NUR 356 Exam 3: Mental Health Theory & Application V3 -
Arizona College Updated and Latest Questions and Correct
Answers with Rationale
1. A patient taking lithium carbonate for bipolar disorder reports vomiting, diarrhea, and blurred vision.
Which nursing action is the priority?
A. Check the serum lithium level immediately.
B. Administer the next dose as scheduled.
C. Encourage increased fluid intake.
D. Provide a low-sodium meal.
Ans: A
Explanation: Lithium has a narrow therapeutic index, making toxicity a significant risk for patients.
Symptoms like vomiting and blurred vision are indicative of lithium toxicity levels typically above 1.5
mEq/L. The nurse must prioritize assessing the serum level to confirm the severity of the situation.
Continuing the medication would exacerbate the condition and potentially lead to permanent organ
damage. Withholding the dose and notifying the provider are critical steps following the lab results.
2. A patient with treatment-resistant schizophrenia is prescribed clozapine. Which laboratory finding
requires immediate notification to the provider?
A. Hemoglobin of 12 g/dL.
B. Platelet count of 150,000/mm³.
C. WBC count of 2,500/mm³.
D. Fasting blood glucose of 100 mg/dL.
Ans: C
,Explanation: Clozapine is associated with a risk of agranulocytosis, a life-threatening decrease in white
blood cells. A WBC count below 3,000/mm³ or an absolute neutrophil count below 1,500/mm³ requires
immediate intervention. The nurse must monitor these values weekly or bi-weekly according to
standardized protocols. Failure to detect low levels can lead to severe infections and sepsis. Therefore,
the provider must be notified to discontinue or adjust the medication immediately.
3. A patient taking sertraline for depression exhibits muscle rigidity, fever, and diaphoresis. What
complication is the nurse most likely observing?
A. Tardive dyskinesia.
B. Serotonin syndrome.
C. Neuroleptic malignant syndrome.
D. Anticholinergic crisis.
Ans: B
Explanation: Serotonin syndrome occurs when there is an overabundance of serotonin in the synaptic
cleft. It is characterized by autonomic instability, neuromuscular hyperactivity, and altered mental status.
Muscle rigidity and hyperpyrexia are classic signs that require immediate medical attention. The nurse
should stop the causative agent and prepare for supportive care. Distinguishing this from NMS is crucial
as the treatments and causative agents differ.
4. A patient with borderline personality disorder alternates between overvaluing and devaluing the nursing
staff. Which defense mechanism is being used?
A. Projective identification.
B. Splitting.
C. Reaction formation.
, D. Displacement.
Ans: B
Explanation: Splitting is a primary defense mechanism used by individuals with borderline personality
disorder to manage internal conflict. It involves viewing people or situations as either all good or all bad
with no middle ground. This behavior often leads to conflict within the healthcare team as staff members
are played against each other. Nurses must maintain consistent boundaries and use a team-based
approach to minimize the impact of splitting. Understanding this mechanism helps the nurse remain
objective and therapeutic during interactions.
5. A patient receiving haloperidol develops acute dystonia. Which medication should the nurse expect to
administer?
A. Olanzapine.
B. Lorazepam.
C. Benztropine.
D. Propranolol.
Ans: C
Explanation: Acute dystonia is a type of extrapyramidal side effect characterized by involuntary muscle
contractions. Benztropine is an anticholinergic medication frequently used to reverse these painful
spasms quickly. The nurse should administer this medication via intramuscular injection for rapid effect
in emergency situations. Monitoring the patient for further signs of EPS is essential after the initial crisis
is resolved. Education regarding side effects of first-generation antipsychotics is a key nursing
responsibility.
Arizona College Updated and Latest Questions and Correct
Answers with Rationale
1. A patient taking lithium carbonate for bipolar disorder reports vomiting, diarrhea, and blurred vision.
Which nursing action is the priority?
A. Check the serum lithium level immediately.
B. Administer the next dose as scheduled.
C. Encourage increased fluid intake.
D. Provide a low-sodium meal.
Ans: A
Explanation: Lithium has a narrow therapeutic index, making toxicity a significant risk for patients.
Symptoms like vomiting and blurred vision are indicative of lithium toxicity levels typically above 1.5
mEq/L. The nurse must prioritize assessing the serum level to confirm the severity of the situation.
Continuing the medication would exacerbate the condition and potentially lead to permanent organ
damage. Withholding the dose and notifying the provider are critical steps following the lab results.
2. A patient with treatment-resistant schizophrenia is prescribed clozapine. Which laboratory finding
requires immediate notification to the provider?
A. Hemoglobin of 12 g/dL.
B. Platelet count of 150,000/mm³.
C. WBC count of 2,500/mm³.
D. Fasting blood glucose of 100 mg/dL.
Ans: C
,Explanation: Clozapine is associated with a risk of agranulocytosis, a life-threatening decrease in white
blood cells. A WBC count below 3,000/mm³ or an absolute neutrophil count below 1,500/mm³ requires
immediate intervention. The nurse must monitor these values weekly or bi-weekly according to
standardized protocols. Failure to detect low levels can lead to severe infections and sepsis. Therefore,
the provider must be notified to discontinue or adjust the medication immediately.
3. A patient taking sertraline for depression exhibits muscle rigidity, fever, and diaphoresis. What
complication is the nurse most likely observing?
A. Tardive dyskinesia.
B. Serotonin syndrome.
C. Neuroleptic malignant syndrome.
D. Anticholinergic crisis.
Ans: B
Explanation: Serotonin syndrome occurs when there is an overabundance of serotonin in the synaptic
cleft. It is characterized by autonomic instability, neuromuscular hyperactivity, and altered mental status.
Muscle rigidity and hyperpyrexia are classic signs that require immediate medical attention. The nurse
should stop the causative agent and prepare for supportive care. Distinguishing this from NMS is crucial
as the treatments and causative agents differ.
4. A patient with borderline personality disorder alternates between overvaluing and devaluing the nursing
staff. Which defense mechanism is being used?
A. Projective identification.
B. Splitting.
C. Reaction formation.
, D. Displacement.
Ans: B
Explanation: Splitting is a primary defense mechanism used by individuals with borderline personality
disorder to manage internal conflict. It involves viewing people or situations as either all good or all bad
with no middle ground. This behavior often leads to conflict within the healthcare team as staff members
are played against each other. Nurses must maintain consistent boundaries and use a team-based
approach to minimize the impact of splitting. Understanding this mechanism helps the nurse remain
objective and therapeutic during interactions.
5. A patient receiving haloperidol develops acute dystonia. Which medication should the nurse expect to
administer?
A. Olanzapine.
B. Lorazepam.
C. Benztropine.
D. Propranolol.
Ans: C
Explanation: Acute dystonia is a type of extrapyramidal side effect characterized by involuntary muscle
contractions. Benztropine is an anticholinergic medication frequently used to reverse these painful
spasms quickly. The nurse should administer this medication via intramuscular injection for rapid effect
in emergency situations. Monitoring the patient for further signs of EPS is essential after the initial crisis
is resolved. Education regarding side effects of first-generation antipsychotics is a key nursing
responsibility.
