RASMUSSEN: MENTAL HEALTH EXAM 2 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) PLUS
RATIONALES 2026 Q&A |LATEST EXAM UPDATE 2026/2027
SECTION ONE: QUESTIONS 1–100
1. A nurse is caring for a client with schizophrenia who is experiencing auditory hallucinations. Which
intervention is most appropriate initially?
A. Tell the client the voices are not real and to ignore them.
B. Ask the client what the voices are saying and how they make him feel.
C. Encourage the client to participate in group therapy to distract him.
D. Place the client in seclusion until the hallucinations subside.
🟢 B. Ask the client what the voices are saying and how they make him feel.
🔴 RATIONALE: Assessing the content and emotional impact of the hallucinations is the first step in
understanding the client's experience and ensuring safety. This provides valuable data for the treatment plan.
2. A client diagnosed with major depressive disorder is started on phenelzine (Nardil). Which dietary
restriction is most critical for the nurse to teach?
A. Avoiding foods high in tyramine.
B. Restricting fluid intake to 1.5 liters per day.
C. Increasing intake of foods high in potassium.
D. Avoiding foods high in vitamin K.
🟢 A. Avoiding foods high in tyramine.
🔴 RATIONALE: Phenelzine is a monoamine oxidase inhibitor (MAOI). A diet high in tyramine can precipitate a
hypertensive crisis, which is a life-threatening emergency.
,3. A nurse is assessing a client with antisocial personality disorder. Which characteristic is the nurse most
likely to observe?
A. A pervasive pattern of social inhibition and feelings of inadequacy.
B. A pervasive pattern of grandiosity and need for admiration.
C. A pervasive pattern of disregard for and violation of the rights of others.
D. A pervasive pattern of instability in interpersonal relationships and self-image.
🟢 C. A pervasive pattern of disregard for and violation of the rights of others.
🔴 RATIONALE: Antisocial personality disorder is characterized by a long-standing pattern of manipulating,
exploiting, and violating the rights of others, often without remorse.
4. The nurse is planning care for a client with obsessive-compulsive disorder (OCD). Which intervention is
most appropriate to help the client manage compulsive behaviors?
A. Allowing unlimited time for rituals to reduce anxiety.
B. Gently but firmly interrupting the ritual and redirecting the client.
C. Setting strict limits on the time allowed for rituals and gradually decreasing it.
D. Praising the client each time a ritual is performed successfully.
🟢 C. Setting strict limits on the time allowed for rituals and gradually decreasing it.
🔴 RATIONALE: This is a behavioral intervention, often part of exposure and response prevention (ERP), where
the time for compulsions is systematically reduced to help the client gain control.
5. A client with bipolar disorder is in the manic phase. Which nursing intervention is the priority for this
client's physical safety?
A. Encouraging attendance at all group therapy sessions.
B. Engaging the client in a game of chess to focus his energy.
C. Providing a high-calorie, high-protein diet in a quiet environment.
D. Assisting the client in choosing appropriate, non-stimulating activities.
,🟢 C. Providing a high-calorie, high-protein diet in a quiet environment.
🔴 RATIONALE: During the manic phase, clients are hyperactive and may not eat or sleep. A high-calorie, high-
protein diet that can be eaten on the go is essential to prevent malnutrition and dehydration. A quiet
environment minimizes overstimulation.
6. A client is prescribed risperidone (Risperdal). The nurse should monitor for which potential side effect?
A. Weight gain and metabolic syndrome.
B. Agranulocytosis.
C. Hypertensive crisis.
D. Photosensitivity.
🟢 A. Weight gain and metabolic syndrome.
🔴 RATIONALE: Risperidone is an atypical antipsychotic known to cause significant weight gain, increased
blood glucose, and dyslipidemia, which are components of metabolic syndrome. Regular monitoring is crucial.
7. According to Erikson's theory of psychosocial development, a young adult (age 20-35) who is unable to
form close, intimate relationships is at risk for developing which feeling?
A. Stagnation.
B. Role confusion.
C. Isolation.
D. Guilt.
🟢 C. Isolation.
🔴 RATIONALE: Erikson's stage for young adulthood is Intimacy vs. Isolation. Failure to develop intimate
relationships results in feelings of isolation and loneliness.
8. A client is brought to the emergency department after taking an overdose of lorazepam (Ativan). Which
assessment finding is most concerning?
A. Blood pressure 110/70 mmHg.
, B. Heart rate 100 bpm.
C. Respiratory rate of 8 breaths per minute.
D. Pupils dilated and reactive to light.
🟢 C. Respiratory rate of 8 breaths per minute.
🔴 RATIONALE: Benzodiazepines are central nervous system depressants. Severe overdose can cause
respiratory depression, which is life-threatening. A respiratory rate of 8 is critically low and requires immediate
intervention.
9. The nurse is teaching a client about disulfiram (Antabuse) therapy for alcohol use disorder. What
information is crucial to include?
A. The medication will decrease the craving for alcohol.
B. The medication will cause severe nausea and vomiting if alcohol is consumed.
C. The medication is safe to take with over-the-counter cough syrups.
D. The medication's effects are only temporary and last for 24 hours.
🟢 B. The medication will cause severe nausea and vomiting if alcohol is consumed.
🔴 RATIONALE: Disulfiram is an aversive therapy that works by inhibiting aldehyde dehydrogenase, leading to a
buildup of acetaldehyde when alcohol is ingested. This causes a highly unpleasant reaction, including flushing,
nausea, and vomiting.
10. A client with post-traumatic stress disorder (PTSD) reports recurrent, distressing nightmares of a combat
event. The nurse recognizes this as which type of symptom?
A. Arousal and reactivity symptom.
B. Negative cognition and mood symptom.
C. Intrusion symptom.
D. Avoidance symptom.
🟢 C. Intrusion symptom.
RATIONALES 2026 Q&A |LATEST EXAM UPDATE 2026/2027
SECTION ONE: QUESTIONS 1–100
1. A nurse is caring for a client with schizophrenia who is experiencing auditory hallucinations. Which
intervention is most appropriate initially?
A. Tell the client the voices are not real and to ignore them.
B. Ask the client what the voices are saying and how they make him feel.
C. Encourage the client to participate in group therapy to distract him.
D. Place the client in seclusion until the hallucinations subside.
🟢 B. Ask the client what the voices are saying and how they make him feel.
🔴 RATIONALE: Assessing the content and emotional impact of the hallucinations is the first step in
understanding the client's experience and ensuring safety. This provides valuable data for the treatment plan.
2. A client diagnosed with major depressive disorder is started on phenelzine (Nardil). Which dietary
restriction is most critical for the nurse to teach?
A. Avoiding foods high in tyramine.
B. Restricting fluid intake to 1.5 liters per day.
C. Increasing intake of foods high in potassium.
D. Avoiding foods high in vitamin K.
🟢 A. Avoiding foods high in tyramine.
🔴 RATIONALE: Phenelzine is a monoamine oxidase inhibitor (MAOI). A diet high in tyramine can precipitate a
hypertensive crisis, which is a life-threatening emergency.
,3. A nurse is assessing a client with antisocial personality disorder. Which characteristic is the nurse most
likely to observe?
A. A pervasive pattern of social inhibition and feelings of inadequacy.
B. A pervasive pattern of grandiosity and need for admiration.
C. A pervasive pattern of disregard for and violation of the rights of others.
D. A pervasive pattern of instability in interpersonal relationships and self-image.
🟢 C. A pervasive pattern of disregard for and violation of the rights of others.
🔴 RATIONALE: Antisocial personality disorder is characterized by a long-standing pattern of manipulating,
exploiting, and violating the rights of others, often without remorse.
4. The nurse is planning care for a client with obsessive-compulsive disorder (OCD). Which intervention is
most appropriate to help the client manage compulsive behaviors?
A. Allowing unlimited time for rituals to reduce anxiety.
B. Gently but firmly interrupting the ritual and redirecting the client.
C. Setting strict limits on the time allowed for rituals and gradually decreasing it.
D. Praising the client each time a ritual is performed successfully.
🟢 C. Setting strict limits on the time allowed for rituals and gradually decreasing it.
🔴 RATIONALE: This is a behavioral intervention, often part of exposure and response prevention (ERP), where
the time for compulsions is systematically reduced to help the client gain control.
5. A client with bipolar disorder is in the manic phase. Which nursing intervention is the priority for this
client's physical safety?
A. Encouraging attendance at all group therapy sessions.
B. Engaging the client in a game of chess to focus his energy.
C. Providing a high-calorie, high-protein diet in a quiet environment.
D. Assisting the client in choosing appropriate, non-stimulating activities.
,🟢 C. Providing a high-calorie, high-protein diet in a quiet environment.
🔴 RATIONALE: During the manic phase, clients are hyperactive and may not eat or sleep. A high-calorie, high-
protein diet that can be eaten on the go is essential to prevent malnutrition and dehydration. A quiet
environment minimizes overstimulation.
6. A client is prescribed risperidone (Risperdal). The nurse should monitor for which potential side effect?
A. Weight gain and metabolic syndrome.
B. Agranulocytosis.
C. Hypertensive crisis.
D. Photosensitivity.
🟢 A. Weight gain and metabolic syndrome.
🔴 RATIONALE: Risperidone is an atypical antipsychotic known to cause significant weight gain, increased
blood glucose, and dyslipidemia, which are components of metabolic syndrome. Regular monitoring is crucial.
7. According to Erikson's theory of psychosocial development, a young adult (age 20-35) who is unable to
form close, intimate relationships is at risk for developing which feeling?
A. Stagnation.
B. Role confusion.
C. Isolation.
D. Guilt.
🟢 C. Isolation.
🔴 RATIONALE: Erikson's stage for young adulthood is Intimacy vs. Isolation. Failure to develop intimate
relationships results in feelings of isolation and loneliness.
8. A client is brought to the emergency department after taking an overdose of lorazepam (Ativan). Which
assessment finding is most concerning?
A. Blood pressure 110/70 mmHg.
, B. Heart rate 100 bpm.
C. Respiratory rate of 8 breaths per minute.
D. Pupils dilated and reactive to light.
🟢 C. Respiratory rate of 8 breaths per minute.
🔴 RATIONALE: Benzodiazepines are central nervous system depressants. Severe overdose can cause
respiratory depression, which is life-threatening. A respiratory rate of 8 is critically low and requires immediate
intervention.
9. The nurse is teaching a client about disulfiram (Antabuse) therapy for alcohol use disorder. What
information is crucial to include?
A. The medication will decrease the craving for alcohol.
B. The medication will cause severe nausea and vomiting if alcohol is consumed.
C. The medication is safe to take with over-the-counter cough syrups.
D. The medication's effects are only temporary and last for 24 hours.
🟢 B. The medication will cause severe nausea and vomiting if alcohol is consumed.
🔴 RATIONALE: Disulfiram is an aversive therapy that works by inhibiting aldehyde dehydrogenase, leading to a
buildup of acetaldehyde when alcohol is ingested. This causes a highly unpleasant reaction, including flushing,
nausea, and vomiting.
10. A client with post-traumatic stress disorder (PTSD) reports recurrent, distressing nightmares of a combat
event. The nurse recognizes this as which type of symptom?
A. Arousal and reactivity symptom.
B. Negative cognition and mood symptom.
C. Intrusion symptom.
D. Avoidance symptom.
🟢 C. Intrusion symptom.
