BSN 246 EXAM 1: PSYCHIATRIC-
MENTAL HEALTH NURSING
ESSENTIALS QUESTIONS AND
VERIFIED ANSWERS |100% CORRECT|
GRADE A+ NIGHTINGALE
1. A nurse is caring for a patient who is involuntarily committed to a psychiatric unit. The
patient refuses to take his prescribed antipsychotic medication. Which action should the
nurse take?
A. Administer the medication against the patient’s will because he is involuntarily
committed.
B. Call the physician to have the patient’s commitment status changed to ‘emergency’.
C. Inform the patient that refusal will lead to a loss of privileges.
D. Respect the patient’s refusal unless he poses an immediate danger to himself or others.
Answer: D
Conceptual Explanation: Involuntary commitment does not automatically waive the right
to refuse treatment. Patients retain the right to refuse medication unless there is a court
order or an immediate emergency situation where the patient is a danger.
,2. Which defense mechanism is a client using when they unconsciously transfer feelings
about a difficult boss onto a younger sibling at home?
A. Displacement
B. Reaction Formation
C. Sublimation
D. Projection
Answer: A
Conceptual Explanation: Displacement involves transferring strong feelings from the
original object to a less threatening substitute target.
3. A client with schizophrenia states, ‘The voices are telling me that the food is poisoned.’
Which response by the nurse is the most therapeutic?
A. The food is fine; I saw the chef prepare it myself.
B. You should ignore the voices and try to eat to stay strong.
C. Why would anyone want to poison your food?
D. I don’t hear any voices, but I can see that you are feeling frightened.
Answer: D
Conceptual Explanation: Acknowledging the client’s feelings while presenting reality
without arguing is a core therapeutic technique for managing hallucinations.
, 4. The nurse is reviewing the laboratory results for a client taking Lithium Carbonate. Which
level would indicate the nurse should withhold the dose and notify the provider?
A. 0.6 mEq/L
B. 1.8 mEq/L
C. 1.2 mEq/L
D. 0.9 mEq/L
Answer: B
Conceptual Explanation: The therapeutic range for lithium is generally 0.6 to 1.2 mEq/L.
A level of 1.8 mEq/L is considered toxic and requires immediate intervention.
5. A client is admitted for alcohol detoxification. Which vital sign changes should the nurse
expect to see during early withdrawal?
A. Bradycardia and hypotension
B. Tachycardia and hypertension
C. Decreased respiratory rate and hypothermia
D. Increased appetite and lethargy
Answer: B
Conceptual Explanation: Alcohol withdrawal causes autonomic hyperactivity, leading to
increased heart rate (tachycardia) and elevated blood pressure (hypertension).
MENTAL HEALTH NURSING
ESSENTIALS QUESTIONS AND
VERIFIED ANSWERS |100% CORRECT|
GRADE A+ NIGHTINGALE
1. A nurse is caring for a patient who is involuntarily committed to a psychiatric unit. The
patient refuses to take his prescribed antipsychotic medication. Which action should the
nurse take?
A. Administer the medication against the patient’s will because he is involuntarily
committed.
B. Call the physician to have the patient’s commitment status changed to ‘emergency’.
C. Inform the patient that refusal will lead to a loss of privileges.
D. Respect the patient’s refusal unless he poses an immediate danger to himself or others.
Answer: D
Conceptual Explanation: Involuntary commitment does not automatically waive the right
to refuse treatment. Patients retain the right to refuse medication unless there is a court
order or an immediate emergency situation where the patient is a danger.
,2. Which defense mechanism is a client using when they unconsciously transfer feelings
about a difficult boss onto a younger sibling at home?
A. Displacement
B. Reaction Formation
C. Sublimation
D. Projection
Answer: A
Conceptual Explanation: Displacement involves transferring strong feelings from the
original object to a less threatening substitute target.
3. A client with schizophrenia states, ‘The voices are telling me that the food is poisoned.’
Which response by the nurse is the most therapeutic?
A. The food is fine; I saw the chef prepare it myself.
B. You should ignore the voices and try to eat to stay strong.
C. Why would anyone want to poison your food?
D. I don’t hear any voices, but I can see that you are feeling frightened.
Answer: D
Conceptual Explanation: Acknowledging the client’s feelings while presenting reality
without arguing is a core therapeutic technique for managing hallucinations.
, 4. The nurse is reviewing the laboratory results for a client taking Lithium Carbonate. Which
level would indicate the nurse should withhold the dose and notify the provider?
A. 0.6 mEq/L
B. 1.8 mEq/L
C. 1.2 mEq/L
D. 0.9 mEq/L
Answer: B
Conceptual Explanation: The therapeutic range for lithium is generally 0.6 to 1.2 mEq/L.
A level of 1.8 mEq/L is considered toxic and requires immediate intervention.
5. A client is admitted for alcohol detoxification. Which vital sign changes should the nurse
expect to see during early withdrawal?
A. Bradycardia and hypotension
B. Tachycardia and hypertension
C. Decreased respiratory rate and hypothermia
D. Increased appetite and lethargy
Answer: B
Conceptual Explanation: Alcohol withdrawal causes autonomic hyperactivity, leading to
increased heart rate (tachycardia) and elevated blood pressure (hypertension).
