NUR 208/NUR208 Exam 4 V2 | Mental
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a client with Bipolar I Disorder who is experiencing a manic episode.
The client is moving rapidly around the unit, talking loudly, and interrupting others. Which of
the following nursing interventions is the priority?
A. Provide the client with a high-calorie finger food snack.
B. Encourage the client to join a group therapy session.
C. Escort the client to a quiet area with low stimulation.
D. Administer a prescribed PRN sedative immediately.
Correct Answer: C
Expert Explanation: Clients in a manic state are easily overstimulated by their
environment, which can escalate their agitation and hyperactivity. Moving the client to a
quiet, low-stimulus area helps decrease external triggers and promotes safety. While
nutrition is important, environmental management is the immediate priority to prevent
further escalation.
2. A client is prescribed Clozapine for treatment-resistant Schizophrenia. Which laboratory
value must the nurse monitor most closely to ensure client safety?
A. Serum potassium levels
,B. Blood urea nitrogen (BUN)
C. White blood cell (WBC) count
D. Liver function tests (LFTs)
Correct Answer: C
Expert Explanation: Clozapine carries a significant risk for agranulocytosis, a life-
threatening drop in white blood cell counts. Regular monitoring of the absolute neutrophil
count (ANC) and WBC count is mandatory per FDA protocols. Patients must be educated to
report signs of infection such as fever or sore throat immediately.
3. A nurse is assessing a client for potential Lithium toxicity. The client’s serum Lithium level is
1.8 mEq/L. Which clinical finding should the nurse expect?
A. Vomiting, diarrhea, and coarse tremors
B. Vivid hallucinations and high fever
C. Fine hand tremors and mild thirst
D. Increased urinary output and weight gain
Correct Answer: A
Expert Explanation: A lithium level of 1.8 mEq/L is above the therapeutic range (typically
0.6-1.2 mEq/L) and indicates moderate toxicity. Early signs of toxicity include
gastrointestinal distress like vomiting and diarrhea, along with neurological signs like
,coarse tremors. The nurse must hold the medication and notify the healthcare provider
immediately.
4. A client with Borderline Personality Disorder is observed ‘splitting’ staff members, telling
one nurse they are the only one who cares while telling another nurse that the rest of the
staff is incompetent. What is the most appropriate nursing response?
A. Confront the client about their manipulative behavior.
B. Hold a staff meeting to ensure a consistent approach.
C. Thank the client for the compliment to build rapport.
D. Assign only one nurse to care for the client each shift.
Correct Answer: B
Expert Explanation: Splitting is a defense mechanism common in Borderline Personality
Disorder where individuals view others as all good or all bad. Consistency among the
treatment team is vital to prevent the client from playing staff against each other. Regular
staff communication ensures that limits are set and maintained uniformly.
5. A client is admitted to the unit following a suicide attempt. Which of the following
statements by the nurse is the most therapeutic?
A. Why did you think suicide was your only option?
B. I am glad you are safe now and can get help.
C. Let’s talk about the events that led to your decision.
, D. You have so much to live for; think of your family.
Correct Answer: C
Expert Explanation: Open-ended statements encourage the client to share their feelings
and perspectives without judgment. Avoiding ‘why’ questions prevents the client from
becoming defensive or feeling interrogated. Focusing on the client’s internal experience
helps the nurse assess the severity of the crisis.
6. The nurse is educating a client who has been started on Phenelzine (an MAOI). Which food
choice by the client indicates an understanding of the dietary restrictions?
A. Grilled chicken breast with roasted potatoes
B. Pepperoni pizza with extra cheese
C. Smoked salmon and cream cheese bagel
D. Avocado salad with aged cheddar cheese
Correct Answer: A
Expert Explanation: Clients taking Monoamine Oxidase Inhibitors (MAOIs) must avoid
foods high in tyramine to prevent a hypertensive crisis. Foods such as aged cheeses, cured
meats (like pepperoni), and smoked fish are rich in tyramine and dangerous. Fresh meats
like grilled chicken are low in tyramine and safe for consumption.
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a client with Bipolar I Disorder who is experiencing a manic episode.
The client is moving rapidly around the unit, talking loudly, and interrupting others. Which of
the following nursing interventions is the priority?
A. Provide the client with a high-calorie finger food snack.
B. Encourage the client to join a group therapy session.
C. Escort the client to a quiet area with low stimulation.
D. Administer a prescribed PRN sedative immediately.
Correct Answer: C
Expert Explanation: Clients in a manic state are easily overstimulated by their
environment, which can escalate their agitation and hyperactivity. Moving the client to a
quiet, low-stimulus area helps decrease external triggers and promotes safety. While
nutrition is important, environmental management is the immediate priority to prevent
further escalation.
2. A client is prescribed Clozapine for treatment-resistant Schizophrenia. Which laboratory
value must the nurse monitor most closely to ensure client safety?
A. Serum potassium levels
,B. Blood urea nitrogen (BUN)
C. White blood cell (WBC) count
D. Liver function tests (LFTs)
Correct Answer: C
Expert Explanation: Clozapine carries a significant risk for agranulocytosis, a life-
threatening drop in white blood cell counts. Regular monitoring of the absolute neutrophil
count (ANC) and WBC count is mandatory per FDA protocols. Patients must be educated to
report signs of infection such as fever or sore throat immediately.
3. A nurse is assessing a client for potential Lithium toxicity. The client’s serum Lithium level is
1.8 mEq/L. Which clinical finding should the nurse expect?
A. Vomiting, diarrhea, and coarse tremors
B. Vivid hallucinations and high fever
C. Fine hand tremors and mild thirst
D. Increased urinary output and weight gain
Correct Answer: A
Expert Explanation: A lithium level of 1.8 mEq/L is above the therapeutic range (typically
0.6-1.2 mEq/L) and indicates moderate toxicity. Early signs of toxicity include
gastrointestinal distress like vomiting and diarrhea, along with neurological signs like
,coarse tremors. The nurse must hold the medication and notify the healthcare provider
immediately.
4. A client with Borderline Personality Disorder is observed ‘splitting’ staff members, telling
one nurse they are the only one who cares while telling another nurse that the rest of the
staff is incompetent. What is the most appropriate nursing response?
A. Confront the client about their manipulative behavior.
B. Hold a staff meeting to ensure a consistent approach.
C. Thank the client for the compliment to build rapport.
D. Assign only one nurse to care for the client each shift.
Correct Answer: B
Expert Explanation: Splitting is a defense mechanism common in Borderline Personality
Disorder where individuals view others as all good or all bad. Consistency among the
treatment team is vital to prevent the client from playing staff against each other. Regular
staff communication ensures that limits are set and maintained uniformly.
5. A client is admitted to the unit following a suicide attempt. Which of the following
statements by the nurse is the most therapeutic?
A. Why did you think suicide was your only option?
B. I am glad you are safe now and can get help.
C. Let’s talk about the events that led to your decision.
, D. You have so much to live for; think of your family.
Correct Answer: C
Expert Explanation: Open-ended statements encourage the client to share their feelings
and perspectives without judgment. Avoiding ‘why’ questions prevents the client from
becoming defensive or feeling interrogated. Focusing on the client’s internal experience
helps the nurse assess the severity of the crisis.
6. The nurse is educating a client who has been started on Phenelzine (an MAOI). Which food
choice by the client indicates an understanding of the dietary restrictions?
A. Grilled chicken breast with roasted potatoes
B. Pepperoni pizza with extra cheese
C. Smoked salmon and cream cheese bagel
D. Avocado salad with aged cheddar cheese
Correct Answer: A
Expert Explanation: Clients taking Monoamine Oxidase Inhibitors (MAOIs) must avoid
foods high in tyramine to prevent a hypertensive crisis. Foods such as aged cheeses, cured
meats (like pepperoni), and smoked fish are rich in tyramine and dangerous. Fresh meats
like grilled chicken are low in tyramine and safe for consumption.
