NU 160 Final Exam V3 | NU 160 Mental
Health Concepts | NCLEX (NGN) Q&A with
Rationale (NU160 Final Exam)
1. A nurse is caring for a client with schizophrenia who reports hearing voices telling them to
‘hurt the others.’ Which action should the nurse take first?
A. Ask the client to describe what the voices are saying in detail.
B. Initiate one-on-one observation to ensure safety.
C. Notify security to stand by the client’s room.
D. Administer an as-needed dose of an antipsychotic medication.
Correct Answer: B
Explanation: The client is experiencing command hallucinations, which pose an immediate
safety risk to others. Prioritizing safety through constant observation is the most critical
first step in the nursing process. This intervention allows the nurse to monitor the client
closely while further assessments and interventions are implemented.
2. A client is admitted to the psychiatric unit with a diagnosis of Major Depressive Disorder.
Which statement by the client requires immediate intervention?
A. I just don’t have any energy to get out of bed anymore.
B. I can’t seem to focus on even the simplest tasks lately.
C. My family would be better off if I weren’t around.
,D. I have a plan to end it all once I get home tonight.
Correct Answer: D
Explanation: The statement indicating a specific plan and intent to commit suicide
represents a high-risk situation that requires immediate intervention. Assessing for
lethality and providing a safe environment are the nurse’s primary responsibilities. The
nurse must implement suicide precautions immediately to prevent self-harm.
3. A client with Bipolar I Disorder is in the manic phase and is moving rapidly around the unit.
What is the most appropriate snack for the nurse to provide?
A. A bowl of hot chicken noodle soup.
B. A large green salad with dressing.
C. A cup of fruit yogurt with a spoon.
D. A peanut butter and jelly sandwich.
Correct Answer: D
Explanation: Clients in a manic state often have difficulty sitting down to eat and require
high-calorie ‘finger foods’ that can be eaten while moving. A peanut butter and jelly
sandwich provides protein and carbohydrates in a portable format. This helps maintain
nutritional status without requiring the client to remain stationary for long periods.
4. Which laboratory value is most important for a nurse to monitor in a client taking Lithium
Carbonate?
A. Serum potassium levels.
, B. White blood cell count.
C. Serum sodium levels.
D. Fast blood glucose levels.
Correct Answer: C
Explanation: Lithium is a salt, and its excretion is closely linked to sodium levels in the
body. If sodium levels drop, the kidneys may retain lithium, leading to toxicity. Monitoring
serum sodium is essential to ensure the client remains within a safe therapeutic range for
lithium.
5. A nurse is conducting a mental status examination (MSE). Which finding should the nurse
document under the category of ‘Affect’?
A. The client reports feeling very sad today.
B. The client demonstrates logical and sequential thoughts.
C. The client is oriented to person, place, and time.
D. The client’s facial expression remains flat and unchanged.
Correct Answer: D
Explanation: Affect refers to the external, observable expression of a person’s internal
emotional state. A flat facial expression is an objective finding that describes the client’s
affect. This is distinct from mood, which is the client’s subjective report of how they feel.
Health Concepts | NCLEX (NGN) Q&A with
Rationale (NU160 Final Exam)
1. A nurse is caring for a client with schizophrenia who reports hearing voices telling them to
‘hurt the others.’ Which action should the nurse take first?
A. Ask the client to describe what the voices are saying in detail.
B. Initiate one-on-one observation to ensure safety.
C. Notify security to stand by the client’s room.
D. Administer an as-needed dose of an antipsychotic medication.
Correct Answer: B
Explanation: The client is experiencing command hallucinations, which pose an immediate
safety risk to others. Prioritizing safety through constant observation is the most critical
first step in the nursing process. This intervention allows the nurse to monitor the client
closely while further assessments and interventions are implemented.
2. A client is admitted to the psychiatric unit with a diagnosis of Major Depressive Disorder.
Which statement by the client requires immediate intervention?
A. I just don’t have any energy to get out of bed anymore.
B. I can’t seem to focus on even the simplest tasks lately.
C. My family would be better off if I weren’t around.
,D. I have a plan to end it all once I get home tonight.
Correct Answer: D
Explanation: The statement indicating a specific plan and intent to commit suicide
represents a high-risk situation that requires immediate intervention. Assessing for
lethality and providing a safe environment are the nurse’s primary responsibilities. The
nurse must implement suicide precautions immediately to prevent self-harm.
3. A client with Bipolar I Disorder is in the manic phase and is moving rapidly around the unit.
What is the most appropriate snack for the nurse to provide?
A. A bowl of hot chicken noodle soup.
B. A large green salad with dressing.
C. A cup of fruit yogurt with a spoon.
D. A peanut butter and jelly sandwich.
Correct Answer: D
Explanation: Clients in a manic state often have difficulty sitting down to eat and require
high-calorie ‘finger foods’ that can be eaten while moving. A peanut butter and jelly
sandwich provides protein and carbohydrates in a portable format. This helps maintain
nutritional status without requiring the client to remain stationary for long periods.
4. Which laboratory value is most important for a nurse to monitor in a client taking Lithium
Carbonate?
A. Serum potassium levels.
, B. White blood cell count.
C. Serum sodium levels.
D. Fast blood glucose levels.
Correct Answer: C
Explanation: Lithium is a salt, and its excretion is closely linked to sodium levels in the
body. If sodium levels drop, the kidneys may retain lithium, leading to toxicity. Monitoring
serum sodium is essential to ensure the client remains within a safe therapeutic range for
lithium.
5. A nurse is conducting a mental status examination (MSE). Which finding should the nurse
document under the category of ‘Affect’?
A. The client reports feeling very sad today.
B. The client demonstrates logical and sequential thoughts.
C. The client is oriented to person, place, and time.
D. The client’s facial expression remains flat and unchanged.
Correct Answer: D
Explanation: Affect refers to the external, observable expression of a person’s internal
emotional state. A flat facial expression is an objective finding that describes the client’s
affect. This is distinct from mood, which is the client’s subjective report of how they feel.
