,NURS 3381 Exam 2 | Psychiatric MH Nursing (2026) Q&A
| University of Texas at Arlington
1. A client with major depressive disorder states, "I don't see the point in going on.
Everyone would be better off without me." Which nursing intervention is the priority?
A) Remind the client that suicide is a sin
B) Ask the client directly if they have a plan to harm themselves
C) Change the subject to something more positive
D) Tell the client they have a lot to live for
Correct Answer: Ask the client directly if they have a plan to harm themselves
Rationale: When a client expresses suicidal ideation, the nurse must conduct a thorough
suicide risk assessment, including direct questions about intent, plan, and access to means.
Direct questioning does not increase risk and is essential for safety planning. Minimizing
the statement, offering false reassurance, or changing the subject are nontherapeutic and
unsafe.
2. Which finding is considered a behavioral clue for suicide risk?
A) Sleeping more than usual
B) Giving away prized possessions
C) Increased appetite
D) Requesting more visitors
Correct Answer: Giving away prized possessions
Rationale: Behavioral clues for suicide include giving away prized possessions, writing
farewell notes, making a will, and putting personal affairs in order. These actions suggest
,the client is preparing for death. Sleeping more, increased appetite, and requesting visitors
are not typical behavioral warning signs.
3. A client taking lithium reports vomiting, confusion, and a coarse hand tremor. What is the
nurse's priority action?
A) Continue the current dose and reassess in one week
B) Administer an additional dose of lithium
C) Hold lithium and obtain a serum lithium level immediately
D) Increase the lithium dose to stabilize mood
Correct Answer: Hold lithium and obtain a serum lithium level immediately
Rationale: Vomiting, confusion, and coarse hand tremor suggest lithium toxicity, which
requires immediate discontinuation of lithium and serum level measurement. Continuing
or increasing the dose could worsen toxicity and lead to seizures, coma, or renal damage.
4. Which symptom cluster is most characteristic of schizophrenia?
A) Anhedonia and psychomotor retardation
B) Pressured speech and grandiosity
C) Hallucinations, delusions, and disorganized speech
D) Compulsions and obsessions
Correct Answer: Hallucinations, delusions, and disorganized speech
Rationale: Schizophrenia is characterized by positive symptoms such as hallucinations,
delusions, and disorganized speech, along with negative symptoms and cognitive deficits.
Anhedonia and psychomotor retardation suggest depression, pressured speech and
grandiosity suggest mania, and compulsions and obsessions suggest OCD.
, 5. Which extrapyramidal symptom is characterized by an acute, painful, sustained muscle
contraction, often of the tongue, head, and neck?
A) Akathisia
B) Tardive dyskinesia
C) Pseudoparkinsonism
D) Acute dystonia
Correct Answer: Acute dystonia
Rationale: Acute dystonia is a painful, sustained muscle contraction that typically occurs
within 2 to 5 days of starting antipsychotic medication and often affects the tongue, head,
and neck. Akathisia involves restlessness, tardive dyskinesia involves involuntary
movements, and pseudoparkinsonism mimics Parkinson disease.
6. A client with bipolar disorder is in an acute manic phase. Which intervention is most
appropriate initially?
A) Encourage the client to attend multiple stimulating group activities
B) Provide a quiet, low-stimulation environment and promote rest
C) Challenge the client's grandiose ideas directly
D) Allow the client to stay awake to avoid missing information
Correct Answer: Provide a quiet, low-stimulation environment and promote rest
Rationale: During acute mania, the priority is to reduce stimulation, promote rest and
sleep, ensure safety, and prevent exhaustion. Stimulating activities, directly challenging
grandiosity, or allowing sleep deprivation can worsen mania and escalation.
| University of Texas at Arlington
1. A client with major depressive disorder states, "I don't see the point in going on.
Everyone would be better off without me." Which nursing intervention is the priority?
A) Remind the client that suicide is a sin
B) Ask the client directly if they have a plan to harm themselves
C) Change the subject to something more positive
D) Tell the client they have a lot to live for
Correct Answer: Ask the client directly if they have a plan to harm themselves
Rationale: When a client expresses suicidal ideation, the nurse must conduct a thorough
suicide risk assessment, including direct questions about intent, plan, and access to means.
Direct questioning does not increase risk and is essential for safety planning. Minimizing
the statement, offering false reassurance, or changing the subject are nontherapeutic and
unsafe.
2. Which finding is considered a behavioral clue for suicide risk?
A) Sleeping more than usual
B) Giving away prized possessions
C) Increased appetite
D) Requesting more visitors
Correct Answer: Giving away prized possessions
Rationale: Behavioral clues for suicide include giving away prized possessions, writing
farewell notes, making a will, and putting personal affairs in order. These actions suggest
,the client is preparing for death. Sleeping more, increased appetite, and requesting visitors
are not typical behavioral warning signs.
3. A client taking lithium reports vomiting, confusion, and a coarse hand tremor. What is the
nurse's priority action?
A) Continue the current dose and reassess in one week
B) Administer an additional dose of lithium
C) Hold lithium and obtain a serum lithium level immediately
D) Increase the lithium dose to stabilize mood
Correct Answer: Hold lithium and obtain a serum lithium level immediately
Rationale: Vomiting, confusion, and coarse hand tremor suggest lithium toxicity, which
requires immediate discontinuation of lithium and serum level measurement. Continuing
or increasing the dose could worsen toxicity and lead to seizures, coma, or renal damage.
4. Which symptom cluster is most characteristic of schizophrenia?
A) Anhedonia and psychomotor retardation
B) Pressured speech and grandiosity
C) Hallucinations, delusions, and disorganized speech
D) Compulsions and obsessions
Correct Answer: Hallucinations, delusions, and disorganized speech
Rationale: Schizophrenia is characterized by positive symptoms such as hallucinations,
delusions, and disorganized speech, along with negative symptoms and cognitive deficits.
Anhedonia and psychomotor retardation suggest depression, pressured speech and
grandiosity suggest mania, and compulsions and obsessions suggest OCD.
, 5. Which extrapyramidal symptom is characterized by an acute, painful, sustained muscle
contraction, often of the tongue, head, and neck?
A) Akathisia
B) Tardive dyskinesia
C) Pseudoparkinsonism
D) Acute dystonia
Correct Answer: Acute dystonia
Rationale: Acute dystonia is a painful, sustained muscle contraction that typically occurs
within 2 to 5 days of starting antipsychotic medication and often affects the tongue, head,
and neck. Akathisia involves restlessness, tardive dyskinesia involves involuntary
movements, and pseudoparkinsonism mimics Parkinson disease.
6. A client with bipolar disorder is in an acute manic phase. Which intervention is most
appropriate initially?
A) Encourage the client to attend multiple stimulating group activities
B) Provide a quiet, low-stimulation environment and promote rest
C) Challenge the client's grandiose ideas directly
D) Allow the client to stay awake to avoid missing information
Correct Answer: Provide a quiet, low-stimulation environment and promote rest
Rationale: During acute mania, the priority is to reduce stimulation, promote rest and
sleep, ensure safety, and prevent exhaustion. Stimulating activities, directly challenging
grandiosity, or allowing sleep deprivation can worsen mania and escalation.
