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NUR 208 Exam 2 Mental Health Nursing Newest
Exam Preparation With Complete Questions And
Correct Answers With Rationales Already Graded
A+Brand New Version!!
QUESTION 1
A client diagnosed with major depressive disorder states, "I don't see
the point in trying anymore. Nothing I do matters." Which nursing
diagnosis is the priority?
A) Chronic Low Self-Esteem
B) Risk for Suicide
C) Social Isolation
D) Hopelessness
Answer: B) Risk for Suicide
Rationale: The client's statement reflects profound despair and a
potential suicidal ideation. While hopelessness, low self-esteem, and
social isolation are all relevant to major depressive disorder, the
presence of a direct verbalization of futility and meaninglessness
indicates an imminent risk for self-harm. Patient safety is always the
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priority in psychiatric nursing. The nurse must first assess the client's
specific suicide plan, means, and intent.
QUESTION 2
A nurse is caring for a client with schizophrenia who reports hearing
voices that command him to hurt himself. Which intervention should
the nurse implement first?
A) Place the client in seclusion
B) Administer an antipsychotic medication
C) Initiate one-to-one observation
D) Ask the client what the voices are saying
Answer: D) Ask the client what the voices are saying
Rationale: Assessment precedes intervention. The nurse must first
gather data to determine the content, frequency, and intensity of the
command hallucinations. Asking the client what the voices are saying is
crucial to assess the level of risk. One-to-one observation and
medication administration are important, but they come after the initial
assessment. Seclusion is a restrictive measure used only when less
restrictive interventions have failed and the client poses an immediate
danger.
QUESTION 3
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A client with bipolar disorder who is in a manic phase is admitted to the
unit. Which nursing intervention is most appropriate for managing this
client's hyperactivity?
A) Place the client in a private room with minimal stimulation
B) Encourage the client to participate in group therapy to use up excess
energy
C) Provide the client with frequent, high-calorie snacks and finger foods
D) Restrict the client's fluid intake to prevent bathroom accidents
Answer: C) Provide the client with frequent, high-calorie snacks and
finger foods
Rationale: Clients in a manic state are often too hyperactive to sit down
for a full meal, leading to poor nutritional intake and weight loss. Finger
foods and high-calorie snacks that can be eaten on the go help maintain
nutritional status. A private room with minimal stimulation is
appropriate, but the priority for hyperactivity is safety and meeting
physiological needs. Group therapy would likely overstimulate the
client, and fluid restriction is not indicated.
QUESTION 4
A client with generalized anxiety disorder is experiencing moderate
anxiety. Which teaching point regarding the physiological response to
anxiety should the nurse prioritize?
A) "Your heart is racing because your parasympathetic nervous system
is overactive."
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B) "The fight-or-flight response is triggered by the release of
epinephrine and norepinephrine."
C) "Your increased respiratory rate is a sign of respiratory alkalosis
requiring immediate intervention."
D) "The anxiety you feel is purely psychological and has no physical
basis."
Answer: B) "The fight-or-flight response is triggered by the release of
epinephrine and norepinephrine."
Rationale: The sympathetic nervous system releases catecholamines
(epinephrine and norepinephrine) in response to a perceived threat. This
is the physiological basis for the "fight-or-flight" response, which
includes increased heart rate, respiratory rate, and blood pressure.
Option A is incorrect because the parasympathetic system is responsible
for rest and digestion. Option C is inaccurate unless the hyperventilation
is severe enough to cause symptoms. Option D is false; anxiety has a
very real physiological component.
QUESTION 5
A client diagnosed with borderline personality disorder uses splitting as
a defense mechanism. Which statement by the client is most indicative
of this behavior?
A) "I feel so empty inside, like I don't know who I am."
B) "You are the only nurse who understands me. The day shift nurse is
incompetent."
C) "I cut myself to feel something other than this numbness."
NUR 208 Exam 2 Mental Health Nursing Newest
Exam Preparation With Complete Questions And
Correct Answers With Rationales Already Graded
A+Brand New Version!!
QUESTION 1
A client diagnosed with major depressive disorder states, "I don't see
the point in trying anymore. Nothing I do matters." Which nursing
diagnosis is the priority?
A) Chronic Low Self-Esteem
B) Risk for Suicide
C) Social Isolation
D) Hopelessness
Answer: B) Risk for Suicide
Rationale: The client's statement reflects profound despair and a
potential suicidal ideation. While hopelessness, low self-esteem, and
social isolation are all relevant to major depressive disorder, the
presence of a direct verbalization of futility and meaninglessness
indicates an imminent risk for self-harm. Patient safety is always the
,2|Page
priority in psychiatric nursing. The nurse must first assess the client's
specific suicide plan, means, and intent.
QUESTION 2
A nurse is caring for a client with schizophrenia who reports hearing
voices that command him to hurt himself. Which intervention should
the nurse implement first?
A) Place the client in seclusion
B) Administer an antipsychotic medication
C) Initiate one-to-one observation
D) Ask the client what the voices are saying
Answer: D) Ask the client what the voices are saying
Rationale: Assessment precedes intervention. The nurse must first
gather data to determine the content, frequency, and intensity of the
command hallucinations. Asking the client what the voices are saying is
crucial to assess the level of risk. One-to-one observation and
medication administration are important, but they come after the initial
assessment. Seclusion is a restrictive measure used only when less
restrictive interventions have failed and the client poses an immediate
danger.
QUESTION 3
,3|Page
A client with bipolar disorder who is in a manic phase is admitted to the
unit. Which nursing intervention is most appropriate for managing this
client's hyperactivity?
A) Place the client in a private room with minimal stimulation
B) Encourage the client to participate in group therapy to use up excess
energy
C) Provide the client with frequent, high-calorie snacks and finger foods
D) Restrict the client's fluid intake to prevent bathroom accidents
Answer: C) Provide the client with frequent, high-calorie snacks and
finger foods
Rationale: Clients in a manic state are often too hyperactive to sit down
for a full meal, leading to poor nutritional intake and weight loss. Finger
foods and high-calorie snacks that can be eaten on the go help maintain
nutritional status. A private room with minimal stimulation is
appropriate, but the priority for hyperactivity is safety and meeting
physiological needs. Group therapy would likely overstimulate the
client, and fluid restriction is not indicated.
QUESTION 4
A client with generalized anxiety disorder is experiencing moderate
anxiety. Which teaching point regarding the physiological response to
anxiety should the nurse prioritize?
A) "Your heart is racing because your parasympathetic nervous system
is overactive."
, 4|Page
B) "The fight-or-flight response is triggered by the release of
epinephrine and norepinephrine."
C) "Your increased respiratory rate is a sign of respiratory alkalosis
requiring immediate intervention."
D) "The anxiety you feel is purely psychological and has no physical
basis."
Answer: B) "The fight-or-flight response is triggered by the release of
epinephrine and norepinephrine."
Rationale: The sympathetic nervous system releases catecholamines
(epinephrine and norepinephrine) in response to a perceived threat. This
is the physiological basis for the "fight-or-flight" response, which
includes increased heart rate, respiratory rate, and blood pressure.
Option A is incorrect because the parasympathetic system is responsible
for rest and digestion. Option C is inaccurate unless the hyperventilation
is severe enough to cause symptoms. Option D is false; anxiety has a
very real physiological component.
QUESTION 5
A client diagnosed with borderline personality disorder uses splitting as
a defense mechanism. Which statement by the client is most indicative
of this behavior?
A) "I feel so empty inside, like I don't know who I am."
B) "You are the only nurse who understands me. The day shift nurse is
incompetent."
C) "I cut myself to feel something other than this numbness."
