NUR 208/NUR208 Exam 2 V3 | Mental
Health Nursing Q&A with Rationale | Fortis
College
1. A client with Bipolar I Disorder is experiencing an acute manic episode. Which nursing
intervention is the highest priority for the safety of the client and others?
A. Encourage the client to attend a group therapy session on anger management.
B. Provide a high-calorie, portable snack such as a protein bar and juice.
C. Engage the client in a competitive game of basketball to release excess energy.
D. Decrease environmental stimuli by placing the client in a quiet, low-light area.
Correct Answer: D
Expert Explanation: Decreasing environmental stimuli is the priority to prevent further
escalation of manic behavior. High-calorie finger foods are important for nutrition, but
safety and stabilization of the manic state come first. Competitive activities should be
avoided as they can increase agitation and lead to physical aggression.
2. A client is prescribed Lithium Carbonate for the treatment of Bipolar Disorder. The nurse
should instruct the client to maintain a consistent intake of which substance?
A. Sodium
B. Potassium
C. Vitamin B12
,D. Calcium
Correct Answer: A
Expert Explanation: Lithium is a salt, and its excretion is closely tied to sodium levels in
the body. If sodium intake decreases or is lost through sweating, the kidneys will retain
lithium, leading to toxicity. Clients must maintain consistent salt and fluid intake to ensure
therapeutic blood levels remain stable.
3. A nurse is assessing a client for possible Lithium toxicity. Which of the following serum
lithium levels would the nurse identify as being within the toxic range?
A. 0.6 mEq/L
B. 2.0 mEq/L
C. 1.2 mEq/L
D. 1.0 mEq/L
Correct Answer: B
Expert Explanation: The therapeutic range for Lithium is typically 0.6 to 1.2 mEq/L for
maintenance and up to 1.5 mEq/L for acute mania. A level of 2.0 mEq/L is significantly
elevated and indicates moderate to severe toxicity. Symptoms at this level include blurred
vision, ataxia, and persistent gastrointestinal upset.
4. A client taking Phenelzine, an MAOI, is at the hospital for a follow-up. Which food choice
indicated by the client suggests a need for further education?
A. Fresh grilled chicken breast
, B. Steamed broccoli and carrots
C. Pepperoni and aged cheddar cheese
D. Hard-boiled eggs
Correct Answer: C
Expert Explanation: MAOIs interact with tyramine-rich foods, which can trigger a
hypertensive crisis. Pepperoni and aged cheeses are high in tyramine and must be avoided.
Fresh meats and vegetables are generally safe for clients on this medication class.
5. A nurse is caring for a client with Obsessive-Compulsive Disorder (OCD) who spends 45
minutes washing their hands before meals. Which is the initial nursing action?
A. Lock the bathroom door to prevent the client from washing their hands.
B. Explain to the client that their hands are already clean.
C. Allow the client enough time at the start of treatment to perform the ritual.
D. Set a strict 5-minute limit on handwashing immediately upon admission.
Correct Answer: C
Expert Explanation: Initially, the nurse should allow the client to perform the ritual to
prevent overwhelming anxiety. Stopping the ritual abruptly can lead to panic and a
breakdown in the therapeutic relationship. Over time, the nurse will work with the client to
gradually limit the time spent on rituals and develop alternative coping mechanisms.
Health Nursing Q&A with Rationale | Fortis
College
1. A client with Bipolar I Disorder is experiencing an acute manic episode. Which nursing
intervention is the highest priority for the safety of the client and others?
A. Encourage the client to attend a group therapy session on anger management.
B. Provide a high-calorie, portable snack such as a protein bar and juice.
C. Engage the client in a competitive game of basketball to release excess energy.
D. Decrease environmental stimuli by placing the client in a quiet, low-light area.
Correct Answer: D
Expert Explanation: Decreasing environmental stimuli is the priority to prevent further
escalation of manic behavior. High-calorie finger foods are important for nutrition, but
safety and stabilization of the manic state come first. Competitive activities should be
avoided as they can increase agitation and lead to physical aggression.
2. A client is prescribed Lithium Carbonate for the treatment of Bipolar Disorder. The nurse
should instruct the client to maintain a consistent intake of which substance?
A. Sodium
B. Potassium
C. Vitamin B12
,D. Calcium
Correct Answer: A
Expert Explanation: Lithium is a salt, and its excretion is closely tied to sodium levels in
the body. If sodium intake decreases or is lost through sweating, the kidneys will retain
lithium, leading to toxicity. Clients must maintain consistent salt and fluid intake to ensure
therapeutic blood levels remain stable.
3. A nurse is assessing a client for possible Lithium toxicity. Which of the following serum
lithium levels would the nurse identify as being within the toxic range?
A. 0.6 mEq/L
B. 2.0 mEq/L
C. 1.2 mEq/L
D. 1.0 mEq/L
Correct Answer: B
Expert Explanation: The therapeutic range for Lithium is typically 0.6 to 1.2 mEq/L for
maintenance and up to 1.5 mEq/L for acute mania. A level of 2.0 mEq/L is significantly
elevated and indicates moderate to severe toxicity. Symptoms at this level include blurred
vision, ataxia, and persistent gastrointestinal upset.
4. A client taking Phenelzine, an MAOI, is at the hospital for a follow-up. Which food choice
indicated by the client suggests a need for further education?
A. Fresh grilled chicken breast
, B. Steamed broccoli and carrots
C. Pepperoni and aged cheddar cheese
D. Hard-boiled eggs
Correct Answer: C
Expert Explanation: MAOIs interact with tyramine-rich foods, which can trigger a
hypertensive crisis. Pepperoni and aged cheeses are high in tyramine and must be avoided.
Fresh meats and vegetables are generally safe for clients on this medication class.
5. A nurse is caring for a client with Obsessive-Compulsive Disorder (OCD) who spends 45
minutes washing their hands before meals. Which is the initial nursing action?
A. Lock the bathroom door to prevent the client from washing their hands.
B. Explain to the client that their hands are already clean.
C. Allow the client enough time at the start of treatment to perform the ritual.
D. Set a strict 5-minute limit on handwashing immediately upon admission.
Correct Answer: C
Expert Explanation: Initially, the nurse should allow the client to perform the ritual to
prevent overwhelming anxiety. Stopping the ritual abruptly can lead to panic and a
breakdown in the therapeutic relationship. Over time, the nurse will work with the client to
gradually limit the time spent on rituals and develop alternative coping mechanisms.
