NSG221/NSG 221 Final Exam V1 | Mental
Health Nursing Q&A with Rationale |
Herzing University
1. A client is admitted to the psychiatric unit with a diagnosis of acute mania. Which of the
following nursing interventions is the priority during the first 24 hours of admission?
A. Encouraging the client to participate in group therapy sessions.
B. Conducting an in-depth psychosocial assessment regarding past trauma.
C. Assisting the client with detailed personal hygiene and grooming.
D. Providing a high-calorie, finger-food diet to maintain nutrition.
Correct Answer: D
Rationale: Clients in acute mania often exhibit excessive psychomotor activity and have
difficulty sitting down for full meals. Providing finger foods allows the client to consume
necessary calories while on the move, which addresses the physical risk of exhaustion and
nutritional deficit. This intervention prioritizes physiological needs over psychological
exploration during the acute phase of illness.
2. A nurse is caring for a client who is receiving Clozapine for treatment-resistant
schizophrenia. Which laboratory result must the nurse monitor most closely?
A. White blood cell (WBC) count
B. Blood urea nitrogen (BUN)
,C. Serum potassium levels
D. Creatinine clearance
Correct Answer: A
Rationale: Clozapine is associated with a risk of agranulocytosis, which is a life-
threatening decrease in the white blood cell count. Due to this risk, federal regulations
require regular monitoring of the absolute neutrophil count and WBC count to ensure
patient safety. If the WBC count drops below a specific threshold, the medication must be
discontinued immediately to prevent severe infection.
3. A client with Major Depressive Disorder is being started on a Selective Serotonin Reuptake
Inhibitor (SSRI). Which education should the nurse provide regarding the onset of therapeutic
effects?
A. The client will feel an immediate elevation in mood within 24 hours.
B. The medication will work better if taken with a high-tyramine diet.
C. Full therapeutic benefits may take 4 to 6 weeks to achieve.
D. The client should stop the medication if they feel better after two weeks.
Correct Answer: C
Rationale: SSRIs do not produce an immediate effect on mood and typically require
several weeks of consistent dosing to reach therapeutic levels in the brain. It is crucial for
the nurse to manage client expectations to prevent early discontinuation of the treatment.
, Clients must be monitored closely during this period for increased energy levels that might
precede mood improvement, which can increase suicide risk.
4. A nurse is performing a suicide risk assessment. Which of the following factors represents
the highest immediate risk for a client?
A. A history of depression in a first-degree relative.
B. The client expressing feelings of mild hopelessness.
C. Having a specific, lethal plan and the means to carry it out.
D. Occasional thoughts of wishing they were not alive.
Correct Answer: C
Rationale: A specific plan paired with the availability of lethal means indicates a high level
of intent and immediate danger. While history and feelings of hopelessness are significant,
the presence of a concrete plan is the most critical predictor of an imminent attempt.
Nurses must prioritize safety by implementing immediate observation or hospitalization in
such cases.
5. A client is experiencing a severe panic attack. Which nursing action is the most appropriate
at this time?
A. Teaching the client deep breathing and relaxation techniques for future use.
B. Encouraging the client to explain what triggered the panic attack.
C. Leaving the client alone to allow them to calm down in a quiet room.
Health Nursing Q&A with Rationale |
Herzing University
1. A client is admitted to the psychiatric unit with a diagnosis of acute mania. Which of the
following nursing interventions is the priority during the first 24 hours of admission?
A. Encouraging the client to participate in group therapy sessions.
B. Conducting an in-depth psychosocial assessment regarding past trauma.
C. Assisting the client with detailed personal hygiene and grooming.
D. Providing a high-calorie, finger-food diet to maintain nutrition.
Correct Answer: D
Rationale: Clients in acute mania often exhibit excessive psychomotor activity and have
difficulty sitting down for full meals. Providing finger foods allows the client to consume
necessary calories while on the move, which addresses the physical risk of exhaustion and
nutritional deficit. This intervention prioritizes physiological needs over psychological
exploration during the acute phase of illness.
2. A nurse is caring for a client who is receiving Clozapine for treatment-resistant
schizophrenia. Which laboratory result must the nurse monitor most closely?
A. White blood cell (WBC) count
B. Blood urea nitrogen (BUN)
,C. Serum potassium levels
D. Creatinine clearance
Correct Answer: A
Rationale: Clozapine is associated with a risk of agranulocytosis, which is a life-
threatening decrease in the white blood cell count. Due to this risk, federal regulations
require regular monitoring of the absolute neutrophil count and WBC count to ensure
patient safety. If the WBC count drops below a specific threshold, the medication must be
discontinued immediately to prevent severe infection.
3. A client with Major Depressive Disorder is being started on a Selective Serotonin Reuptake
Inhibitor (SSRI). Which education should the nurse provide regarding the onset of therapeutic
effects?
A. The client will feel an immediate elevation in mood within 24 hours.
B. The medication will work better if taken with a high-tyramine diet.
C. Full therapeutic benefits may take 4 to 6 weeks to achieve.
D. The client should stop the medication if they feel better after two weeks.
Correct Answer: C
Rationale: SSRIs do not produce an immediate effect on mood and typically require
several weeks of consistent dosing to reach therapeutic levels in the brain. It is crucial for
the nurse to manage client expectations to prevent early discontinuation of the treatment.
, Clients must be monitored closely during this period for increased energy levels that might
precede mood improvement, which can increase suicide risk.
4. A nurse is performing a suicide risk assessment. Which of the following factors represents
the highest immediate risk for a client?
A. A history of depression in a first-degree relative.
B. The client expressing feelings of mild hopelessness.
C. Having a specific, lethal plan and the means to carry it out.
D. Occasional thoughts of wishing they were not alive.
Correct Answer: C
Rationale: A specific plan paired with the availability of lethal means indicates a high level
of intent and immediate danger. While history and feelings of hopelessness are significant,
the presence of a concrete plan is the most critical predictor of an imminent attempt.
Nurses must prioritize safety by implementing immediate observation or hospitalization in
such cases.
5. A client is experiencing a severe panic attack. Which nursing action is the most appropriate
at this time?
A. Teaching the client deep breathing and relaxation techniques for future use.
B. Encouraging the client to explain what triggered the panic attack.
C. Leaving the client alone to allow them to calm down in a quiet room.
