NSG 322/NSG322 Final Exam V2 |
Behavioral Health Nursing Q&A with
Rationale | Grand Canyon University
1. A patient is prescribed Lithium Carbonate for Bipolar I Disorder. Which of the following lab
values would indicate a toxic level requiring immediate intervention?
A. 0.6 mEq/L
B. 1.8 mEq/L
C. 1.2 mEq/L
D. 1.0 mEq/L
Answer: B
Rationale: The therapeutic range for lithium is narrow, typically between 0.6 and 1.2
mEq/L for maintenance. A level of 1.8 mEq/L indicates moderate to severe toxicity, which
can lead to seizures and organ failure. The nurse must monitor for clinical signs such as
persistent diarrhea, vomiting, and tremors when levels rise above 1.5 mEq/L.
2. A nurse is caring for a client with Schizophrenia who is experiencing auditory
hallucinations. Which response by the nurse is most therapeutic?
A. I don’t hear the voices, but I understand they are real to you.
B. The voices are not real; you are just having a bad day.
C. What are the voices telling you to do right now?
,D. Try to ignore the voices and focus on the TV.
Answer: C
Rationale: The priority intervention is to assess for command hallucinations that may
endanger the client or others. By asking what the voices are saying, the nurse identifies
potential safety risks. While validating the client’s reality is important, safety assessment
takes precedence in a psychiatric crisis.
3. A client is admitted for alcohol detoxification. Which medication is the nurse most likely to
administer to prevent seizures and delirium tremens?
A. Chlordiazepoxide
B. Disulfiram
C. Methadone
D. Naloxone
Answer: A
Rationale: Chlordiazepoxide is a benzodiazepine commonly used to manage the symptoms
of acute alcohol withdrawal. It helps stabilize vital signs and prevents the progression to
life-threatening seizures. Nurses must monitor the CIWA score to determine the
appropriate dosage during the detoxification process.
4. Which defense mechanism is a client using when they say, I drink because my wife is so
nagging, even though they have a history of DUI?
A. Projection
, B. Rationalization
C. Sublimation
D. Reaction Formation
Answer: B
Rationale: Rationalization involves creating logical or socially acceptable explanations for
unacceptable behavior or feelings. In this case, the client blames their spouse to justify
their pathological drinking. This mechanism serves to protect the individual from the guilt
associated with their addiction.
5. A patient taking Clozapine for treatment-resistant Schizophrenia must have regular blood
tests for which potential side effect?
A. Hyperglycemia
B. Agranulocytosis
C. Hypothyroidism
D. Nephrotoxicity
Answer: B
Rationale: Agranulocytosis is a severe reduction in white blood cell count that puts the
patient at high risk for infection. Clozapine protocols require weekly or bi-weekly Absolute
Neutrophil Count (ANC) monitoring. The medication must be discontinued if the ANC falls
below a specific threshold determined by the FDA.
Behavioral Health Nursing Q&A with
Rationale | Grand Canyon University
1. A patient is prescribed Lithium Carbonate for Bipolar I Disorder. Which of the following lab
values would indicate a toxic level requiring immediate intervention?
A. 0.6 mEq/L
B. 1.8 mEq/L
C. 1.2 mEq/L
D. 1.0 mEq/L
Answer: B
Rationale: The therapeutic range for lithium is narrow, typically between 0.6 and 1.2
mEq/L for maintenance. A level of 1.8 mEq/L indicates moderate to severe toxicity, which
can lead to seizures and organ failure. The nurse must monitor for clinical signs such as
persistent diarrhea, vomiting, and tremors when levels rise above 1.5 mEq/L.
2. A nurse is caring for a client with Schizophrenia who is experiencing auditory
hallucinations. Which response by the nurse is most therapeutic?
A. I don’t hear the voices, but I understand they are real to you.
B. The voices are not real; you are just having a bad day.
C. What are the voices telling you to do right now?
,D. Try to ignore the voices and focus on the TV.
Answer: C
Rationale: The priority intervention is to assess for command hallucinations that may
endanger the client or others. By asking what the voices are saying, the nurse identifies
potential safety risks. While validating the client’s reality is important, safety assessment
takes precedence in a psychiatric crisis.
3. A client is admitted for alcohol detoxification. Which medication is the nurse most likely to
administer to prevent seizures and delirium tremens?
A. Chlordiazepoxide
B. Disulfiram
C. Methadone
D. Naloxone
Answer: A
Rationale: Chlordiazepoxide is a benzodiazepine commonly used to manage the symptoms
of acute alcohol withdrawal. It helps stabilize vital signs and prevents the progression to
life-threatening seizures. Nurses must monitor the CIWA score to determine the
appropriate dosage during the detoxification process.
4. Which defense mechanism is a client using when they say, I drink because my wife is so
nagging, even though they have a history of DUI?
A. Projection
, B. Rationalization
C. Sublimation
D. Reaction Formation
Answer: B
Rationale: Rationalization involves creating logical or socially acceptable explanations for
unacceptable behavior or feelings. In this case, the client blames their spouse to justify
their pathological drinking. This mechanism serves to protect the individual from the guilt
associated with their addiction.
5. A patient taking Clozapine for treatment-resistant Schizophrenia must have regular blood
tests for which potential side effect?
A. Hyperglycemia
B. Agranulocytosis
C. Hypothyroidism
D. Nephrotoxicity
Answer: B
Rationale: Agranulocytosis is a severe reduction in white blood cell count that puts the
patient at high risk for infection. Clozapine protocols require weekly or bi-weekly Absolute
Neutrophil Count (ANC) monitoring. The medication must be discontinued if the ANC falls
below a specific threshold determined by the FDA.
