PNR 200/PNR200 Exam 2 V3 | Mental Health
Nursing Q&A with Rationale | Fortis College
1. A client is admitted to the psychiatric unit with a diagnosis of Bipolar I Disorder, currently
in a manic phase. Which nursing intervention is the highest priority?
A. Encouraging the client to participate in group sports.
B. Providing high-calorie finger foods.
C. Ensuring a quiet, low-stimulus environment.
D. Teaching the client about lithium side effects.
Correct Answer: C
Explanation: Clients in a manic state are easily overstimulated, which can lead to
increased agitation and potential violence. Reducing environmental stimuli is the priority
nursing intervention to ensure the safety of the client and others. This action helps to
decrease the client’s hyperactivity and promotes a sense of calm during an acute episode.
2. A client taking Clozapine for Schizophrenia reports a sore throat and fever. What is the
nurse’s priority action?
A. Administer an antipyretic as ordered.
B. Notify the healthcare provider to obtain a White Blood Cell (WBC) count.
C. Document the findings as a common side effect.
D. Advise the client to increase fluid intake.
,Correct Answer: B
Explanation: Clozapine is associated with a high risk of agranulocytosis, a life-threatening
reduction in white blood cells. Symptoms like fever and sore throat are early indicators of
infection resulting from bone marrow suppression. The nurse must prioritize obtaining a
lab count to assess the risk of sepsis and immediately report findings to the provider.
3. Which assessment finding is characteristic of a client experiencing a ‘Panic’ level of
anxiety?
A. The client is able to focus on problem-solving.
B. The client experiences perceptual distortion and may lose touch with reality.
C. The client reports a mild sense of restlessness.
D. The client asks repetitive questions to seek reassurance.
Correct Answer: B
Explanation: During the panic stage of anxiety, the individual’s perceptual field is
significantly narrowed, often resulting in a loss of contact with reality. Physical symptoms
are extreme and may include palpitations, chest pain, or shortness of breath. The nurse
must remain with the client to ensure safety as they are unable to process information or
follow directions.
4. A nurse is caring for a client with Obsessive-Compulsive Disorder (OCD) who spends hours
washing their hands. What is the most appropriate initial nursing intervention?
A. Physically prevent the client from using the sink.
, B. Set a strict time limit for handwashing immediately.
C. Allow the client enough time to perform the ritual initially to reduce anxiety.
D. Explain the irrational nature of the ritual to the client.
Correct Answer: C
Explanation: In the early stages of treatment for OCD, it is important to allow the client to
perform their rituals to prevent overwhelming anxiety. Attempting to stop the behavior
abruptly can lead to a panic attack or increased distress. The nursing focus should
eventually shift to gradually limiting the time spent on rituals while teaching new coping
mechanisms.
5. Which medication is considered the first-line treatment for Long-term management of
Generalized Anxiety Disorder (GAD)?
A. Alprazolam
B. Lorazepam
C. Escitalopram
D. Diphenhydramine
Correct Answer: C
Explanation: Selective Serotonin Reuptake Inhibitors (SSRIs) such as Escitalopram are the
gold standard for long-term anxiety management due to their efficacy and lower risk of
dependency. Benzodiazepines like Alprazolam and Lorazepam are generally reserved for
Nursing Q&A with Rationale | Fortis College
1. A client is admitted to the psychiatric unit with a diagnosis of Bipolar I Disorder, currently
in a manic phase. Which nursing intervention is the highest priority?
A. Encouraging the client to participate in group sports.
B. Providing high-calorie finger foods.
C. Ensuring a quiet, low-stimulus environment.
D. Teaching the client about lithium side effects.
Correct Answer: C
Explanation: Clients in a manic state are easily overstimulated, which can lead to
increased agitation and potential violence. Reducing environmental stimuli is the priority
nursing intervention to ensure the safety of the client and others. This action helps to
decrease the client’s hyperactivity and promotes a sense of calm during an acute episode.
2. A client taking Clozapine for Schizophrenia reports a sore throat and fever. What is the
nurse’s priority action?
A. Administer an antipyretic as ordered.
B. Notify the healthcare provider to obtain a White Blood Cell (WBC) count.
C. Document the findings as a common side effect.
D. Advise the client to increase fluid intake.
,Correct Answer: B
Explanation: Clozapine is associated with a high risk of agranulocytosis, a life-threatening
reduction in white blood cells. Symptoms like fever and sore throat are early indicators of
infection resulting from bone marrow suppression. The nurse must prioritize obtaining a
lab count to assess the risk of sepsis and immediately report findings to the provider.
3. Which assessment finding is characteristic of a client experiencing a ‘Panic’ level of
anxiety?
A. The client is able to focus on problem-solving.
B. The client experiences perceptual distortion and may lose touch with reality.
C. The client reports a mild sense of restlessness.
D. The client asks repetitive questions to seek reassurance.
Correct Answer: B
Explanation: During the panic stage of anxiety, the individual’s perceptual field is
significantly narrowed, often resulting in a loss of contact with reality. Physical symptoms
are extreme and may include palpitations, chest pain, or shortness of breath. The nurse
must remain with the client to ensure safety as they are unable to process information or
follow directions.
4. A nurse is caring for a client with Obsessive-Compulsive Disorder (OCD) who spends hours
washing their hands. What is the most appropriate initial nursing intervention?
A. Physically prevent the client from using the sink.
, B. Set a strict time limit for handwashing immediately.
C. Allow the client enough time to perform the ritual initially to reduce anxiety.
D. Explain the irrational nature of the ritual to the client.
Correct Answer: C
Explanation: In the early stages of treatment for OCD, it is important to allow the client to
perform their rituals to prevent overwhelming anxiety. Attempting to stop the behavior
abruptly can lead to a panic attack or increased distress. The nursing focus should
eventually shift to gradually limiting the time spent on rituals while teaching new coping
mechanisms.
5. Which medication is considered the first-line treatment for Long-term management of
Generalized Anxiety Disorder (GAD)?
A. Alprazolam
B. Lorazepam
C. Escitalopram
D. Diphenhydramine
Correct Answer: C
Explanation: Selective Serotonin Reuptake Inhibitors (SSRIs) such as Escitalopram are the
gold standard for long-term anxiety management due to their efficacy and lower risk of
dependency. Benzodiazepines like Alprazolam and Lorazepam are generally reserved for
