NUR 384
EXAM 3
(Mental Health Nursing)
Actual Questions with Correct Answers
Concordia University’s
What’s Included:
• 70+ verified questions with Correct answers with
Rationales.
• NCLEX-style multiple-choice questions
• select-all-that-apply (SATA) questions
• Case Studies / Scenario-Based questions
• Ideal for exam preparation and concept reinforcement.
,1. Which finding is a key diagnostic criterion for major depressive disorder?
A. Persistent mild depression for at least one month
B. Elevated or irritable mood lasting at least four days
C. Depressed mood or loss of interest or pleasure for at least two weeks
D. Alternating manic and depressive episodes
Correct Answer:
C. Depressed mood or loss of interest or pleasure for at least two weeks
Expert Rationale:
Major depressive disorder involves at least two weeks of depressed mood or loss of
interest or pleasure accompanied by additional symptoms, such as sleep disturbance,
appetite changes, fatigue, impaired concentration, guilt, psychomotor changes, or suicidal
thoughts.
2. A client with depression states, “I cannot get out of bed anymore. Nothing feels
worth doing.” What should the nurse do first?
A. Encourage the client to identify enjoyable activities.
B. Document the statement and continue the interview.
C. Administer the prescribed antidepressant.
D. Assess the client directly for suicidal thoughts, intent, plan, and means.
Correct Answer:
D. Assess the client directly for suicidal thoughts, intent, plan, and means.
Expert Rationale:
Expressions of hopelessness may indicate suicide risk. Safety takes priority, so the nurse
must immediately conduct a direct suicide assessment before proceeding with routine
interventions.
3. A client taking an SSRI develops agitation, confusion, tachycardia, and muscle
rigidity. What should the nurse suspect?
A. Serotonin syndrome; hold the medication and obtain immediate medical assistance
B. Expected SSRI effects; reassure the client
C. Antidepressant withdrawal; administer a larger dose
D. Mild allergy; administer an antihistamine
,Correct Answer:
A. Serotonin syndrome; hold the medication and obtain immediate medical
assistance
Expert Rationale:
Serotonin syndrome is a potentially life-threatening condition associated with mental-
status changes, autonomic instability, hyperreflexia, clonus, tremor, fever, and muscle
rigidity. Serotonergic medications should be stopped, and emergency treatment initiated.
4. A client experiencing mania moves rapidly from one topic to another, with
recognizable but superficial connections between ideas. Which term describes this
finding?
A. Neologism
B. Flight of ideas
C. Word salad
D. Delusion
Correct Answer:
B. Flight of ideas
Expert Rationale:
Flight of ideas is a rapid shift from one topic to another, often based on understandable
associations. It is commonly observed during manic episodes.
5. Which instruction is most important for a client prescribed lithium?
A. Take lithium only when manic symptoms develop.
B. Restrict fluid intake to less than 1 L per day.
C. Stop lithium whenever mild side effects occur.
D. Maintain a consistent intake of sodium and fluids.
Correct Answer:
D. Maintain a consistent intake of sodium and fluids.
Expert Rationale:
Dehydration and sodium depletion reduce lithium excretion and increase the risk of
toxicity. Clients should maintain consistent fluid and dietary sodium intake, especially
during exercise, hot weather, vomiting, or diarrhea.
, 6. A client taking lithium has a serum level of 1.8 mEq/L and is experiencing
nausea, vomiting, and worsening tremors. What is the priority nursing action?
A. Administer an antiemetic and continue lithium.
B. Hold lithium and notify the provider immediately.
C. Administer lorazepam for the tremors.
D. Encourage fluids and reassess at the next appointment.
Correct Answer:
B. Hold lithium and notify the provider immediately.
Expert Rationale:
A lithium level of 1.8 mEq/L with gastrointestinal and neurological manifestations
indicates toxicity. Lithium should be withheld, and the client requires urgent assessment,
laboratory monitoring, hydration, and possible hospital treatment.
7. Which client statement indicates the highest immediate suicide risk?
A. “My family would probably be better off without me.”
B. “Sometimes I wish I would not wake up.”
C. “I have been thinking about killing myself, and I have a loaded gun in my closet.”
D. “I do not see much purpose in living anymore.”
Correct Answer:
C. “I have been thinking about killing myself, and I have a loaded gun in my closet.”
Expert Rationale:
A specific plan combined with immediate access to a highly lethal method indicates
imminent risk. The nurse must maintain constant safety, remove access to the weapon
through appropriate emergency procedures, and arrange immediate evaluation.
8. A client acknowledges having suicidal thoughts. Which question should the nurse
ask next to assess lethality?
A. “Do you have a specific plan for killing yourself?”
B. “What has caused you to feel this way?”
C. “Have you discussed these feelings with your family?”
D. “What activities usually help you feel better?”
Correct Answer:
A. “Do you have a specific plan for killing yourself?”
EXAM 3
(Mental Health Nursing)
Actual Questions with Correct Answers
Concordia University’s
What’s Included:
• 70+ verified questions with Correct answers with
Rationales.
• NCLEX-style multiple-choice questions
• select-all-that-apply (SATA) questions
• Case Studies / Scenario-Based questions
• Ideal for exam preparation and concept reinforcement.
,1. Which finding is a key diagnostic criterion for major depressive disorder?
A. Persistent mild depression for at least one month
B. Elevated or irritable mood lasting at least four days
C. Depressed mood or loss of interest or pleasure for at least two weeks
D. Alternating manic and depressive episodes
Correct Answer:
C. Depressed mood or loss of interest or pleasure for at least two weeks
Expert Rationale:
Major depressive disorder involves at least two weeks of depressed mood or loss of
interest or pleasure accompanied by additional symptoms, such as sleep disturbance,
appetite changes, fatigue, impaired concentration, guilt, psychomotor changes, or suicidal
thoughts.
2. A client with depression states, “I cannot get out of bed anymore. Nothing feels
worth doing.” What should the nurse do first?
A. Encourage the client to identify enjoyable activities.
B. Document the statement and continue the interview.
C. Administer the prescribed antidepressant.
D. Assess the client directly for suicidal thoughts, intent, plan, and means.
Correct Answer:
D. Assess the client directly for suicidal thoughts, intent, plan, and means.
Expert Rationale:
Expressions of hopelessness may indicate suicide risk. Safety takes priority, so the nurse
must immediately conduct a direct suicide assessment before proceeding with routine
interventions.
3. A client taking an SSRI develops agitation, confusion, tachycardia, and muscle
rigidity. What should the nurse suspect?
A. Serotonin syndrome; hold the medication and obtain immediate medical assistance
B. Expected SSRI effects; reassure the client
C. Antidepressant withdrawal; administer a larger dose
D. Mild allergy; administer an antihistamine
,Correct Answer:
A. Serotonin syndrome; hold the medication and obtain immediate medical
assistance
Expert Rationale:
Serotonin syndrome is a potentially life-threatening condition associated with mental-
status changes, autonomic instability, hyperreflexia, clonus, tremor, fever, and muscle
rigidity. Serotonergic medications should be stopped, and emergency treatment initiated.
4. A client experiencing mania moves rapidly from one topic to another, with
recognizable but superficial connections between ideas. Which term describes this
finding?
A. Neologism
B. Flight of ideas
C. Word salad
D. Delusion
Correct Answer:
B. Flight of ideas
Expert Rationale:
Flight of ideas is a rapid shift from one topic to another, often based on understandable
associations. It is commonly observed during manic episodes.
5. Which instruction is most important for a client prescribed lithium?
A. Take lithium only when manic symptoms develop.
B. Restrict fluid intake to less than 1 L per day.
C. Stop lithium whenever mild side effects occur.
D. Maintain a consistent intake of sodium and fluids.
Correct Answer:
D. Maintain a consistent intake of sodium and fluids.
Expert Rationale:
Dehydration and sodium depletion reduce lithium excretion and increase the risk of
toxicity. Clients should maintain consistent fluid and dietary sodium intake, especially
during exercise, hot weather, vomiting, or diarrhea.
, 6. A client taking lithium has a serum level of 1.8 mEq/L and is experiencing
nausea, vomiting, and worsening tremors. What is the priority nursing action?
A. Administer an antiemetic and continue lithium.
B. Hold lithium and notify the provider immediately.
C. Administer lorazepam for the tremors.
D. Encourage fluids and reassess at the next appointment.
Correct Answer:
B. Hold lithium and notify the provider immediately.
Expert Rationale:
A lithium level of 1.8 mEq/L with gastrointestinal and neurological manifestations
indicates toxicity. Lithium should be withheld, and the client requires urgent assessment,
laboratory monitoring, hydration, and possible hospital treatment.
7. Which client statement indicates the highest immediate suicide risk?
A. “My family would probably be better off without me.”
B. “Sometimes I wish I would not wake up.”
C. “I have been thinking about killing myself, and I have a loaded gun in my closet.”
D. “I do not see much purpose in living anymore.”
Correct Answer:
C. “I have been thinking about killing myself, and I have a loaded gun in my closet.”
Expert Rationale:
A specific plan combined with immediate access to a highly lethal method indicates
imminent risk. The nurse must maintain constant safety, remove access to the weapon
through appropriate emergency procedures, and arrange immediate evaluation.
8. A client acknowledges having suicidal thoughts. Which question should the nurse
ask next to assess lethality?
A. “Do you have a specific plan for killing yourself?”
B. “What has caused you to feel this way?”
C. “Have you discussed these feelings with your family?”
D. “What activities usually help you feel better?”
Correct Answer:
A. “Do you have a specific plan for killing yourself?”
