BSN 246 PSYCHIATRIC MENTAL
HEALTH NURSING - EXAM 2
CHALLENGE QUESTIONS AND
VERIFIED ANSWERS |100% CORRECT|
GRADE A+ NIGHTINGALE
1. A patient with obsessive-compulsive disorder (OCD) is late for breakfast because they must
fold their clothes in a specific ritual. What is the most appropriate initial nursing
intervention?
A. Inform the patient that they will miss breakfast if they do not stop.
B. Allow the patient extra time to perform the ritual in the morning.
C. Interrupt the ritual to ensure the patient adheres to the unit schedule.
D. Administer a PRN dose of anxiolytic medication immediately.
Answer: B
Conceptual Explanation: Initially, the nurse should allow time for rituals to prevent
extreme anxiety. Over time, the nurse and patient will work to limit the time spent on
rituals.
2. A nurse is caring for a client experiencing a manic episode. Which meal choice is most
appropriate for this client?
A. A bowl of hot soup and crackers.
,B. A turkey sandwich and an apple.
C. Spaghetti and meatballs with a salad.
D. Steak and mashed potatoes.
Answer: B
Conceptual Explanation: Clients in a manic phase have high energy and difficulty sitting
still; ‘finger foods’ that can be eaten while moving are most appropriate.
3. A patient taking Clozapine for schizophrenia reports a sore throat and fever. Which
laboratory result should the nurse prioritize for review?
A. Blood Urea Nitrogen (BUN)
B. Serum Potassium levels
C. Complete Blood Count (CBC) with differential
D. Aspartate aminotransferase (AST)
Answer: C
Conceptual Explanation: Clozapine carries a risk of agranulocytosis. A sore throat and
fever are signs of infection, requiring immediate check of the White Blood Cell (WBC)
count.
4. Which assessment finding in a patient taking Lithium carbonate (Eskalith) suggests lithium
toxicity?
A. Fine hand tremors and mild thirst.
, B. Coarse tremors, diarrhea, and confusion.
C. Increased appetite and weight gain.
D. Occasional nausea and polyuria.
Answer: B
Conceptual Explanation: Coarse tremors, gastrointestinal upset (diarrhea), and CNS
changes like confusion are classic signs of moderate to severe lithium toxicity.
5. A client is admitted for severe depression and states, ‘I won’t be a burden much longer.’
What is the nurse’s priority action?
A. Ask the client directly if they have a plan for suicide.
B. Document the statement in the medical record.
C. Encourage the client to participate in group therapy.
D. Contact the family to discuss the client’s feelings.
Answer: A
Conceptual Explanation: Safety is the priority. When a client makes a veiled suicidal
comment, the nurse must assess for lethality and intent immediately.
6. A patient is experiencing a panic attack. What should the nurse say to the patient?
A. ‘Calm down, there is nothing here that can hurt you.’
B. ‘You are safe. I will stay here with you.’
HEALTH NURSING - EXAM 2
CHALLENGE QUESTIONS AND
VERIFIED ANSWERS |100% CORRECT|
GRADE A+ NIGHTINGALE
1. A patient with obsessive-compulsive disorder (OCD) is late for breakfast because they must
fold their clothes in a specific ritual. What is the most appropriate initial nursing
intervention?
A. Inform the patient that they will miss breakfast if they do not stop.
B. Allow the patient extra time to perform the ritual in the morning.
C. Interrupt the ritual to ensure the patient adheres to the unit schedule.
D. Administer a PRN dose of anxiolytic medication immediately.
Answer: B
Conceptual Explanation: Initially, the nurse should allow time for rituals to prevent
extreme anxiety. Over time, the nurse and patient will work to limit the time spent on
rituals.
2. A nurse is caring for a client experiencing a manic episode. Which meal choice is most
appropriate for this client?
A. A bowl of hot soup and crackers.
,B. A turkey sandwich and an apple.
C. Spaghetti and meatballs with a salad.
D. Steak and mashed potatoes.
Answer: B
Conceptual Explanation: Clients in a manic phase have high energy and difficulty sitting
still; ‘finger foods’ that can be eaten while moving are most appropriate.
3. A patient taking Clozapine for schizophrenia reports a sore throat and fever. Which
laboratory result should the nurse prioritize for review?
A. Blood Urea Nitrogen (BUN)
B. Serum Potassium levels
C. Complete Blood Count (CBC) with differential
D. Aspartate aminotransferase (AST)
Answer: C
Conceptual Explanation: Clozapine carries a risk of agranulocytosis. A sore throat and
fever are signs of infection, requiring immediate check of the White Blood Cell (WBC)
count.
4. Which assessment finding in a patient taking Lithium carbonate (Eskalith) suggests lithium
toxicity?
A. Fine hand tremors and mild thirst.
, B. Coarse tremors, diarrhea, and confusion.
C. Increased appetite and weight gain.
D. Occasional nausea and polyuria.
Answer: B
Conceptual Explanation: Coarse tremors, gastrointestinal upset (diarrhea), and CNS
changes like confusion are classic signs of moderate to severe lithium toxicity.
5. A client is admitted for severe depression and states, ‘I won’t be a burden much longer.’
What is the nurse’s priority action?
A. Ask the client directly if they have a plan for suicide.
B. Document the statement in the medical record.
C. Encourage the client to participate in group therapy.
D. Contact the family to discuss the client’s feelings.
Answer: A
Conceptual Explanation: Safety is the priority. When a client makes a veiled suicidal
comment, the nurse must assess for lethality and intent immediately.
6. A patient is experiencing a panic attack. What should the nurse say to the patient?
A. ‘Calm down, there is nothing here that can hurt you.’
B. ‘You are safe. I will stay here with you.’
