NUR 208/NUR208 Exam 2 V2 | Mental Health
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a client who is experiencing a moderate level of anxiety. Which of the
following findings should the nurse expect?
A. The client has a narrowed perceptual field.
B. The client reports feelings of impending doom.
C. The client is unable to follow directions.
D. The client has a heightened awareness of the environment.
Correct Answer: A
Explanation: Moderate anxiety causes a narrowing of the perceptual field, where the
individual focuses on the immediate concern. In contrast, mild anxiety often results in
heightened awareness, while severe or panic levels lead to feelings of doom or inability to
follow directions. The nurse should use simple language when communicating with a client
at this level.
2. A client is prescribed Lithium Carbonate for the treatment of Bipolar Disorder. Which of the
following laboratory values indicates the client is within the therapeutic range?
A. 1.0 mEq/L
B. 0.4 mEq/L
C. 1.6 mEq/L
,D. 2.1 mEq/L
Correct Answer: A
Explanation: The therapeutic maintenance range for serum lithium is generally
considered to be 0.6 to 1.2 mEq/L. A level of 1.0 mEq/L falls directly within this safe and
effective window for mood stabilization. Levels above 1.5 mEq/L are toxic and require
immediate medical intervention to prevent severe complications.
3. A nurse is caring for a client with Major Depressive Disorder who suddenly appears much
more energetic and states, ‘Everything is fine now.’ What is the nurse’s priority action?
A. Initiate suicide precautions and increase monitoring.
B. Document the improvement in the client’s mood.
C. Request a discharge evaluation from the provider.
D. Encourage the client to join a group therapy session.
Correct Answer: A
Explanation: A sudden, unexplained improvement in mood or energy in a depressed client
is a major red flag for suicide. This often indicates the client has finalized a plan and feels
relief at the prospect of ending their suffering. The nurse must prioritize safety by
assessing for a plan and increasing observation immediately.
4. A nurse is providing discharge teaching for a client prescribed Phenelzine (Nardil). Which
food choice by the client indicates a need for further teaching?
A. Grilled cheese made with aged cheddar
, B. Fresh chicken breast
C. Steamed broccoli
D. Fresh sliced apples
Correct Answer: A
Explanation: Phenelzine is an MAOI, which requires a low-tyramine diet to prevent a
hypertensive crisis. Aged cheeses, such as cheddar, are high in tyramine and must be
avoided. Fresh meats and most fresh fruits/vegetables are generally safe for clients on this
medication.
5. Which clinical manifestation is characteristic of a client experiencing a Panic Attack?
A. Decreased heart rate
B. Palpitations and chest pain
C. Somnolence
D. Increased appetite
Correct Answer: B
Explanation: Panic attacks are characterized by intense physical symptoms, including
palpitations, sweating, tremors, and chest pain, which often mimic a myocardial infarction.
These symptoms usually peak within 10 minutes and can be accompanied by a fear of
dying. The nurse should stay with the client and maintain a calm, quiet environment.
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a client who is experiencing a moderate level of anxiety. Which of the
following findings should the nurse expect?
A. The client has a narrowed perceptual field.
B. The client reports feelings of impending doom.
C. The client is unable to follow directions.
D. The client has a heightened awareness of the environment.
Correct Answer: A
Explanation: Moderate anxiety causes a narrowing of the perceptual field, where the
individual focuses on the immediate concern. In contrast, mild anxiety often results in
heightened awareness, while severe or panic levels lead to feelings of doom or inability to
follow directions. The nurse should use simple language when communicating with a client
at this level.
2. A client is prescribed Lithium Carbonate for the treatment of Bipolar Disorder. Which of the
following laboratory values indicates the client is within the therapeutic range?
A. 1.0 mEq/L
B. 0.4 mEq/L
C. 1.6 mEq/L
,D. 2.1 mEq/L
Correct Answer: A
Explanation: The therapeutic maintenance range for serum lithium is generally
considered to be 0.6 to 1.2 mEq/L. A level of 1.0 mEq/L falls directly within this safe and
effective window for mood stabilization. Levels above 1.5 mEq/L are toxic and require
immediate medical intervention to prevent severe complications.
3. A nurse is caring for a client with Major Depressive Disorder who suddenly appears much
more energetic and states, ‘Everything is fine now.’ What is the nurse’s priority action?
A. Initiate suicide precautions and increase monitoring.
B. Document the improvement in the client’s mood.
C. Request a discharge evaluation from the provider.
D. Encourage the client to join a group therapy session.
Correct Answer: A
Explanation: A sudden, unexplained improvement in mood or energy in a depressed client
is a major red flag for suicide. This often indicates the client has finalized a plan and feels
relief at the prospect of ending their suffering. The nurse must prioritize safety by
assessing for a plan and increasing observation immediately.
4. A nurse is providing discharge teaching for a client prescribed Phenelzine (Nardil). Which
food choice by the client indicates a need for further teaching?
A. Grilled cheese made with aged cheddar
, B. Fresh chicken breast
C. Steamed broccoli
D. Fresh sliced apples
Correct Answer: A
Explanation: Phenelzine is an MAOI, which requires a low-tyramine diet to prevent a
hypertensive crisis. Aged cheeses, such as cheddar, are high in tyramine and must be
avoided. Fresh meats and most fresh fruits/vegetables are generally safe for clients on this
medication.
5. Which clinical manifestation is characteristic of a client experiencing a Panic Attack?
A. Decreased heart rate
B. Palpitations and chest pain
C. Somnolence
D. Increased appetite
Correct Answer: B
Explanation: Panic attacks are characterized by intense physical symptoms, including
palpitations, sweating, tremors, and chest pain, which often mimic a myocardial infarction.
These symptoms usually peak within 10 minutes and can be accompanied by a fear of
dying. The nurse should stay with the client and maintain a calm, quiet environment.
