EXAM 2: 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 with schizophrenia tells the nurse, "The aliens are controlling my
thoughts through the television." What is the most appropriate initial response
by the nurse?
A. "That sounds frightening. Tell me more about what you are experiencing."
B. "Aliens cannot control your thoughts. That is not based in reality."
C. "I don't see any aliens. Let's turn the television off."
D. "Why do you think the aliens are doing that?"
Correct Answer: A
Rationale: This response uses therapeutic communication by validating the client's
feelings without reinforcing the delusion. It encourages the client to express their
experience, which is crucial for assessment and building trust. Options B and C are
confrontational and dismissive, which can damage the therapeutic relationship.
Option D asks "why," which is non-therapeutic and can make the client defensive.
2. A client diagnosed with major depressive disorder is started on fluoxetine
(Prozac). Which statement by the client indicates a need for further teaching?
,A. "I should take this medication in the morning."
B. "It may take 4 to 6 weeks to feel the full effects."
C. "I can stop this medication once I feel better."
D. "I should report any signs of increased anxiety or agitation."
Correct Answer: C
Rationale: Antidepressants like fluoxetine should be continued for several months
to a year after symptom improvement to prevent relapse. Stopping the medication
abruptly can lead to discontinuation syndrome and a relapse of depression. Taking
it in the morning is correct to minimize insomnia, and reporting increased anxiety
is important as it can be a side effect or sign of activation syndrome.
3. A client with bipolar disorder is experiencing a manic episode. Which nursing
intervention is a priority for this client?
A. Engage the client in a competitive game to channel energy.
B. Provide a high-calorie, high-protein diet to maintain weight.
C. Maintain a calm, non-stimulating environment with frequent rest periods.
D. Encourage the client to attend group therapy to promote socialization.
Correct Answer: C
Rationale: During a manic episode, clients are highly susceptible to sensory
overload. A calm, structured, and low-stimulation environment helps to reduce
agitation and prevent escalation. Providing rest periods is also crucial as mania
can lead to exhaustion. Competitive games and overstimulating groups can
increase agitation, and while nutrition is important, it is not the priority over
milieu management.
4. A client with severe anxiety is hyperventilating and reports feeling like they
are going to die. What is the nurse's priority action?
A. Instruct the client to take slow, deep breaths.
B. Administer a PRN dose of lorazepam (Ativan).
C. Place a paper bag over the client's mouth and nose.
D. Encourage the client to "snap out of it."
,Correct Answer: A
Rationale: The priority is to assist the client in regaining control of their breathing.
Instructing slow, deep breaths can help reduce hyperventilation and its symptoms,
such as lightheadedness and paresthesias. While medication may be needed, non-
pharmacological interventions should be tried first. Using a paper bag is generally
not recommended as it can worsen hypoxia, and telling the client to "snap out of
it" is dismissive and non-therapeutic.
5. A client with a history of alcohol use disorder is admitted with confusion,
ataxia, and nystagmus. Which vitamin deficiency is most likely the cause of
these symptoms?
A. Vitamin B12 (Cobalamin)
B. Vitamin B1 (Thiamine)
C. Vitamin B3 (Niacin)
D. Vitamin B6 (Pyridoxine)
Correct Answer: B
Rationale: These symptoms are classic for Wernicke's encephalopathy, a
neurological emergency caused by a severe thiamine (Vitamin B1) deficiency. It is
commonly seen in individuals with chronic alcohol use disorder due to poor
nutrition and impaired absorption. Prompt administration of thiamine is critical to
prevent progression to Korsakoff syndrome.
6. The nurse is assessing a client who reports hearing voices that tell them to
harm themselves. The client is restless and pacing. What is the nurse's priority
intervention?
A. Ask the client what the voices are saying.
B. Place the client in seclusion for safety.
C. Administer a PRN dose of haloperidol (Haldol).
D. Initiate one-to-one observation and stay with the client.
Correct Answer: D
Rationale: The client is exhibiting signs of imminent risk to self (command
hallucinations telling them to self-harm). The priority is to ensure safety through
, constant observation and staying with the client. While assessing the content of
the hallucinations is important, the immediate priority is safety. Seclusion and
medication may be necessary, but are not the initial action without attempting
less restrictive measures first.
7. A client is prescribed lithium carbonate (Lithobid) for bipolar disorder. Which
laboratory value should the nurse monitor most closely?
A. Serum sodium level
B. Serum potassium level
C. Serum calcium level
D. Serum lithium level
Correct Answer: D
Rationale: Lithium has a very narrow therapeutic index (0.8-1.2 mEq/L for acute
mania, 0.6-1.2 mEq/L for maintenance). Monitoring the serum lithium level is
crucial to prevent toxicity, which can be life-threatening. While sodium levels can
affect lithium excretion, the direct serum level is the most critical monitor.
8. A client with post-traumatic stress disorder (PTSD) reports frequent
nightmares and flashbacks. Which class of medications is most commonly used
as a first-line treatment for PTSD?
A. Benzodiazepines
B. Antipsychotics
C. SSRIs (Selective Serotonin Reuptake Inhibitors)
D. Tricyclic Antidepressants (TCAs)
Correct Answer: C
Rationale: SSRIs, such as sertraline and paroxetine, are considered first-line
pharmacological treatments for PTSD. They are effective in reducing core
symptoms like re-experiencing, avoidance, and hyperarousal. Benzodiazepines are
generally avoided due to their potential for dependence and lack of efficacy for
core PTSD symptoms.
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 with schizophrenia tells the nurse, "The aliens are controlling my
thoughts through the television." What is the most appropriate initial response
by the nurse?
A. "That sounds frightening. Tell me more about what you are experiencing."
B. "Aliens cannot control your thoughts. That is not based in reality."
C. "I don't see any aliens. Let's turn the television off."
D. "Why do you think the aliens are doing that?"
Correct Answer: A
Rationale: This response uses therapeutic communication by validating the client's
feelings without reinforcing the delusion. It encourages the client to express their
experience, which is crucial for assessment and building trust. Options B and C are
confrontational and dismissive, which can damage the therapeutic relationship.
Option D asks "why," which is non-therapeutic and can make the client defensive.
2. A client diagnosed with major depressive disorder is started on fluoxetine
(Prozac). Which statement by the client indicates a need for further teaching?
,A. "I should take this medication in the morning."
B. "It may take 4 to 6 weeks to feel the full effects."
C. "I can stop this medication once I feel better."
D. "I should report any signs of increased anxiety or agitation."
Correct Answer: C
Rationale: Antidepressants like fluoxetine should be continued for several months
to a year after symptom improvement to prevent relapse. Stopping the medication
abruptly can lead to discontinuation syndrome and a relapse of depression. Taking
it in the morning is correct to minimize insomnia, and reporting increased anxiety
is important as it can be a side effect or sign of activation syndrome.
3. A client with bipolar disorder is experiencing a manic episode. Which nursing
intervention is a priority for this client?
A. Engage the client in a competitive game to channel energy.
B. Provide a high-calorie, high-protein diet to maintain weight.
C. Maintain a calm, non-stimulating environment with frequent rest periods.
D. Encourage the client to attend group therapy to promote socialization.
Correct Answer: C
Rationale: During a manic episode, clients are highly susceptible to sensory
overload. A calm, structured, and low-stimulation environment helps to reduce
agitation and prevent escalation. Providing rest periods is also crucial as mania
can lead to exhaustion. Competitive games and overstimulating groups can
increase agitation, and while nutrition is important, it is not the priority over
milieu management.
4. A client with severe anxiety is hyperventilating and reports feeling like they
are going to die. What is the nurse's priority action?
A. Instruct the client to take slow, deep breaths.
B. Administer a PRN dose of lorazepam (Ativan).
C. Place a paper bag over the client's mouth and nose.
D. Encourage the client to "snap out of it."
,Correct Answer: A
Rationale: The priority is to assist the client in regaining control of their breathing.
Instructing slow, deep breaths can help reduce hyperventilation and its symptoms,
such as lightheadedness and paresthesias. While medication may be needed, non-
pharmacological interventions should be tried first. Using a paper bag is generally
not recommended as it can worsen hypoxia, and telling the client to "snap out of
it" is dismissive and non-therapeutic.
5. A client with a history of alcohol use disorder is admitted with confusion,
ataxia, and nystagmus. Which vitamin deficiency is most likely the cause of
these symptoms?
A. Vitamin B12 (Cobalamin)
B. Vitamin B1 (Thiamine)
C. Vitamin B3 (Niacin)
D. Vitamin B6 (Pyridoxine)
Correct Answer: B
Rationale: These symptoms are classic for Wernicke's encephalopathy, a
neurological emergency caused by a severe thiamine (Vitamin B1) deficiency. It is
commonly seen in individuals with chronic alcohol use disorder due to poor
nutrition and impaired absorption. Prompt administration of thiamine is critical to
prevent progression to Korsakoff syndrome.
6. The nurse is assessing a client who reports hearing voices that tell them to
harm themselves. The client is restless and pacing. What is the nurse's priority
intervention?
A. Ask the client what the voices are saying.
B. Place the client in seclusion for safety.
C. Administer a PRN dose of haloperidol (Haldol).
D. Initiate one-to-one observation and stay with the client.
Correct Answer: D
Rationale: The client is exhibiting signs of imminent risk to self (command
hallucinations telling them to self-harm). The priority is to ensure safety through
, constant observation and staying with the client. While assessing the content of
the hallucinations is important, the immediate priority is safety. Seclusion and
medication may be necessary, but are not the initial action without attempting
less restrictive measures first.
7. A client is prescribed lithium carbonate (Lithobid) for bipolar disorder. Which
laboratory value should the nurse monitor most closely?
A. Serum sodium level
B. Serum potassium level
C. Serum calcium level
D. Serum lithium level
Correct Answer: D
Rationale: Lithium has a very narrow therapeutic index (0.8-1.2 mEq/L for acute
mania, 0.6-1.2 mEq/L for maintenance). Monitoring the serum lithium level is
crucial to prevent toxicity, which can be life-threatening. While sodium levels can
affect lithium excretion, the direct serum level is the most critical monitor.
8. A client with post-traumatic stress disorder (PTSD) reports frequent
nightmares and flashbacks. Which class of medications is most commonly used
as a first-line treatment for PTSD?
A. Benzodiazepines
B. Antipsychotics
C. SSRIs (Selective Serotonin Reuptake Inhibitors)
D. Tricyclic Antidepressants (TCAs)
Correct Answer: C
Rationale: SSRIs, such as sertraline and paroxetine, are considered first-line
pharmacological treatments for PTSD. They are effective in reducing core
symptoms like re-experiencing, avoidance, and hyperarousal. Benzodiazepines are
generally avoided due to their potential for dependence and lack of efficacy for
core PTSD symptoms.
