FINAL EXAM V2: NR326 / NR 326 MENTAL HEALTH
(LATEST UPDATE) | ALL POSSIBLE AND
CURRENTLY MOST TESTED 100 PRACTICE
QUESTIONS AND 100% CORRECT VERIFIED
ANSWERS WITH DETAILED RATIONALES PLUS
ANSWER KEY ALREADY A+ GRADED MOST
RECENT!!!
1. A client diagnosed with schizophrenia tells the nurse, "The FBI is watching my
house because they know I can read the President's thoughts." Which term best
describes this statement?
a) Ideas of reference
b) Grandiose delusion
c) Persecutory delusion
d) Thought broadcasting
c) Persecutory delusion
Rationale: A persecutory delusion involves the false belief that one is being
malevolently targeted, harassed, or followed. The client’s belief that the FBI is
watching him is a classic example of this. Ideas of reference involve believing
neutral events have personal significance, grandiose delusions involve inflated
self-importance, and thought broadcasting is the belief that one's thoughts are
audible to others.
2. A client with major depressive disorder is prescribed phenelzine (Nardil). Which
dietary instruction is most important for the nurse to include in the teaching plan?
a) Avoid aged cheeses and cured meats.
,b) Increase intake of foods rich in tryptophan.
c) Restrict fluids to prevent water intoxication.
d) Take the medication with a high-protein meal.
a) Avoid aged cheeses and cured meats.
Rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI). Consuming
foods high in tyramine (aged cheeses, cured meats, fermented products) can
precipitate a hypertensive crisis. This is the most critical dietary teaching point.
The other options are not standard precautions for MAOIs.
3. A client on an inpatient unit is experiencing a panic attack. Which nursing
intervention is the priority?
a) Encourage the client to discuss the source of the anxiety.
b) Instruct the client to take deep, slow breaths.
c) Place the client in a quiet, low-stimulus environment.
d) Administer a PRN dose of lorazepam (Ativan).
c) Place the client in a quiet, low-stimulus environment.
Rationale: During a panic attack, the client is overwhelmed by fear and sensory
input. The priority is to reduce external stimuli to help the client feel safe and
regain control. While breathing exercises and medication are helpful, a quiet
environment is the first and most immediate non-pharmacological intervention
to implement.
4. A client with bipolar disorder is in a manic episode and is exhibiting flight of
ideas. Which communication technique is most appropriate for the nurse to use?
a) Speak rapidly to match the client's pace.
b) Use simple, concrete language and short sentences.
c) Challenge the client's illogical thought processes.
d) Allow the client to speak freely without interruption to express feelings.
b) Use simple, concrete language and short sentences.
Rationale: A client with flight of ideas has difficulty focusing and processing
complex information. Using simple, concrete, and brief statements helps the
client understand the communication. Matching their pace would exacerbate
,the issue, challenging them can lead to agitation, and allowing them to speak
freely may not be safe or therapeutic in an acute manic state.
5. A client is admitted with a diagnosis of borderline personality disorder. Which
nursing intervention is most crucial for maintaining a therapeutic relationship?
a) Establishing clear, consistent, and firm limits on behavior.
b) Allowing the client to set the agenda for therapy sessions.
c) Giving in to the client's demands to build trust.
d) Avoiding discussing the client's negative behaviors.
a) Establishing clear, consistent, and firm limits on behavior.
Rationale: Clients with borderline personality disorder often test boundaries and
engage in manipulative or splitting behaviors. Clear, consistent limits provide a
sense of security and structure, which is essential for a therapeutic relationship.
Inconsistency reinforces maladaptive behaviors. Allowing the client to set all
agendas or giving in to demands would be counterproductive and enabling.
6. A client receiving haloperidol (Haldol) develops acute dystonia. Which
medication should the nurse anticipate administering?
a) Benztropine (Cogentin)
b) Diphenhydramine (Benadryl)
c) Propranolol (Inderal)
d) Amantadine (Symmetrel)
b) Diphenhydramine (Benadryl)
Rationale: Acute dystonia, a severe spasm of muscles in the neck, tongue, or
eyes, is a common extrapyramidal side effect (EPS) of first-generation
antipsychotics. It is an emergency and is treated with anticholinergic
medications. Diphenhydramine (Benadryl) or benztropine (Cogentin) is given
intramuscularly or intravenously for rapid relief. Both are correct, but the
question asks which medication should be anticipated; diphenhydramine is a
frequent choice due to its availability and fast action.
, 7. A client with post-traumatic stress disorder (PTSD) reports having frequent
flashbacks of a traumatic event. Which symptom is the client experiencing?
a) Dissociative amnesia
b) Hypervigilance
c) Intrusive re-experiencing
d) Avoidance
c) Intrusive re-experiencing
Rationale: Flashbacks are a classic symptom of intrusive re-experiencing of the
traumatic event. This is one of the core symptom clusters of PTSD, along with
avoidance, negative alterations in cognition/mood, and alterations in
arousal/reactivity (like hypervigilance). Hypervigilance is a state of increased
arousal, not a flashback.
8. A client is prescribed lithium carbonate. The nurse assesses a lithium level of 1.8
mEq/L. Which finding would the nurse most likely expect?
a) Fine hand tremors and polyuria
b) Severe diarrhea, vomiting, and confusion
c) Sedation and weight gain
d) Dysphoria and muscle weakness
b) Severe diarrhea, vomiting, and confusion
Rationale: A lithium level of 1.8 mEq/L is in the toxic range (above 1.5 mEq/L).
Symptoms of early toxicity include severe gastrointestinal distress (nausea,
vomiting, diarrhea) and neurological changes such as confusion, ataxia, and
coarse tremors. Fine tremors and polyuria are common side effects at
therapeutic levels (0.6-1.2 mEq/L) but are not indicative of toxicity at this level.
9. Which nursing diagnosis is the priority for a client experiencing severe alcohol
withdrawal?
a) Risk for Injury
b) Impaired Verbal Communication
c) Disturbed Sleep Pattern
d) Chronic Low Self-Esteem
a) Risk for Injury
(LATEST UPDATE) | ALL POSSIBLE AND
CURRENTLY MOST TESTED 100 PRACTICE
QUESTIONS AND 100% CORRECT VERIFIED
ANSWERS WITH DETAILED RATIONALES PLUS
ANSWER KEY ALREADY A+ GRADED MOST
RECENT!!!
1. A client diagnosed with schizophrenia tells the nurse, "The FBI is watching my
house because they know I can read the President's thoughts." Which term best
describes this statement?
a) Ideas of reference
b) Grandiose delusion
c) Persecutory delusion
d) Thought broadcasting
c) Persecutory delusion
Rationale: A persecutory delusion involves the false belief that one is being
malevolently targeted, harassed, or followed. The client’s belief that the FBI is
watching him is a classic example of this. Ideas of reference involve believing
neutral events have personal significance, grandiose delusions involve inflated
self-importance, and thought broadcasting is the belief that one's thoughts are
audible to others.
2. A client with major depressive disorder is prescribed phenelzine (Nardil). Which
dietary instruction is most important for the nurse to include in the teaching plan?
a) Avoid aged cheeses and cured meats.
,b) Increase intake of foods rich in tryptophan.
c) Restrict fluids to prevent water intoxication.
d) Take the medication with a high-protein meal.
a) Avoid aged cheeses and cured meats.
Rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI). Consuming
foods high in tyramine (aged cheeses, cured meats, fermented products) can
precipitate a hypertensive crisis. This is the most critical dietary teaching point.
The other options are not standard precautions for MAOIs.
3. A client on an inpatient unit is experiencing a panic attack. Which nursing
intervention is the priority?
a) Encourage the client to discuss the source of the anxiety.
b) Instruct the client to take deep, slow breaths.
c) Place the client in a quiet, low-stimulus environment.
d) Administer a PRN dose of lorazepam (Ativan).
c) Place the client in a quiet, low-stimulus environment.
Rationale: During a panic attack, the client is overwhelmed by fear and sensory
input. The priority is to reduce external stimuli to help the client feel safe and
regain control. While breathing exercises and medication are helpful, a quiet
environment is the first and most immediate non-pharmacological intervention
to implement.
4. A client with bipolar disorder is in a manic episode and is exhibiting flight of
ideas. Which communication technique is most appropriate for the nurse to use?
a) Speak rapidly to match the client's pace.
b) Use simple, concrete language and short sentences.
c) Challenge the client's illogical thought processes.
d) Allow the client to speak freely without interruption to express feelings.
b) Use simple, concrete language and short sentences.
Rationale: A client with flight of ideas has difficulty focusing and processing
complex information. Using simple, concrete, and brief statements helps the
client understand the communication. Matching their pace would exacerbate
,the issue, challenging them can lead to agitation, and allowing them to speak
freely may not be safe or therapeutic in an acute manic state.
5. A client is admitted with a diagnosis of borderline personality disorder. Which
nursing intervention is most crucial for maintaining a therapeutic relationship?
a) Establishing clear, consistent, and firm limits on behavior.
b) Allowing the client to set the agenda for therapy sessions.
c) Giving in to the client's demands to build trust.
d) Avoiding discussing the client's negative behaviors.
a) Establishing clear, consistent, and firm limits on behavior.
Rationale: Clients with borderline personality disorder often test boundaries and
engage in manipulative or splitting behaviors. Clear, consistent limits provide a
sense of security and structure, which is essential for a therapeutic relationship.
Inconsistency reinforces maladaptive behaviors. Allowing the client to set all
agendas or giving in to demands would be counterproductive and enabling.
6. A client receiving haloperidol (Haldol) develops acute dystonia. Which
medication should the nurse anticipate administering?
a) Benztropine (Cogentin)
b) Diphenhydramine (Benadryl)
c) Propranolol (Inderal)
d) Amantadine (Symmetrel)
b) Diphenhydramine (Benadryl)
Rationale: Acute dystonia, a severe spasm of muscles in the neck, tongue, or
eyes, is a common extrapyramidal side effect (EPS) of first-generation
antipsychotics. It is an emergency and is treated with anticholinergic
medications. Diphenhydramine (Benadryl) or benztropine (Cogentin) is given
intramuscularly or intravenously for rapid relief. Both are correct, but the
question asks which medication should be anticipated; diphenhydramine is a
frequent choice due to its availability and fast action.
, 7. A client with post-traumatic stress disorder (PTSD) reports having frequent
flashbacks of a traumatic event. Which symptom is the client experiencing?
a) Dissociative amnesia
b) Hypervigilance
c) Intrusive re-experiencing
d) Avoidance
c) Intrusive re-experiencing
Rationale: Flashbacks are a classic symptom of intrusive re-experiencing of the
traumatic event. This is one of the core symptom clusters of PTSD, along with
avoidance, negative alterations in cognition/mood, and alterations in
arousal/reactivity (like hypervigilance). Hypervigilance is a state of increased
arousal, not a flashback.
8. A client is prescribed lithium carbonate. The nurse assesses a lithium level of 1.8
mEq/L. Which finding would the nurse most likely expect?
a) Fine hand tremors and polyuria
b) Severe diarrhea, vomiting, and confusion
c) Sedation and weight gain
d) Dysphoria and muscle weakness
b) Severe diarrhea, vomiting, and confusion
Rationale: A lithium level of 1.8 mEq/L is in the toxic range (above 1.5 mEq/L).
Symptoms of early toxicity include severe gastrointestinal distress (nausea,
vomiting, diarrhea) and neurological changes such as confusion, ataxia, and
coarse tremors. Fine tremors and polyuria are common side effects at
therapeutic levels (0.6-1.2 mEq/L) but are not indicative of toxicity at this level.
9. Which nursing diagnosis is the priority for a client experiencing severe alcohol
withdrawal?
a) Risk for Injury
b) Impaired Verbal Communication
c) Disturbed Sleep Pattern
d) Chronic Low Self-Esteem
a) Risk for Injury
