,NSG 221 Mental Health Final Exam | Herzing
University | Latest 2026/2027 Updated (PDF)
1. A client is admitted to the psychiatric unit with a diagnosis of acute mania. Which nursing
intervention is the priority during the first 24 hours of admission?
A) Encouraging the client to participate in group therapy sessions
B) Conducting an in-depth psychosocial assessment regarding past trauma
C) Assisting the client with detailed personal hygiene and grooming
D) Providing a high-calorie, finger-food diet to maintain nutrition
Correct Answer: Providing a high-calorie, finger-food diet to maintain nutrition
Rationale: Clients in acute mania exhibit excessive psychomotor activity and have difficulty sitting for
full meals. Providing finger foods allows the client to consume necessary calories while on the move,
addressing the physical risk of exhaustion and nutritional deficit. This intervention prioritizes
physiological needs over psychological exploration during the acute phase of illness. Group therapy,
trauma assessment, and detailed hygiene are inappropriate until the client's basic physiological needs
are stabilized.
2. A nurse is caring for a client who is receiving Clozapine for treatment-resistant schizophrenia.
Which laboratory result must the nurse monitor most closely?
A) White blood cell (WBC) count
B) Blood urea nitrogen (BUN)
C) Serum potassium levels
D) Creatinine clearance
Correct Answer: White blood cell (WBC) count
Rationale: Clozapine is associated with a risk of agranulocytosis, a life-threatening decrease in the
white blood cell count. Federal regulations require regular monitoring of the absolute neutrophil
count and WBC count to ensure patient safety. If the WBC count drops below a specific threshold, the
medication must be discontinued immediately to prevent severe infection. BUN, potassium, and
creatinine are not specific to Clozapine's primary risk profile.
,3. A client with Major Depressive Disorder is being started on a Selective Serotonin Reuptake Inhibitor
(SSRI). Which education should the nurse provide regarding the onset of therapeutic effects?
A) The client will feel an immediate elevation in mood within 24 hours
B) The medication will work better if taken with a high-tyramine diet
C) Full therapeutic benefits may take 4 to 6 weeks to achieve
D) The client should stop the medication if they feel better after two weeks
Correct Answer: Full therapeutic benefits may take 4 to 6 weeks to achieve
Rationale: SSRIs do not produce an immediate effect on mood and typically require several weeks of
consistent dosing to reach therapeutic levels in the brain. It is crucial for the nurse to manage client
expectations to prevent early discontinuation of the treatment. Clients must be monitored closely
during this period for increased energy levels that might precede mood improvement, which can
increase suicide risk. High-tyramine foods are a concern with MAOIs, not SSRIs.
4. A nurse is performing a suicide risk assessment. Which factor represents the highest immediate risk
for a client?
A) A history of depression in a first-degree relative
B) The client expressing feelings of mild hopelessness
C) Having a specific, lethal plan and the means to carry it out
D) Occasional thoughts of wishing they were not alive
Correct Answer: Having a specific, lethal plan and the means to carry it out
Rationale: A specific plan paired with the availability of lethal means indicates a high level of intent
and immediate danger. While history and feelings of hopelessness are significant, the presence of a
concrete plan is the most critical predictor of an imminent attempt. Nurses must prioritize safety by
implementing immediate observation or hospitalization in such cases.
5. A client is experiencing a severe panic attack. Which nursing action is the most appropriate at this
time?
, A) Teaching the client deep breathing and relaxation techniques for future use
B) Encouraging the client to explain what triggered the panic attack
C) Leaving the client alone to allow them to calm down in a quiet room
D) Staying with the client and using grounding techniques in the present moment
Correct Answer: Staying with the client and using grounding techniques in the present moment
Rationale: During a panic attack, the client's cognitive processing is impaired, and the priority is to
help the client regain control through grounding and present-focused techniques. Teaching techniques
for future use is inappropriate during the acute episode as the client cannot process new information.
Exploring triggers is ineffective and may increase anxiety. Leaving the client alone may increase
feelings of abandonment and panic.
6. A client with Major Depressive Disorder is admitted to the psychiatric unit. The client gives away
their favorite collection of watches to a peer. Which action should the nurse take first?
A) Document the behavior in the client's chart
B) Notify the healthcare provider of the client's action
C) Assess the client for a specific suicide plan
D) Encourage the client to discuss feelings about the watches
Correct Answer: Assess the client for a specific suicide plan
Rationale: Giving away prized possessions is a significant warning sign of impending suicide. The nurse
must prioritize safety and assess for a specific suicide plan immediately. This behavior indicates that
the client may have decided to end their life and is 'settling' their affairs. Documentation and
notification are important but secondary to the immediate safety assessment.
7. A client with Schizophrenia is experiencing auditory hallucinations. What is the most appropriate
initial nursing intervention?
A) Ask the client directly what the voices are saying
B) Tell the client that there are no voices and it is just their imagination
C) Turn up the television to drown out the internal noise
University | Latest 2026/2027 Updated (PDF)
1. A client is admitted to the psychiatric unit with a diagnosis of acute mania. Which nursing
intervention is the priority during the first 24 hours of admission?
A) Encouraging the client to participate in group therapy sessions
B) Conducting an in-depth psychosocial assessment regarding past trauma
C) Assisting the client with detailed personal hygiene and grooming
D) Providing a high-calorie, finger-food diet to maintain nutrition
Correct Answer: Providing a high-calorie, finger-food diet to maintain nutrition
Rationale: Clients in acute mania exhibit excessive psychomotor activity and have difficulty sitting for
full meals. Providing finger foods allows the client to consume necessary calories while on the move,
addressing the physical risk of exhaustion and nutritional deficit. This intervention prioritizes
physiological needs over psychological exploration during the acute phase of illness. Group therapy,
trauma assessment, and detailed hygiene are inappropriate until the client's basic physiological needs
are stabilized.
2. A nurse is caring for a client who is receiving Clozapine for treatment-resistant schizophrenia.
Which laboratory result must the nurse monitor most closely?
A) White blood cell (WBC) count
B) Blood urea nitrogen (BUN)
C) Serum potassium levels
D) Creatinine clearance
Correct Answer: White blood cell (WBC) count
Rationale: Clozapine is associated with a risk of agranulocytosis, a life-threatening decrease in the
white blood cell count. Federal regulations require regular monitoring of the absolute neutrophil
count and WBC count to ensure patient safety. If the WBC count drops below a specific threshold, the
medication must be discontinued immediately to prevent severe infection. BUN, potassium, and
creatinine are not specific to Clozapine's primary risk profile.
,3. A client with Major Depressive Disorder is being started on a Selective Serotonin Reuptake Inhibitor
(SSRI). Which education should the nurse provide regarding the onset of therapeutic effects?
A) The client will feel an immediate elevation in mood within 24 hours
B) The medication will work better if taken with a high-tyramine diet
C) Full therapeutic benefits may take 4 to 6 weeks to achieve
D) The client should stop the medication if they feel better after two weeks
Correct Answer: Full therapeutic benefits may take 4 to 6 weeks to achieve
Rationale: SSRIs do not produce an immediate effect on mood and typically require several weeks of
consistent dosing to reach therapeutic levels in the brain. It is crucial for the nurse to manage client
expectations to prevent early discontinuation of the treatment. Clients must be monitored closely
during this period for increased energy levels that might precede mood improvement, which can
increase suicide risk. High-tyramine foods are a concern with MAOIs, not SSRIs.
4. A nurse is performing a suicide risk assessment. Which factor represents the highest immediate risk
for a client?
A) A history of depression in a first-degree relative
B) The client expressing feelings of mild hopelessness
C) Having a specific, lethal plan and the means to carry it out
D) Occasional thoughts of wishing they were not alive
Correct Answer: Having a specific, lethal plan and the means to carry it out
Rationale: A specific plan paired with the availability of lethal means indicates a high level of intent
and immediate danger. While history and feelings of hopelessness are significant, the presence of a
concrete plan is the most critical predictor of an imminent attempt. Nurses must prioritize safety by
implementing immediate observation or hospitalization in such cases.
5. A client is experiencing a severe panic attack. Which nursing action is the most appropriate at this
time?
, A) Teaching the client deep breathing and relaxation techniques for future use
B) Encouraging the client to explain what triggered the panic attack
C) Leaving the client alone to allow them to calm down in a quiet room
D) Staying with the client and using grounding techniques in the present moment
Correct Answer: Staying with the client and using grounding techniques in the present moment
Rationale: During a panic attack, the client's cognitive processing is impaired, and the priority is to
help the client regain control through grounding and present-focused techniques. Teaching techniques
for future use is inappropriate during the acute episode as the client cannot process new information.
Exploring triggers is ineffective and may increase anxiety. Leaving the client alone may increase
feelings of abandonment and panic.
6. A client with Major Depressive Disorder is admitted to the psychiatric unit. The client gives away
their favorite collection of watches to a peer. Which action should the nurse take first?
A) Document the behavior in the client's chart
B) Notify the healthcare provider of the client's action
C) Assess the client for a specific suicide plan
D) Encourage the client to discuss feelings about the watches
Correct Answer: Assess the client for a specific suicide plan
Rationale: Giving away prized possessions is a significant warning sign of impending suicide. The nurse
must prioritize safety and assess for a specific suicide plan immediately. This behavior indicates that
the client may have decided to end their life and is 'settling' their affairs. Documentation and
notification are important but secondary to the immediate safety assessment.
7. A client with Schizophrenia is experiencing auditory hallucinations. What is the most appropriate
initial nursing intervention?
A) Ask the client directly what the voices are saying
B) Tell the client that there are no voices and it is just their imagination
C) Turn up the television to drown out the internal noise
