NCLEX RN Mental Health Nursing
Exam 3 100 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 should focus on the positive things in your life.”
B. “Do you have a specific plan to harm yourself?”
C. “Your family would be devastated if you died.”
D. “You need to promise me that you will not hurt yourself.”
Answer: “Do you have a specific plan to harm yourself?”
Rationale: Direct assessment of suicidal thoughts, intent, plan, means, and
access to means is essential for determining immediate safety risk.
2. A client experiencing acute mania is pacing and talking rapidly. Which
nursing intervention is most appropriate?
A. Encourage participation in group activities.
B. Provide a quiet, low-stimulation environment.
C. Ask the client to explain feelings in detail.
D. Encourage frequent social interaction.
Answer: Provide a quiet, low-stimulation environment.
Rationale: Clients experiencing mania benefit from reduced environmental
stimulation, clear limits, and concise communication to decrease escalation
and exhaustion.
3. A client taking lithium reports severe diarrhea, vomiting, coarse hand
tremors, and difficulty walking. What should the nurse do first?
,A. Administer the next lithium dose.
B. Encourage increased sodium restriction.
C. Hold the lithium and notify the provider.
D. Reassure the client that these effects are expected.
Answer: Hold the lithium and notify the provider.
Rationale: Severe gastrointestinal symptoms, coarse tremors, and ataxia
suggest lithium toxicity, which requires prompt intervention.
4. A client with schizophrenia says, “The voices are telling me that I am
worthless.” Which response by the nurse is best?
A. “The voices are real, and you should listen to them.”
B. “I do not hear the voices, but I understand that they are frightening.”
C. “You need to ignore the voices.”
D. “Why do you think the voices are speaking to you?”
Answer: “I do not hear the voices, but I understand that they are frightening.”
Rationale: The nurse acknowledges the client’s experience without
reinforcing the hallucination and communicates empathy and reality
orientation.
5. Which finding in a client taking an antipsychotic medication requires
immediate intervention?
A. Mild dry mouth
B. Increased appetite
C. Muscle rigidity and high fever
D. Mild drowsiness
Answer: Muscle rigidity and high fever
Rationale: Severe rigidity, hyperthermia, altered mental status, and
autonomic instability may indicate neuroleptic malignant syndrome, a
medical emergency.
6. A client with panic disorder is experiencing an acute panic attack. What
should the nurse do first?
,A. Leave the client alone to decrease stimulation.
B. Encourage the client to discuss childhood experiences.
C. Stay with the client and use short, calm statements.
D. Teach detailed relaxation techniques.
Answer: Stay with the client and use short, calm statements.
Rationale: During acute panic, the client has difficulty processing complex
information. Remaining with the client and providing simple reassurance
promotes safety.
7. A client with obsessive-compulsive disorder repeatedly washes the
hands because of contamination fears. Which intervention is
appropriate?
A. Force the client to stop the behavior immediately.
B. Allow unlimited time for handwashing.
C. Establish limits while gradually reducing ritualistic behavior.
D. Ignore all compulsive behaviors.
Answer: Establish limits while gradually reducing ritualistic behavior.
Rationale: Structured limits and behavioral approaches can reduce
compulsions while maintaining a therapeutic and nonjudgmental
relationship.
8. Which statement by a client with post-traumatic stress disorder indicates
understanding of grounding techniques?
A. “I should avoid thinking about the present.”
B. “I can identify things I see, hear, and feel around me.”
C. “I should stay isolated when I feel anxious.”
D. “I should suppress all memories of the trauma.”
Answer: “I can identify things I see, hear, and feel around me.”
Rationale: Grounding techniques help clients reconnect with the present
environment when experiencing flashbacks, dissociation, or severe anxiety.
9. A client with anorexia nervosa has a heart rate of 42/min and reports
dizziness. What is the nurse’s priority action?
, A. Encourage exercise.
B. Place the client on cardiac monitoring and notify the provider.
C. Discuss body-image concerns.
D. Offer a low-calorie meal.
Answer: Place the client on cardiac monitoring and notify the provider.
Rationale: Severe bradycardia and dizziness can indicate cardiovascular
instability associated with severe malnutrition and require immediate
medical evaluation.
10.Which behavior is characteristic of borderline personality disorder?
A. Persistent social detachment without emotional expression
B. Stable relationships and self-image
C. Intense, unstable relationships with fear of abandonment
D. Persistent disregard for all interpersonal relationships
Answer: Intense, unstable relationships with fear of abandonment
Rationale: Borderline personality disorder commonly involves emotional
instability, unstable relationships, impulsivity, and intense fear of
abandonment.
11.A client taking clozapine reports fever and a sore throat. What should
the nurse do?
A. Administer the medication as scheduled.
B. Encourage vigorous exercise.
C. Notify the provider and anticipate a white blood cell count.
D. Tell the client these symptoms are harmless.
Answer: Notify the provider and anticipate a white blood cell count.
Rationale: Clozapine can cause severe neutropenia or agranulocytosis. Fever
and sore throat may indicate infection and require prompt evaluation.
12.A client with generalized anxiety disorder is prescribed buspirone. Which
statement indicates correct understanding?
A. “I can take it only when I have a panic attack.”
B. “I should expect immediate relief after the first dose.”
Exam 3 100 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 should focus on the positive things in your life.”
B. “Do you have a specific plan to harm yourself?”
C. “Your family would be devastated if you died.”
D. “You need to promise me that you will not hurt yourself.”
Answer: “Do you have a specific plan to harm yourself?”
Rationale: Direct assessment of suicidal thoughts, intent, plan, means, and
access to means is essential for determining immediate safety risk.
2. A client experiencing acute mania is pacing and talking rapidly. Which
nursing intervention is most appropriate?
A. Encourage participation in group activities.
B. Provide a quiet, low-stimulation environment.
C. Ask the client to explain feelings in detail.
D. Encourage frequent social interaction.
Answer: Provide a quiet, low-stimulation environment.
Rationale: Clients experiencing mania benefit from reduced environmental
stimulation, clear limits, and concise communication to decrease escalation
and exhaustion.
3. A client taking lithium reports severe diarrhea, vomiting, coarse hand
tremors, and difficulty walking. What should the nurse do first?
,A. Administer the next lithium dose.
B. Encourage increased sodium restriction.
C. Hold the lithium and notify the provider.
D. Reassure the client that these effects are expected.
Answer: Hold the lithium and notify the provider.
Rationale: Severe gastrointestinal symptoms, coarse tremors, and ataxia
suggest lithium toxicity, which requires prompt intervention.
4. A client with schizophrenia says, “The voices are telling me that I am
worthless.” Which response by the nurse is best?
A. “The voices are real, and you should listen to them.”
B. “I do not hear the voices, but I understand that they are frightening.”
C. “You need to ignore the voices.”
D. “Why do you think the voices are speaking to you?”
Answer: “I do not hear the voices, but I understand that they are frightening.”
Rationale: The nurse acknowledges the client’s experience without
reinforcing the hallucination and communicates empathy and reality
orientation.
5. Which finding in a client taking an antipsychotic medication requires
immediate intervention?
A. Mild dry mouth
B. Increased appetite
C. Muscle rigidity and high fever
D. Mild drowsiness
Answer: Muscle rigidity and high fever
Rationale: Severe rigidity, hyperthermia, altered mental status, and
autonomic instability may indicate neuroleptic malignant syndrome, a
medical emergency.
6. A client with panic disorder is experiencing an acute panic attack. What
should the nurse do first?
,A. Leave the client alone to decrease stimulation.
B. Encourage the client to discuss childhood experiences.
C. Stay with the client and use short, calm statements.
D. Teach detailed relaxation techniques.
Answer: Stay with the client and use short, calm statements.
Rationale: During acute panic, the client has difficulty processing complex
information. Remaining with the client and providing simple reassurance
promotes safety.
7. A client with obsessive-compulsive disorder repeatedly washes the
hands because of contamination fears. Which intervention is
appropriate?
A. Force the client to stop the behavior immediately.
B. Allow unlimited time for handwashing.
C. Establish limits while gradually reducing ritualistic behavior.
D. Ignore all compulsive behaviors.
Answer: Establish limits while gradually reducing ritualistic behavior.
Rationale: Structured limits and behavioral approaches can reduce
compulsions while maintaining a therapeutic and nonjudgmental
relationship.
8. Which statement by a client with post-traumatic stress disorder indicates
understanding of grounding techniques?
A. “I should avoid thinking about the present.”
B. “I can identify things I see, hear, and feel around me.”
C. “I should stay isolated when I feel anxious.”
D. “I should suppress all memories of the trauma.”
Answer: “I can identify things I see, hear, and feel around me.”
Rationale: Grounding techniques help clients reconnect with the present
environment when experiencing flashbacks, dissociation, or severe anxiety.
9. A client with anorexia nervosa has a heart rate of 42/min and reports
dizziness. What is the nurse’s priority action?
, A. Encourage exercise.
B. Place the client on cardiac monitoring and notify the provider.
C. Discuss body-image concerns.
D. Offer a low-calorie meal.
Answer: Place the client on cardiac monitoring and notify the provider.
Rationale: Severe bradycardia and dizziness can indicate cardiovascular
instability associated with severe malnutrition and require immediate
medical evaluation.
10.Which behavior is characteristic of borderline personality disorder?
A. Persistent social detachment without emotional expression
B. Stable relationships and self-image
C. Intense, unstable relationships with fear of abandonment
D. Persistent disregard for all interpersonal relationships
Answer: Intense, unstable relationships with fear of abandonment
Rationale: Borderline personality disorder commonly involves emotional
instability, unstable relationships, impulsivity, and intense fear of
abandonment.
11.A client taking clozapine reports fever and a sore throat. What should
the nurse do?
A. Administer the medication as scheduled.
B. Encourage vigorous exercise.
C. Notify the provider and anticipate a white blood cell count.
D. Tell the client these symptoms are harmless.
Answer: Notify the provider and anticipate a white blood cell count.
Rationale: Clozapine can cause severe neutropenia or agranulocytosis. Fever
and sore throat may indicate infection and require prompt evaluation.
12.A client with generalized anxiety disorder is prescribed buspirone. Which
statement indicates correct understanding?
A. “I can take it only when I have a panic attack.”
B. “I should expect immediate relief after the first dose.”
