NCLEX RN Mental Health Nursing
Exam 2 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026
Question 1
A client with major depressive disorder says, “Everyone would be better off
without me.” What is the nurse’s priority response?
A. “You should focus on the positive things in your life.”
B. “Why do you think everyone would be better off without you?”
C. “Are you thinking about killing yourself?”
D. “Your family would be devastated if you died.”
Answer: C. “Are you thinking about killing yourself?”
Rationale: Directly assessing suicidal thoughts is essential when a client
expresses hopelessness or perceived burdensomeness. Asking about suicide
does not increase suicidal behavior and allows the nurse to determine
immediate safety needs.
Question 2
A client experiencing acute mania is pacing, shouting, and interrupting other
clients. Which intervention is most appropriate?
A. Encourage participation in a group activity.
B. Provide a quiet, low-stimulation environment.
C. Ask the client to explain the reason for the behavior.
D. Allow unlimited physical activity.
Answer: B. Provide a quiet, low-stimulation environment.
,Rationale: Clients experiencing mania benefit from reduced environmental
stimulation, clear limits, and structured activities. Excessive stimulation can
worsen agitation and impulsivity.
Question 3
A client with schizophrenia says, “The voices are telling me that I am evil.”
Which response by the nurse is best?
A. “The voices are not real, so ignore them.”
B. “I hear the voices too.”
C. “I don't hear the voices, but I understand that they are frightening you.”
D. “What did you do to make the voices angry?”
Answer: C. “I don't hear the voices, but I understand that they are frightening
you.”
Rationale: The nurse acknowledges the client’s feelings without validating
the hallucination. This approach promotes trust while maintaining reality-
based communication.
Question 4
A client with obsessive-compulsive disorder repeatedly washes their hands.
Which nursing intervention is appropriate?
A. Immediately stop the handwashing behavior.
B. Encourage the client to discuss the anxiety associated with the behavior.
C. Tell the client the behavior is irrational.
D. Prevent the client from washing their hands under all circumstances.
Answer: B. Encourage the client to discuss the anxiety associated with the
behavior.
Rationale: Compulsions temporarily reduce anxiety. Helping the client
identify triggers and anxiety is therapeutic. Abruptly preventing compulsions
can significantly increase anxiety.
,Question 5
A client is having a panic attack and reports feeling unable to breathe. What
should the nurse do first?
A. Ask the client to describe the source of the anxiety.
B. Stay with the client and use short, simple statements.
C. Leave the client alone in a quiet room.
D. Encourage the client to participate in deep group breathing exercises.
Answer: B. Stay with the client and use short, simple statements.
Rationale: During severe anxiety, the client has difficulty processing complex
information. Staying with the client provides safety and using simple
statements helps decrease stimulation.
Question 6
Which finding is most characteristic of generalized anxiety disorder?
A. Recurrent intrusive thoughts followed by compulsions
B. Persistent excessive worry about multiple areas of life
C. Flashbacks following a traumatic event
D. Episodes of elevated mood and decreased sleep
Answer: B. Persistent excessive worry about multiple areas of life
Rationale: Generalized anxiety disorder involves excessive and difficult-to-
control worry about multiple areas of life, often accompanied by tension,
restlessness, fatigue, and sleep disturbance.
Question 7
A client taking lithium reports severe diarrhea, vomiting, coarse tremors, and
confusion. What should the nurse do?
A. Administer the next dose with food.
B. Encourage increased caffeine intake.
, C. Hold lithium and notify the healthcare provider.
D. Reassure the client that these are expected effects.
Answer: C. Hold lithium and notify the healthcare provider.
Rationale: Severe gastrointestinal symptoms, coarse tremor, and confusion
may indicate lithium toxicity. Lithium should be withheld and the provider
notified promptly.
Question 8
Which laboratory value is especially important for a client taking lithium?
A. Serum lithium level
B. Hemoglobin A1c
C. Troponin level
D. Serum amylase
Answer: A. Serum lithium level
Rationale: Lithium has a narrow therapeutic range. Serum lithium levels are
monitored to ensure therapeutic effectiveness and prevent toxicity.
Question 9
A client taking clozapine reports a sore throat and fever. What is the priority
nursing action?
A. Encourage increased fluid intake.
B. Obtain a white blood cell count and notify the provider.
C. Administer acetaminophen and reassess tomorrow.
D. Tell the client to continue the medication normally.
Answer: B. Obtain a white blood cell count and notify the provider.
Rationale: Clozapine can cause severe neutropenia or agranulocytosis. Fever
and sore throat may indicate infection associated with a dangerously low
neutrophil count.
Exam 2 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026
Question 1
A client with major depressive disorder says, “Everyone would be better off
without me.” What is the nurse’s priority response?
A. “You should focus on the positive things in your life.”
B. “Why do you think everyone would be better off without you?”
C. “Are you thinking about killing yourself?”
D. “Your family would be devastated if you died.”
Answer: C. “Are you thinking about killing yourself?”
Rationale: Directly assessing suicidal thoughts is essential when a client
expresses hopelessness or perceived burdensomeness. Asking about suicide
does not increase suicidal behavior and allows the nurse to determine
immediate safety needs.
Question 2
A client experiencing acute mania is pacing, shouting, and interrupting other
clients. Which intervention is most appropriate?
A. Encourage participation in a group activity.
B. Provide a quiet, low-stimulation environment.
C. Ask the client to explain the reason for the behavior.
D. Allow unlimited physical activity.
Answer: B. Provide a quiet, low-stimulation environment.
,Rationale: Clients experiencing mania benefit from reduced environmental
stimulation, clear limits, and structured activities. Excessive stimulation can
worsen agitation and impulsivity.
Question 3
A client with schizophrenia says, “The voices are telling me that I am evil.”
Which response by the nurse is best?
A. “The voices are not real, so ignore them.”
B. “I hear the voices too.”
C. “I don't hear the voices, but I understand that they are frightening you.”
D. “What did you do to make the voices angry?”
Answer: C. “I don't hear the voices, but I understand that they are frightening
you.”
Rationale: The nurse acknowledges the client’s feelings without validating
the hallucination. This approach promotes trust while maintaining reality-
based communication.
Question 4
A client with obsessive-compulsive disorder repeatedly washes their hands.
Which nursing intervention is appropriate?
A. Immediately stop the handwashing behavior.
B. Encourage the client to discuss the anxiety associated with the behavior.
C. Tell the client the behavior is irrational.
D. Prevent the client from washing their hands under all circumstances.
Answer: B. Encourage the client to discuss the anxiety associated with the
behavior.
Rationale: Compulsions temporarily reduce anxiety. Helping the client
identify triggers and anxiety is therapeutic. Abruptly preventing compulsions
can significantly increase anxiety.
,Question 5
A client is having a panic attack and reports feeling unable to breathe. What
should the nurse do first?
A. Ask the client to describe the source of the anxiety.
B. Stay with the client and use short, simple statements.
C. Leave the client alone in a quiet room.
D. Encourage the client to participate in deep group breathing exercises.
Answer: B. Stay with the client and use short, simple statements.
Rationale: During severe anxiety, the client has difficulty processing complex
information. Staying with the client provides safety and using simple
statements helps decrease stimulation.
Question 6
Which finding is most characteristic of generalized anxiety disorder?
A. Recurrent intrusive thoughts followed by compulsions
B. Persistent excessive worry about multiple areas of life
C. Flashbacks following a traumatic event
D. Episodes of elevated mood and decreased sleep
Answer: B. Persistent excessive worry about multiple areas of life
Rationale: Generalized anxiety disorder involves excessive and difficult-to-
control worry about multiple areas of life, often accompanied by tension,
restlessness, fatigue, and sleep disturbance.
Question 7
A client taking lithium reports severe diarrhea, vomiting, coarse tremors, and
confusion. What should the nurse do?
A. Administer the next dose with food.
B. Encourage increased caffeine intake.
, C. Hold lithium and notify the healthcare provider.
D. Reassure the client that these are expected effects.
Answer: C. Hold lithium and notify the healthcare provider.
Rationale: Severe gastrointestinal symptoms, coarse tremor, and confusion
may indicate lithium toxicity. Lithium should be withheld and the provider
notified promptly.
Question 8
Which laboratory value is especially important for a client taking lithium?
A. Serum lithium level
B. Hemoglobin A1c
C. Troponin level
D. Serum amylase
Answer: A. Serum lithium level
Rationale: Lithium has a narrow therapeutic range. Serum lithium levels are
monitored to ensure therapeutic effectiveness and prevent toxicity.
Question 9
A client taking clozapine reports a sore throat and fever. What is the priority
nursing action?
A. Encourage increased fluid intake.
B. Obtain a white blood cell count and notify the provider.
C. Administer acetaminophen and reassess tomorrow.
D. Tell the client to continue the medication normally.
Answer: B. Obtain a white blood cell count and notify the provider.
Rationale: Clozapine can cause severe neutropenia or agranulocytosis. Fever
and sore throat may indicate infection associated with a dangerously low
neutrophil count.
