NSG 3450 FINAL EXAM
NURSING PRACTICE: MENTAL HEALTH
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES ||
100% GUARANTEED PASS!!
<LATEST VERSION>
1. A 28-year-old client presents with persistent sadness, fatigue, and feelings of
worthlessness for the past 6 weeks. Which assessment finding is most critical to
evaluate first?
A. Sleep patterns
B. Appetite changes
C. Suicidal ideation
D. Energy level
Answer: C. Suicidal ideation
Rationale: The priority in any client with depression is safety. Assessing for
suicidal ideation is essential to prevent harm. Other symptoms are important but
secondary to safety.
2. A nurse uses silence as a communication technique during a therapy session.
What is the primary purpose of this technique?
A. To avoid uncomfortable topics
B. To allow the client to organize thoughts
C. To demonstrate authority
D. To encourage rapid disclosure
,Answer: B. To allow the client to organize thoughts
Rationale: Silence is a therapeutic tool that provides the client time to reflect and
express feelings, promoting self-exploration.
3. A client with bipolar I disorder is admitted during a manic episode. Which
nursing intervention is the priority?
A. Encourage group therapy participation
B. Maintain a structured and low-stimulation environment
C. Allow unrestricted social interactions
D. Initiate psychotherapy immediately
Answer: B. Maintain a structured and low-stimulation environment
Rationale: Clients in acute mania benefit from a controlled environment to prevent
injury and reduce overstimulation, which can escalate manic behaviors.
4. A client taking Lithium reports nausea, vomiting, and tremors. Which action
should the nurse take first?
A. Advise the client to take the medication with food
B. Hold the next dose and notify the provider
C. Monitor vital signs every hour
D. Encourage increased fluid intake
Answer: B. Hold the next dose and notify the provider
Rationale: These symptoms indicate possible lithium toxicity, which is a medical
emergency. Immediate intervention and provider notification are essential.
5. During a mental status examination, a client demonstrates rapid, pressured
speech, flight of ideas, and distractibility. Which diagnosis is most consistent?
A. Major Depressive Disorder
B. Bipolar Mania
C. Generalized Anxiety Disorder
D. Schizophrenia
,Answer: B. Bipolar Mania
Rationale: These behaviors are hallmark features of acute mania, including
pressured speech and flight of ideas.
6. A nurse is caring for a client with PTSD who is experiencing intrusive
flashbacks. Which intervention is most appropriate?
A. Encourage avoidance of all reminders of trauma
B. Stay with the client and provide grounding techniques
C. Ask the client to discuss the trauma in detail immediately
D. Suggest that the client use alcohol to manage anxiety
Answer: B. Stay with the client and provide grounding techniques
Rationale: Grounding techniques help the client reorient to the present and reduce
the intensity of flashbacks. Avoidance or substance use is not therapeutic.
7. A client presents with symptoms of serotonin syndrome, including agitation,
hyperreflexia, and tremors. Which medication is most likely contributing?
A. Fluoxetine (SSRI)
B. Lithium
C. Haloperidol
D. Diazepam
Answer: A. Fluoxetine (SSRI)
Rationale: SSRIs increase serotonin levels and can lead to serotonin syndrome
when combined with other serotonergic agents or in overdose.
8. A 35-year-old client is admitted after a suicide attempt via medication overdose.
Which intervention takes priority?
A. Begin group therapy
B. Conduct a suicide risk assessment
C. Administer prescribed antidepressants
D. Encourage journaling
, Answer: B. Conduct a suicide risk assessment
Rationale: Safety assessment and intervention are the top priority. Understanding
risk factors helps guide immediate safety measures.
9. A client with schizophrenia is experiencing auditory hallucinations. Which
response by the nurse is most appropriate?
A. “The voices aren’t real; ignore them.”
B. “I understand the voices are real to you; let’s focus on reality.”
C. “Tell me what the voices are saying in detail.”
D. “You should pray to stop the voices.”
Answer: B. “I understand the voices are real to you; let’s focus on reality.”
Rationale: Validating the client’s experience while gently redirecting to reality is
therapeutic. Denial or judgment is non-therapeutic.
10. A client taking Citalopram reports sexual dysfunction and insomnia. Which
nursing action is appropriate?
A. Discontinue medication immediately
B. Notify the provider for possible dose adjustment or alternative
C. Instruct the client to ignore side effects
D. Advise the client to stop taking all medications
Answer: B. Notify the provider for possible dose adjustment or alternative
Rationale: SSRIs can cause sexual dysfunction and insomnia. The provider may
adjust dose or switch medications while monitoring response.
11. A client in a psychiatric unit becomes verbally aggressive toward staff. Which
intervention is most appropriate initially?
A. Restrain immediately
B. Use a calm voice and maintain a safe distance
C. Yell to assert authority
D. Ignore the behavior
NURSING PRACTICE: MENTAL HEALTH
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES ||
100% GUARANTEED PASS!!
<LATEST VERSION>
1. A 28-year-old client presents with persistent sadness, fatigue, and feelings of
worthlessness for the past 6 weeks. Which assessment finding is most critical to
evaluate first?
A. Sleep patterns
B. Appetite changes
C. Suicidal ideation
D. Energy level
Answer: C. Suicidal ideation
Rationale: The priority in any client with depression is safety. Assessing for
suicidal ideation is essential to prevent harm. Other symptoms are important but
secondary to safety.
2. A nurse uses silence as a communication technique during a therapy session.
What is the primary purpose of this technique?
A. To avoid uncomfortable topics
B. To allow the client to organize thoughts
C. To demonstrate authority
D. To encourage rapid disclosure
,Answer: B. To allow the client to organize thoughts
Rationale: Silence is a therapeutic tool that provides the client time to reflect and
express feelings, promoting self-exploration.
3. A client with bipolar I disorder is admitted during a manic episode. Which
nursing intervention is the priority?
A. Encourage group therapy participation
B. Maintain a structured and low-stimulation environment
C. Allow unrestricted social interactions
D. Initiate psychotherapy immediately
Answer: B. Maintain a structured and low-stimulation environment
Rationale: Clients in acute mania benefit from a controlled environment to prevent
injury and reduce overstimulation, which can escalate manic behaviors.
4. A client taking Lithium reports nausea, vomiting, and tremors. Which action
should the nurse take first?
A. Advise the client to take the medication with food
B. Hold the next dose and notify the provider
C. Monitor vital signs every hour
D. Encourage increased fluid intake
Answer: B. Hold the next dose and notify the provider
Rationale: These symptoms indicate possible lithium toxicity, which is a medical
emergency. Immediate intervention and provider notification are essential.
5. During a mental status examination, a client demonstrates rapid, pressured
speech, flight of ideas, and distractibility. Which diagnosis is most consistent?
A. Major Depressive Disorder
B. Bipolar Mania
C. Generalized Anxiety Disorder
D. Schizophrenia
,Answer: B. Bipolar Mania
Rationale: These behaviors are hallmark features of acute mania, including
pressured speech and flight of ideas.
6. A nurse is caring for a client with PTSD who is experiencing intrusive
flashbacks. Which intervention is most appropriate?
A. Encourage avoidance of all reminders of trauma
B. Stay with the client and provide grounding techniques
C. Ask the client to discuss the trauma in detail immediately
D. Suggest that the client use alcohol to manage anxiety
Answer: B. Stay with the client and provide grounding techniques
Rationale: Grounding techniques help the client reorient to the present and reduce
the intensity of flashbacks. Avoidance or substance use is not therapeutic.
7. A client presents with symptoms of serotonin syndrome, including agitation,
hyperreflexia, and tremors. Which medication is most likely contributing?
A. Fluoxetine (SSRI)
B. Lithium
C. Haloperidol
D. Diazepam
Answer: A. Fluoxetine (SSRI)
Rationale: SSRIs increase serotonin levels and can lead to serotonin syndrome
when combined with other serotonergic agents or in overdose.
8. A 35-year-old client is admitted after a suicide attempt via medication overdose.
Which intervention takes priority?
A. Begin group therapy
B. Conduct a suicide risk assessment
C. Administer prescribed antidepressants
D. Encourage journaling
, Answer: B. Conduct a suicide risk assessment
Rationale: Safety assessment and intervention are the top priority. Understanding
risk factors helps guide immediate safety measures.
9. A client with schizophrenia is experiencing auditory hallucinations. Which
response by the nurse is most appropriate?
A. “The voices aren’t real; ignore them.”
B. “I understand the voices are real to you; let’s focus on reality.”
C. “Tell me what the voices are saying in detail.”
D. “You should pray to stop the voices.”
Answer: B. “I understand the voices are real to you; let’s focus on reality.”
Rationale: Validating the client’s experience while gently redirecting to reality is
therapeutic. Denial or judgment is non-therapeutic.
10. A client taking Citalopram reports sexual dysfunction and insomnia. Which
nursing action is appropriate?
A. Discontinue medication immediately
B. Notify the provider for possible dose adjustment or alternative
C. Instruct the client to ignore side effects
D. Advise the client to stop taking all medications
Answer: B. Notify the provider for possible dose adjustment or alternative
Rationale: SSRIs can cause sexual dysfunction and insomnia. The provider may
adjust dose or switch medications while monitoring response.
11. A client in a psychiatric unit becomes verbally aggressive toward staff. Which
intervention is most appropriate initially?
A. Restrain immediately
B. Use a calm voice and maintain a safe distance
C. Yell to assert authority
D. Ignore the behavior
