NU 160 Final Exam V2 | NU 160 Mental
Health Concepts | NCLEX (NGN) Q&A with
Rationale (NU160 Final Exam)
1. A nurse is caring for a client with major depressive disorder who states, ‘Nothing matters
anymore. I don’t see the point in living.’ Which response by the nurse is most therapeutic?
A. Are you saying that you are feeling hopeless?
B. Are you thinking of hurting yourself or ending your life?
C. I am sure things will look better tomorrow.
D. Why do you feel like nothing matters anymore?
Correct Answer: B
Explanation: When a client expresses feelings of hopelessness or worthlessness, the
nurse’s priority is to assess for suicidal ideation. Asking a direct, closed-ended question
about suicide is necessary to ensure the client’s safety. This approach allows the nurse to
determine the immediate risk and initiate appropriate safety protocols.
2. A client is admitted to the psychiatric unit with a diagnosis of bipolar I disorder, manic
episode. Which nursing intervention is the priority?
A. Ensuring the client remains in a quiet, low-stimulation environment.
B. Providing a high-calorie, finger-food diet.
C. Setting firm limits on intrusive and demanding behaviors.
,D. Encouraging the client to participate in group therapy.
Correct Answer: A
Explanation: Clients in a manic phase are easily overstimulated, which can lead to
increased agitation and physical exhaustion. A low-stimulation environment helps reduce
the frequency of manic behaviors and protects the client from harm. While nutrition and
limit-setting are important, reducing environmental triggers is the foundational priority for
stabilization.
3. A nurse is teaching a client about a new prescription for lithium carbonate. Which
statement by the client indicates a need for further teaching?
A. I will make sure to drink 2 to 3 liters of fluid every day.
B. I should call my doctor if I have severe diarrhea or vomiting.
C. I will need to have my blood drawn regularly for testing.
D. I will limit my salt intake to help the medication work better.
Correct Answer: D
Explanation: Lithium is a salt, and its excretion is closely linked to sodium levels in the
body. Decreasing sodium intake can lead to lithium retention and toxicity, so clients should
maintain a consistent, normal sodium intake. The other options reflect correct knowledge
regarding hydration, toxicity symptoms, and laboratory monitoring.
, 4. A client with schizophrenia is experiencing auditory hallucinations and tells the nurse, ‘The
voices are telling me I am a bad person.’ Which response is appropriate?
A. I don’t hear any voices, but I understand that they are real to you.
B. The voices are not real; you should try to ignore them.
C. What are the voices telling you to do exactly?
D. Why do you think the voices are saying that?
Correct Answer: A
Explanation: This response demonstrates the therapeutic technique of presenting reality
without challenging the client’s perception. It validates the client’s experience while
clarifying that the nurse does not share the hallucination. Avoiding a direct challenge helps
maintain the therapeutic relationship and prevents the client from becoming defensive.
5. A nurse is assessing a client for alcohol withdrawal. Which of the following findings should
the nurse expect first?
A. Visual hallucinations
B. Fine tremors of the hands
C. Grand mal seizures
D. Disorientation to time and place
Correct Answer: B
Health Concepts | NCLEX (NGN) Q&A with
Rationale (NU160 Final Exam)
1. A nurse is caring for a client with major depressive disorder who states, ‘Nothing matters
anymore. I don’t see the point in living.’ Which response by the nurse is most therapeutic?
A. Are you saying that you are feeling hopeless?
B. Are you thinking of hurting yourself or ending your life?
C. I am sure things will look better tomorrow.
D. Why do you feel like nothing matters anymore?
Correct Answer: B
Explanation: When a client expresses feelings of hopelessness or worthlessness, the
nurse’s priority is to assess for suicidal ideation. Asking a direct, closed-ended question
about suicide is necessary to ensure the client’s safety. This approach allows the nurse to
determine the immediate risk and initiate appropriate safety protocols.
2. A client is admitted to the psychiatric unit with a diagnosis of bipolar I disorder, manic
episode. Which nursing intervention is the priority?
A. Ensuring the client remains in a quiet, low-stimulation environment.
B. Providing a high-calorie, finger-food diet.
C. Setting firm limits on intrusive and demanding behaviors.
,D. Encouraging the client to participate in group therapy.
Correct Answer: A
Explanation: Clients in a manic phase are easily overstimulated, which can lead to
increased agitation and physical exhaustion. A low-stimulation environment helps reduce
the frequency of manic behaviors and protects the client from harm. While nutrition and
limit-setting are important, reducing environmental triggers is the foundational priority for
stabilization.
3. A nurse is teaching a client about a new prescription for lithium carbonate. Which
statement by the client indicates a need for further teaching?
A. I will make sure to drink 2 to 3 liters of fluid every day.
B. I should call my doctor if I have severe diarrhea or vomiting.
C. I will need to have my blood drawn regularly for testing.
D. I will limit my salt intake to help the medication work better.
Correct Answer: D
Explanation: Lithium is a salt, and its excretion is closely linked to sodium levels in the
body. Decreasing sodium intake can lead to lithium retention and toxicity, so clients should
maintain a consistent, normal sodium intake. The other options reflect correct knowledge
regarding hydration, toxicity symptoms, and laboratory monitoring.
, 4. A client with schizophrenia is experiencing auditory hallucinations and tells the nurse, ‘The
voices are telling me I am a bad person.’ Which response is appropriate?
A. I don’t hear any voices, but I understand that they are real to you.
B. The voices are not real; you should try to ignore them.
C. What are the voices telling you to do exactly?
D. Why do you think the voices are saying that?
Correct Answer: A
Explanation: This response demonstrates the therapeutic technique of presenting reality
without challenging the client’s perception. It validates the client’s experience while
clarifying that the nurse does not share the hallucination. Avoiding a direct challenge helps
maintain the therapeutic relationship and prevents the client from becoming defensive.
5. A nurse is assessing a client for alcohol withdrawal. Which of the following findings should
the nurse expect first?
A. Visual hallucinations
B. Fine tremors of the hands
C. Grand mal seizures
D. Disorientation to time and place
Correct Answer: B
