NUR 208/NUR208 Final Exam V2 | Mental
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a client who is experiencing a panic attack. Which of the following
actions should the nurse take first?
A. Administer an anti-anxiety medication immediately.
B. Stay with the client and remain calm.
C. Teach the client deep breathing exercises.
D. Ask the client to explain what triggered the attack.
Correct Answer: B
Expert Explanation: During a panic attack, the priority is the safety and security of the
client. Staying with the client provides reassurance and prevents further escalation of
anxiety. The nurse should use simple, clear communication until the panic subsides.
2. A client is prescribed lithium carbonate for bipolar disorder. Which of the following
findings should the nurse identify as an early sign of lithium toxicity?
A. Fine hand tremors and nausea
B. Mental confusion and coarse tremors
C. Seizures and cardiac arrhythmias
,D. Polyuria and mild thirst
Correct Answer: B
Expert Explanation: Early signs of lithium toxicity typically include diarrhea, vomiting,
drowsiness, and muscle weakness. Advanced toxicity leads to mental confusion and coarse
hand tremors which require immediate intervention. The nurse must monitor serum
lithium levels to ensure they stay within the therapeutic range of 0.6 to 1.2 mEq/L.
3. A client with schizophrenia is experiencing auditory hallucinations. Which of the following
responses by the nurse is therapeutic?
A. The voices are just a part of your imagination.
B. Why do you think the voices are talking to you right now?
C. I don’t hear any voices, but I understand they are real to you.
D. What are the voices telling you to do?
Correct Answer: C
Expert Explanation: This response validates the client’s experience without confirming
the hallucination as reality. It establishes a foundation of trust and empathy while
maintaining a focus on the nurse’s perception of reality. Identifying the content of the
voices (option D) is also important but validating reality comes first in therapeutic
interaction.
, 4. A nurse is reviewing the laboratory results of a client taking clozapine. Which of the
following results should the nurse report to the provider immediately?
A. WBC count 2,500/mm3
B. Platelet count 150,000/mm3
C. Serum sodium 138 mEq/L
D. Fast glucose 110 mg/dL
Correct Answer: A
Expert Explanation: Clozapine is associated with a high risk of agranulocytosis, which is a
life-threatening decrease in white blood cells. A WBC count below 3,000/mm3 necessitates
immediate discontinuation of the medication and monitoring. Nurses must ensure weekly
or bi-weekly blood draws for clients on this medication protocol.
5. Which of the following defense mechanisms is a client using when they redirect their anger
about a job loss toward their spouse?
A. Projection
B. Sublimation
C. Displacement
D. Rationalization
Correct Answer: C
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a client who is experiencing a panic attack. Which of the following
actions should the nurse take first?
A. Administer an anti-anxiety medication immediately.
B. Stay with the client and remain calm.
C. Teach the client deep breathing exercises.
D. Ask the client to explain what triggered the attack.
Correct Answer: B
Expert Explanation: During a panic attack, the priority is the safety and security of the
client. Staying with the client provides reassurance and prevents further escalation of
anxiety. The nurse should use simple, clear communication until the panic subsides.
2. A client is prescribed lithium carbonate for bipolar disorder. Which of the following
findings should the nurse identify as an early sign of lithium toxicity?
A. Fine hand tremors and nausea
B. Mental confusion and coarse tremors
C. Seizures and cardiac arrhythmias
,D. Polyuria and mild thirst
Correct Answer: B
Expert Explanation: Early signs of lithium toxicity typically include diarrhea, vomiting,
drowsiness, and muscle weakness. Advanced toxicity leads to mental confusion and coarse
hand tremors which require immediate intervention. The nurse must monitor serum
lithium levels to ensure they stay within the therapeutic range of 0.6 to 1.2 mEq/L.
3. A client with schizophrenia is experiencing auditory hallucinations. Which of the following
responses by the nurse is therapeutic?
A. The voices are just a part of your imagination.
B. Why do you think the voices are talking to you right now?
C. I don’t hear any voices, but I understand they are real to you.
D. What are the voices telling you to do?
Correct Answer: C
Expert Explanation: This response validates the client’s experience without confirming
the hallucination as reality. It establishes a foundation of trust and empathy while
maintaining a focus on the nurse’s perception of reality. Identifying the content of the
voices (option D) is also important but validating reality comes first in therapeutic
interaction.
, 4. A nurse is reviewing the laboratory results of a client taking clozapine. Which of the
following results should the nurse report to the provider immediately?
A. WBC count 2,500/mm3
B. Platelet count 150,000/mm3
C. Serum sodium 138 mEq/L
D. Fast glucose 110 mg/dL
Correct Answer: A
Expert Explanation: Clozapine is associated with a high risk of agranulocytosis, which is a
life-threatening decrease in white blood cells. A WBC count below 3,000/mm3 necessitates
immediate discontinuation of the medication and monitoring. Nurses must ensure weekly
or bi-weekly blood draws for clients on this medication protocol.
5. Which of the following defense mechanisms is a client using when they redirect their anger
about a job loss toward their spouse?
A. Projection
B. Sublimation
C. Displacement
D. Rationalization
Correct Answer: C
