NUR 356 Exam 3: Mental Health Theory & Application V2 -
Arizona College Updated and Latest Questions and Correct
Answers with Rationale
1. A patient taking lithium carbonate for bipolar disorder reports a new onset of blurred vision and severe
diarrhea. What is the nurse’s priority action?
A. Withhold the next dose and obtain a serum lithium level.
B. Request a prescription for an antidiarrheal medication.
C. Inform the patient these are common side effects that will subside.
D. Instruct the patient to increase their dietary sodium intake.
Ans: A
Explanation: Lithium toxicity presents with gastrointestinal distress and neurological symptoms like
blurred vision or ataxia. These symptoms typically occur when serum levels exceed 1.5 mEq/L, which is a
medical emergency. The nurse must immediately stop the medication to prevent further toxicity and
potential organ damage. Obtaining a serum level provides the clinical data needed to determine the
severity of the intoxication. Patient safety is the primary concern when managing medications with a
narrow therapeutic index.
2. Which clinical finding is most characteristic of a patient diagnosed with Neuroleptic Malignant Syndrome
(NMS)?
A. Excessive salivation and diarrhea
B. Tardive dyskinesia and akathisia
C. Hypotension and bradycardia
D. Severe muscle rigidity and hyperpyrexia
,Ans: D
Explanation: Neuroleptic Malignant Syndrome is a rare but life-threatening reaction to antipsychotic
medications. Key symptoms include lead-pipe muscle rigidity, high fever, and autonomic instability. This
condition requires immediate discontinuation of the antipsychotic and intensive supportive care. The
nurse must monitor for secondary complications such as rhabdomyolysis or respiratory failure. Early
recognition of these specific physical signs is critical for improving patient outcomes.
3. A client is admitted for alcohol detoxification. Which medication is the nurse most likely to administer to
prevent seizures during withdrawal?
A. Chlordiazepoxide
B. Methadone
C. Disulfiram
D. Naltrexone
Ans: A
Explanation: Benzodiazepines like chlordiazepoxide are the gold standard for managing acute alcohol
withdrawal symptoms. They work by enhancing GABA activity to prevent life-threatening seizures and
delirium tremens. The dosage is typically adjusted based on standardized withdrawal scales like the
CIWA-Ar. Managing the physiological symptoms of withdrawal is the first priority in substance abuse
treatment. Once stabilized, the patient can then transition to long-term recovery and relapse prevention
strategies.
4. Which intervention should the nurse prioritize for a client experiencing a manic episode of Bipolar I
Disorder?
A. Encouraging the client to participate in group sports.
, B. Discussing the client’s past trauma in detail.
C. Allowing the client to lead a community meeting.
D. Providing high-calorie finger foods and fluids.
Ans: D
Explanation: Patients in a manic state often have excessive physical energy and cannot sit down to eat
regular meals. Providing portable, high-calorie finger foods helps maintain nutritional status and
prevents weight loss. Safety and physical needs must be addressed before psychological or social
interventions are attempted. The nurse should also aim to provide a low-stimulus environment to reduce
agitation. Consistency in the nursing approach helps the patient feel more secure during periods of
instability.
5. A nurse is caring for a client with schizophrenia who reports hearing voices telling them to hurt others.
What is the priority nursing diagnosis?
A. Disturbed Thought Processes
B. Social Isolation
C. Impaired Verbal Communication
D. Risk for Violence Directed at Others
Ans: D
Explanation: Command hallucinations are a critical safety concern as they may lead the patient to act on
the voices. Assessing the content of the hallucinations is the first step in determining the level of risk. The
nurse must provide a safe environment and possibly implement closer observation or 1-to-1 care.
Interventions should focus on reality testing and reassuring the patient that they are safe. Protecting the
patient and others from harm is the fundamental priority in psychiatric care.
Arizona College Updated and Latest Questions and Correct
Answers with Rationale
1. A patient taking lithium carbonate for bipolar disorder reports a new onset of blurred vision and severe
diarrhea. What is the nurse’s priority action?
A. Withhold the next dose and obtain a serum lithium level.
B. Request a prescription for an antidiarrheal medication.
C. Inform the patient these are common side effects that will subside.
D. Instruct the patient to increase their dietary sodium intake.
Ans: A
Explanation: Lithium toxicity presents with gastrointestinal distress and neurological symptoms like
blurred vision or ataxia. These symptoms typically occur when serum levels exceed 1.5 mEq/L, which is a
medical emergency. The nurse must immediately stop the medication to prevent further toxicity and
potential organ damage. Obtaining a serum level provides the clinical data needed to determine the
severity of the intoxication. Patient safety is the primary concern when managing medications with a
narrow therapeutic index.
2. Which clinical finding is most characteristic of a patient diagnosed with Neuroleptic Malignant Syndrome
(NMS)?
A. Excessive salivation and diarrhea
B. Tardive dyskinesia and akathisia
C. Hypotension and bradycardia
D. Severe muscle rigidity and hyperpyrexia
,Ans: D
Explanation: Neuroleptic Malignant Syndrome is a rare but life-threatening reaction to antipsychotic
medications. Key symptoms include lead-pipe muscle rigidity, high fever, and autonomic instability. This
condition requires immediate discontinuation of the antipsychotic and intensive supportive care. The
nurse must monitor for secondary complications such as rhabdomyolysis or respiratory failure. Early
recognition of these specific physical signs is critical for improving patient outcomes.
3. A client is admitted for alcohol detoxification. Which medication is the nurse most likely to administer to
prevent seizures during withdrawal?
A. Chlordiazepoxide
B. Methadone
C. Disulfiram
D. Naltrexone
Ans: A
Explanation: Benzodiazepines like chlordiazepoxide are the gold standard for managing acute alcohol
withdrawal symptoms. They work by enhancing GABA activity to prevent life-threatening seizures and
delirium tremens. The dosage is typically adjusted based on standardized withdrawal scales like the
CIWA-Ar. Managing the physiological symptoms of withdrawal is the first priority in substance abuse
treatment. Once stabilized, the patient can then transition to long-term recovery and relapse prevention
strategies.
4. Which intervention should the nurse prioritize for a client experiencing a manic episode of Bipolar I
Disorder?
A. Encouraging the client to participate in group sports.
, B. Discussing the client’s past trauma in detail.
C. Allowing the client to lead a community meeting.
D. Providing high-calorie finger foods and fluids.
Ans: D
Explanation: Patients in a manic state often have excessive physical energy and cannot sit down to eat
regular meals. Providing portable, high-calorie finger foods helps maintain nutritional status and
prevents weight loss. Safety and physical needs must be addressed before psychological or social
interventions are attempted. The nurse should also aim to provide a low-stimulus environment to reduce
agitation. Consistency in the nursing approach helps the patient feel more secure during periods of
instability.
5. A nurse is caring for a client with schizophrenia who reports hearing voices telling them to hurt others.
What is the priority nursing diagnosis?
A. Disturbed Thought Processes
B. Social Isolation
C. Impaired Verbal Communication
D. Risk for Violence Directed at Others
Ans: D
Explanation: Command hallucinations are a critical safety concern as they may lead the patient to act on
the voices. Assessing the content of the hallucinations is the first step in determining the level of risk. The
nurse must provide a safe environment and possibly implement closer observation or 1-to-1 care.
Interventions should focus on reality testing and reassuring the patient that they are safe. Protecting the
patient and others from harm is the fundamental priority in psychiatric care.
