NCLEX RN Mental Health Nursing
Exam 1 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026
1. A client with major depressive disorder says, “There is no reason for me to
keep living.” What is the nurse’s priority response?
A. “You have so much to live for.”
B. “Why do you feel that way?”
C. “Are you thinking about killing yourself?”
D. “Things will get better with treatment.”
Answer: “Are you thinking about killing yourself?”
Rationale: Directly assessing suicidal thoughts is the priority. Asking about
suicide does not increase the risk and allows the nurse to determine the
client’s immediate safety needs.
2. Which finding is most characteristic of a manic episode?
A. Social withdrawal
B. Decreased need for sleep
C. Slowed speech
D. Increased appetite with weight gain
Answer: Decreased need for sleep
Rationale: Mania commonly causes decreased need for sleep, elevated or
irritable mood, increased energy, rapid speech, impulsivity, and poor
judgment.
,3. A client experiencing a panic attack is trembling and hyperventilating. What
should the nurse do first?
A. Leave the client alone in a quiet room.
B. Ask the client to explain the cause of the anxiety.
C. Stay with the client and use short, simple statements.
D. Encourage the client to participate in group therapy.
Answer: Stay with the client and use short, simple statements.
Rationale: During severe anxiety or panic, the client has difficulty processing
complex information. Remaining with the client provides safety and using
simple statements promotes calm.
4. Which statement by a client taking sertraline indicates correct understanding
of the medication?
A. “I should stop taking it when I feel better.”
B. “I may need several weeks before experiencing the full therapeutic effect.”
C. “This medication will immediately relieve my anxiety.”
D. “I should double the dose if I miss a dose.”
Answer: “I may need several weeks before experiencing the full therapeutic
effect.”
Rationale: SSRIs such as sertraline generally require several weeks to produce
their full therapeutic effects. Abrupt discontinuation and dose doubling
should be avoided.
5. A client taking lithium reports severe diarrhea, vomiting, coarse tremors, and
difficulty walking. What is the nurse’s priority action?
A. Administer the next lithium dose.
B. Encourage increased caffeine intake.
C. Hold the lithium and notify the healthcare provider.
D. Reassure the client that these are expected effects.
Answer: Hold the lithium and notify the healthcare provider.
,Rationale: Severe gastrointestinal symptoms, coarse tremor, and ataxia
suggest lithium toxicity. The medication should be withheld and the provider
notified promptly.
6. Which intervention is most appropriate for a client experiencing auditory
hallucinations?
A. “The voices are not real, so ignore them.”
B. “What are the voices telling you to do?”
C. “You need to stop listening to the voices.”
D. “I hear the voices too.”
Answer: “What are the voices telling you to do?”
Rationale: The nurse should assess the content of hallucinations, especially
for command hallucinations that may place the client or others at risk.
7. A client with schizophrenia says, “The government implanted a device in my
brain.” What is the best nursing response?
A. “That is impossible.”
B. “Why would the government do that?”
C. “I understand that you believe this, but I do not share that belief.”
D. “Yes, the government has been monitoring you.”
Answer: “I understand that you believe this, but I do not share that belief.”
Rationale: The nurse should acknowledge the client’s feelings without
reinforcing the delusion or arguing about its validity.
8. Which behavior is most concerning in a client with depression?
A. Crying during an interview
B. Reporting insomnia
C. Suddenly appearing cheerful after severe depression
D. Expressing feelings of worthlessness
, Answer: Suddenly appearing cheerful after severe depression
Rationale: Sudden improvement in mood may indicate that a severely
depressed client has developed a suicide plan and feels relieved after making
the decision.
9. A client experiencing alcohol withdrawal becomes confused, severely
tremulous, and develops visual hallucinations. Which complication should the
nurse suspect?
A. Neuroleptic malignant syndrome
B. Delirium tremens
C. Serotonin syndrome
D. Wernicke-Korsakoff syndrome
Answer: Delirium tremens
Rationale: Delirium tremens is a severe, potentially life-threatening form of
alcohol withdrawal characterized by confusion, agitation, hallucinations,
autonomic instability, and tremors.
10. Which assessment finding is expected in a client with generalized anxiety
disorder?
A. Persistent excessive worry
B. Grandiose thinking
C. Complete loss of memory
D. Auditory hallucinations
Answer: Persistent excessive worry
Rationale: Generalized anxiety disorder is characterized by excessive and
difficult-to-control worry occurring across multiple areas of life.
11. A client taking an antipsychotic medication develops high fever, severe
muscle rigidity, altered mental status, and autonomic instability. What
condition should the nurse suspect?
Exam 1 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026
1. A client with major depressive disorder says, “There is no reason for me to
keep living.” What is the nurse’s priority response?
A. “You have so much to live for.”
B. “Why do you feel that way?”
C. “Are you thinking about killing yourself?”
D. “Things will get better with treatment.”
Answer: “Are you thinking about killing yourself?”
Rationale: Directly assessing suicidal thoughts is the priority. Asking about
suicide does not increase the risk and allows the nurse to determine the
client’s immediate safety needs.
2. Which finding is most characteristic of a manic episode?
A. Social withdrawal
B. Decreased need for sleep
C. Slowed speech
D. Increased appetite with weight gain
Answer: Decreased need for sleep
Rationale: Mania commonly causes decreased need for sleep, elevated or
irritable mood, increased energy, rapid speech, impulsivity, and poor
judgment.
,3. A client experiencing a panic attack is trembling and hyperventilating. What
should the nurse do first?
A. Leave the client alone in a quiet room.
B. Ask the client to explain the cause of the anxiety.
C. Stay with the client and use short, simple statements.
D. Encourage the client to participate in group therapy.
Answer: Stay with the client and use short, simple statements.
Rationale: During severe anxiety or panic, the client has difficulty processing
complex information. Remaining with the client provides safety and using
simple statements promotes calm.
4. Which statement by a client taking sertraline indicates correct understanding
of the medication?
A. “I should stop taking it when I feel better.”
B. “I may need several weeks before experiencing the full therapeutic effect.”
C. “This medication will immediately relieve my anxiety.”
D. “I should double the dose if I miss a dose.”
Answer: “I may need several weeks before experiencing the full therapeutic
effect.”
Rationale: SSRIs such as sertraline generally require several weeks to produce
their full therapeutic effects. Abrupt discontinuation and dose doubling
should be avoided.
5. A client taking lithium reports severe diarrhea, vomiting, coarse tremors, and
difficulty walking. What is the nurse’s priority action?
A. Administer the next lithium dose.
B. Encourage increased caffeine intake.
C. Hold the lithium and notify the healthcare provider.
D. Reassure the client that these are expected effects.
Answer: Hold the lithium and notify the healthcare provider.
,Rationale: Severe gastrointestinal symptoms, coarse tremor, and ataxia
suggest lithium toxicity. The medication should be withheld and the provider
notified promptly.
6. Which intervention is most appropriate for a client experiencing auditory
hallucinations?
A. “The voices are not real, so ignore them.”
B. “What are the voices telling you to do?”
C. “You need to stop listening to the voices.”
D. “I hear the voices too.”
Answer: “What are the voices telling you to do?”
Rationale: The nurse should assess the content of hallucinations, especially
for command hallucinations that may place the client or others at risk.
7. A client with schizophrenia says, “The government implanted a device in my
brain.” What is the best nursing response?
A. “That is impossible.”
B. “Why would the government do that?”
C. “I understand that you believe this, but I do not share that belief.”
D. “Yes, the government has been monitoring you.”
Answer: “I understand that you believe this, but I do not share that belief.”
Rationale: The nurse should acknowledge the client’s feelings without
reinforcing the delusion or arguing about its validity.
8. Which behavior is most concerning in a client with depression?
A. Crying during an interview
B. Reporting insomnia
C. Suddenly appearing cheerful after severe depression
D. Expressing feelings of worthlessness
, Answer: Suddenly appearing cheerful after severe depression
Rationale: Sudden improvement in mood may indicate that a severely
depressed client has developed a suicide plan and feels relieved after making
the decision.
9. A client experiencing alcohol withdrawal becomes confused, severely
tremulous, and develops visual hallucinations. Which complication should the
nurse suspect?
A. Neuroleptic malignant syndrome
B. Delirium tremens
C. Serotonin syndrome
D. Wernicke-Korsakoff syndrome
Answer: Delirium tremens
Rationale: Delirium tremens is a severe, potentially life-threatening form of
alcohol withdrawal characterized by confusion, agitation, hallucinations,
autonomic instability, and tremors.
10. Which assessment finding is expected in a client with generalized anxiety
disorder?
A. Persistent excessive worry
B. Grandiose thinking
C. Complete loss of memory
D. Auditory hallucinations
Answer: Persistent excessive worry
Rationale: Generalized anxiety disorder is characterized by excessive and
difficult-to-control worry occurring across multiple areas of life.
11. A client taking an antipsychotic medication develops high fever, severe
muscle rigidity, altered mental status, and autonomic instability. What
condition should the nurse suspect?
