off without me." Which nursing action takes priority?
A) Encourage the client to express feelings of hopelessness
B) Assess the client for suicidal ideation and plan
C) Notify the healthcare provider of the client's statement
D) Document the client's statement in the medical record
Correct Answer: Assess the client for suicidal ideation and plan
University | Latest 2026/2027 Updated (PDF)
1. A client diagnosed with Bipolar I Disorder is prescribed Lithium Carbonate. Which serum lithium
level should the nurse identify as being within the therapeutic range for maintenance therapy?
A) 0.4 to 0.8 mEq/L
B) 0.6 to 1.2 mEq/L
C) 1.5 to 2.0 mEq/L
D) 2.1 to 3.0 mEq/L
Correct Answer: 0.6 to 1.2 mEq/L
Rationale: The therapeutic serum lithium level for maintenance therapy is generally 0.6 to 1.2 mEq/L.
Levels above 1.5 mEq/L are associated with toxicity, manifesting as tremors, confusion, and ataxia.
Regular blood monitoring is essential for safety and efficacy. The other ranges are either
subtherapeutic or indicate toxicity.
2. A nurse is caring for a client with Schizophrenia who is experiencing auditory hallucinations. Which
is the most appropriate initial nursing intervention?
A) Tell the client that the voices are not real
B) Leave the client alone to reduce environmental stimuli
C) Ask the client, "What are the voices telling you?"
D) Argue with the client about the validity of the hallucinations
Correct Answer: Ask the client, "What are the voices telling you?"
Rationale: Asking what the voices are saying is critical for assessing safety and identifying command
hallucinations. The nurse should acknowledge the client's experience without validating the
hallucination as reality. Telling the client the voices are not real or arguing is confrontational and
damages rapport; leaving the client alone neglects safety assessment.
3. Which clinical manifestation is considered a negative symptom of Schizophrenia?
,A) Delusions
B) Echolalia
C) Flat affect
D) Hallucinations
Correct Answer: Flat affect
Rationale: Negative symptoms represent a loss of normal function, such as flat affect, alogia, and
avolition. Delusions and hallucinations are positive symptoms because they involve an excess of
normal functions. Understanding this distinction is vital for determining appropriate pharmacological
treatment.
4. A client is admitted to the psychiatric unit with a diagnosis of Borderline Personality Disorder. The
nurse observes the client praising one nurse while demeaning another. This behavior is known as:
A) Sublimation
B) Projection
C) Splitting
D) Reaction Formation
Correct Answer: Splitting
Rationale: Splitting is a common defense mechanism in Borderline Personality Disorder where
individuals view things as all good or all bad. This behavior often creates conflict among staff
members. Sublimation involves channeling unacceptable impulses into acceptable activities,
projection involves attributing one's own feelings to others, and reaction formation involves
expressing the opposite of true feelings.
5. A nurse is assessing a client for alcohol withdrawal. Which symptom should the nurse expect to find
within 6 to 12 hours after the last drink?
A) Visual hallucinations
B) Severe hypotension
C) Tremors and tachycardia
, D) Deep sleep and bradycardia
Correct Answer: Tremors and tachycardia
Rationale: Within 6 to 12 hours after the last drink, the client may experience tremors, tachycardia,
diaphoresis, and anxiety. Visual hallucinations typically occur later (24-72 hours). Hypotension is not
characteristic of alcohol withdrawal; hypertension is more common. Deep sleep and bradycardia are
not withdrawal symptoms.
6. A client experiencing a panic attack reports palpitations, shortness of breath, and a fear of dying.
Which nursing intervention should the nurse implement first?
A) Administer a PRN benzodiazepine as ordered
B) Ask the client to describe the trigger for the panic
C) Help the client use grounding and breathing techniques
D) Explain the physiological basis of the panic response
Correct Answer: Help the client use grounding and breathing techniques
Rationale: During a panic attack, the priority is to help the client regain control through grounding and
focused breathing techniques. These interventions address the immediate physiological and
emotional distress. Administering medication may be appropriate but is not the first intervention;
exploring triggers and providing explanations are ineffective during the acute episode as cognitive
processing is impaired.
7. A client with Major Depressive Disorder (MDD) tells the nurse, "I don't see the point in anything
anymore. Everyone would be better off without me." Which nursing action takes priority?
A) Encourage the client to express feelings of hopelessness
B) Assess the client for suicidal ideation and plan
C) Notify the healthcare provider of the client's statement
D) Document the client's statement in the medical record
Correct Answer: Assess the client for suicidal ideation and plan
