UPDATED FINAL EXAM NUR 208: 160 Comprehensive
Exam Questions, Answers and Rationales
Instructions: This comprehensive exam covers key concepts in psychiatric-mental health
nursing. Select the best answer for each question.
1. A client diagnosed with major depressive disorder states, "I am a terrible person and
everything is my fault." Which nursing response best reflects the use of cognitive-
behavioral techniques? A. "Let's explore the evidence that supports and refutes that
belief." B. "It is important to focus on your strengths instead of your weaknesses." C.
"These feelings are a symptom of your illness and will pass." D. "Why do you think you
feel this way about yourself?" Answer: A. Rationale: Cognitive-behavioral therapy
focuses on identifying and challenging cognitive distortions. Option A directly
addresses the client's automatic negative thought by encouraging them to examine its
validity. Option B offers false reassurance. Option C minimizes the client's feelings.
Option D asks a 'why' question, which can be non-therapeutic and difficult for the
client to answer.
2. A client with schizophrenia is exhibiting akathisia. Which assessment finding supports
this conclusion? A. Involuntary muscle contractions causing twisting movements of the
face. B. A subjective feeling of inner restlessness and an inability to sit still. C. A stiff, rigid
posture with muscle rigidity and a shuffling gait. D. Fine, rapid tremors in the hands and
fingers. Answer: B. Rationale: Akathisia is a movement disorder characterized by
subjective restlessness and an inability to remain still. Option A describes tardive
dyskinesia. Option C describes parkinsonism. Option D describes a tremor, which can
be medication-induced but is not specifically akathisia.
3. A client is admitted involuntarily to the psychiatric unit. Which of the following client
rights is the most important for the nurse to protect? A. The right to refuse all
treatment. B. The right to have visitors at any time. C. The right to a humane treatment
environment. D. The right to vote in national elections. Answer: C. Rationale:
Involuntary commitment does not strip a client of all rights. While they may have
restrictions, they retain the right to a safe and humane environment, which is a
fundamental legal and ethical mandate. The right to refuse treatment is often limited
for involuntarily committed clients, especially in emergencies. Visitation is often
, restricted for safety. The right to vote is preserved but not the most immediate priority
in an inpatient setting.
4. A nurse is teaching a client about lithium therapy. Which statement indicates that the
client understands the teaching? A. "I should drink at least 2 liters of fluid a day to
prevent toxicity." B. "I can take ibuprofen for headaches if I need to." C. "I will need to
have blood drawn frequently to check my liver function." D. "A low-sodium diet is
recommended while I am on this medication." Answer: A. Rationale: Adequate
hydration is crucial for clients on lithium to maintain therapeutic levels and prevent
toxicity, as lithium is excreted by the kidneys. Option B is incorrect because NSAIDs like
ibuprofen can increase lithium levels, leading to toxicity. Option C is incorrect; lithium
requires monitoring of serum levels and kidney/thyroid function, not primarily liver
function. Option D is incorrect; a consistent sodium intake is important, not a low-
sodium diet, as sodium depletion can increase lithium levels.
5. A client with borderline personality disorder is using splitting as a defense mechanism.
The nurse observes the client idealizing one staff member and devaluing another. What
is the nurse's most appropriate initial action? A. Confront the client about this
manipulation of staff. B. Ignore the behavior as it is a common manifestation of the
disorder. C. Set a limit with the client about inappropriate comments. D. Discuss the
behavior with the treatment team to ensure consistent limit setting. Answer: D.
Rationale: Splitting is a common defense mechanism in borderline personality disorder
that can disrupt the therapeutic milieu and split the staff. The best initial action is to
communicate the observation with the treatment team to establish a consistent,
unified approach to limit-setting and avoid staff conflict. Confrontation could be
perceived as punitive. Ignoring the behavior does not address the therapeutic issue.
Setting a limit individually may be necessary but is most effective when done as part of
a team plan.
6. A client is brought to the emergency department after a sexual assault. Which nursing
action is the priority? A. Provide a compassionate, non-judgmental environment for the
client. B. Assess for signs of physical trauma and collect forensic evidence. C. Contact the
client's family to provide support. D. Encourage the client to discuss the details of the
assault. Answer: A. Rationale: The priority in the immediate aftermath of a sexual
assault is to ensure the client's safety and psychological well-being by providing a safe,
compassionate, and non-judgmental environment. While physical assessment and
forensic evidence collection are important, they are part of a later, specialized process
(SAFE exam). Contacting the family is not a priority and may violate the client's
, privacy. Encouraging a detailed discussion of the assault is not recommended
immediately as it can be re-traumatizing.
7. A client experiencing alcohol withdrawal is prescribed chlordiazepoxide. The nurse
understands that the primary purpose of this medication is to: A. Decrease the client's
craving for alcohol. B. Prevent the development of Wernicke-Korsakoff syndrome. C.
Prevent and treat withdrawal seizures and delirium tremens. D. Treat underlying
depression that may be contributing to alcohol use. Answer: C. Rationale:
Benzodiazepines like chlordiazepoxide are the standard treatment for alcohol
withdrawal. They work by central nervous system depression, preventing and treating
potentially life-threatening complications such as seizures and delirium tremens (DTs).
Option A is incorrect; medications like naltrexone or acamprosate are used for craving
reduction. Option B is incorrect; thiamine is administered to prevent Wernicke-
Korsakoff syndrome. Option D is incorrect; while clients may have co-occurring
depression, chlordiazepoxide is specifically for withdrawal symptoms.
8. The nurse is assessing a client with dementia who is experiencing "sundowning." Which
of the following behavioral manifestations is most consistent with this phenomenon? A.
Increased confusion, agitation, and restlessness in the late afternoon and evening. B.
Wandering and getting lost while trying to find their way home. C. Episodic memory loss
for recent events. D. Difficulty with complex tasks such as managing finances. Answer: A.
Rationale: Sundowning refers to a state of increased confusion, agitation, and
restlessness that typically occurs in the late afternoon and evening hours in individuals
with dementia. It is a well-documented phenomenon. Options B, C, and D describe
general symptoms of dementia but are not specifically the "sundowning" syndrome.
9. Which client statement is most consistent with a diagnosis of body dysmorphic disorder?
A. "I feel like my nose is hideous and it dominates my face. I obsess about it for hours."
B. "I hate my thighs; they are so fat that I can barely stand to look at them." C.
"Sometimes I think my skin looks pale, but other people tell me I look fine." D. "I am
constantly worried that I am going to have a serious illness like cancer." Answer: A.
Rationale: Body dysmorphic disorder involves a preoccupation with an imagined or
slight defect in physical appearance that causes significant distress and impairment.
The focus is often on the face, skin, or hair. Option A describes a preoccupation with a
specific facial feature (nose) and significant distress. Option B describes a common
concern but doesn't necessarily indicate a clinical preoccupation. Option C suggests
mild concern. Option D describes illness anxiety disorder (hypochondriasis).
10. A client on the psychiatric unit is placed in seclusion after becoming violent. What is the
nurse's priority intervention during this seclusion episode? A. Ensure the client is
, comfortable and has water. B. Frequently assess the client's physical and emotional
status. C. Document the need for seclusion and the client's behavior. D. Use the time to
encourage the client to reflect on their behavior. Answer: B. Rationale: The priority
during seclusion is the client's safety. This requires frequent, systematic assessment of
the client's physical condition, emotional state, and vital signs to identify any signs of
distress or medical emergency. Comfort and documentation are important but
secondary to safety. Encouraging reflection is not appropriate during the seclusion
episode, as the client is likely highly agitated and may not be able to process
information.
11. The therapeutic nurse-client relationship is best characterized by: A. A social friendship
based on mutual support and trust. B. A professional relationship with clear boundaries
and goals. C. An asymmetrical relationship where the nurse has all the power. D. A brief
relationship focused only on symptom reduction. Answer: B. Rationale: The therapeutic
relationship is a professional, goal-directed, and time-limited relationship with clear
boundaries, roles, and responsibilities. It is not a social friendship (Option A). While
there is an inherent power differential, the goal is to empower the client, not
dominate (Option C). It is not solely focused on symptom reduction but on overall
growth and functioning (Option D).
12. A client is prescribed fluoxetine for depression. The nurse should include which essential
teaching point regarding this medication? A. "You may notice an improvement in your
mood within the first 24-48 hours." B. "It is safe to take this medication with St. John's
Wort." C. "You should avoid foods high in tyramine while taking this medication." D. "It
may take 4 to 6 weeks to experience the full therapeutic effect." Answer: D. Rationale:
SSRIs like fluoxetine typically take 4 to 6 weeks to achieve full therapeutic effect.
Option A is incorrect; the onset of action is weeks, not days. Option B is incorrect;
combining SSRIs with St. John's Wort can increase the risk of serotonin syndrome.
Option C is a guideline for MAOIs, not SSRIs.
13. A nurse is preparing a client for electroconvulsive therapy (ECT). Which client statement
indicates a need for further teaching? A. "I will be given a muscle relaxant and general
anesthesia for the procedure." B. "I may have some memory loss for events around the
time of the treatment." C. "This treatment is a first-line therapy for most types of
depression." D. "I will be closely monitored during and after the procedure." Answer: C.
Rationale: ECT is typically used for severe, treatment-resistant depression, major
depression with psychotic features, or when there is a significant risk of suicide. It is
generally not considered a first-line therapy for most types of depression;
Exam Questions, Answers and Rationales
Instructions: This comprehensive exam covers key concepts in psychiatric-mental health
nursing. Select the best answer for each question.
1. A client diagnosed with major depressive disorder states, "I am a terrible person and
everything is my fault." Which nursing response best reflects the use of cognitive-
behavioral techniques? A. "Let's explore the evidence that supports and refutes that
belief." B. "It is important to focus on your strengths instead of your weaknesses." C.
"These feelings are a symptom of your illness and will pass." D. "Why do you think you
feel this way about yourself?" Answer: A. Rationale: Cognitive-behavioral therapy
focuses on identifying and challenging cognitive distortions. Option A directly
addresses the client's automatic negative thought by encouraging them to examine its
validity. Option B offers false reassurance. Option C minimizes the client's feelings.
Option D asks a 'why' question, which can be non-therapeutic and difficult for the
client to answer.
2. A client with schizophrenia is exhibiting akathisia. Which assessment finding supports
this conclusion? A. Involuntary muscle contractions causing twisting movements of the
face. B. A subjective feeling of inner restlessness and an inability to sit still. C. A stiff, rigid
posture with muscle rigidity and a shuffling gait. D. Fine, rapid tremors in the hands and
fingers. Answer: B. Rationale: Akathisia is a movement disorder characterized by
subjective restlessness and an inability to remain still. Option A describes tardive
dyskinesia. Option C describes parkinsonism. Option D describes a tremor, which can
be medication-induced but is not specifically akathisia.
3. A client is admitted involuntarily to the psychiatric unit. Which of the following client
rights is the most important for the nurse to protect? A. The right to refuse all
treatment. B. The right to have visitors at any time. C. The right to a humane treatment
environment. D. The right to vote in national elections. Answer: C. Rationale:
Involuntary commitment does not strip a client of all rights. While they may have
restrictions, they retain the right to a safe and humane environment, which is a
fundamental legal and ethical mandate. The right to refuse treatment is often limited
for involuntarily committed clients, especially in emergencies. Visitation is often
, restricted for safety. The right to vote is preserved but not the most immediate priority
in an inpatient setting.
4. A nurse is teaching a client about lithium therapy. Which statement indicates that the
client understands the teaching? A. "I should drink at least 2 liters of fluid a day to
prevent toxicity." B. "I can take ibuprofen for headaches if I need to." C. "I will need to
have blood drawn frequently to check my liver function." D. "A low-sodium diet is
recommended while I am on this medication." Answer: A. Rationale: Adequate
hydration is crucial for clients on lithium to maintain therapeutic levels and prevent
toxicity, as lithium is excreted by the kidneys. Option B is incorrect because NSAIDs like
ibuprofen can increase lithium levels, leading to toxicity. Option C is incorrect; lithium
requires monitoring of serum levels and kidney/thyroid function, not primarily liver
function. Option D is incorrect; a consistent sodium intake is important, not a low-
sodium diet, as sodium depletion can increase lithium levels.
5. A client with borderline personality disorder is using splitting as a defense mechanism.
The nurse observes the client idealizing one staff member and devaluing another. What
is the nurse's most appropriate initial action? A. Confront the client about this
manipulation of staff. B. Ignore the behavior as it is a common manifestation of the
disorder. C. Set a limit with the client about inappropriate comments. D. Discuss the
behavior with the treatment team to ensure consistent limit setting. Answer: D.
Rationale: Splitting is a common defense mechanism in borderline personality disorder
that can disrupt the therapeutic milieu and split the staff. The best initial action is to
communicate the observation with the treatment team to establish a consistent,
unified approach to limit-setting and avoid staff conflict. Confrontation could be
perceived as punitive. Ignoring the behavior does not address the therapeutic issue.
Setting a limit individually may be necessary but is most effective when done as part of
a team plan.
6. A client is brought to the emergency department after a sexual assault. Which nursing
action is the priority? A. Provide a compassionate, non-judgmental environment for the
client. B. Assess for signs of physical trauma and collect forensic evidence. C. Contact the
client's family to provide support. D. Encourage the client to discuss the details of the
assault. Answer: A. Rationale: The priority in the immediate aftermath of a sexual
assault is to ensure the client's safety and psychological well-being by providing a safe,
compassionate, and non-judgmental environment. While physical assessment and
forensic evidence collection are important, they are part of a later, specialized process
(SAFE exam). Contacting the family is not a priority and may violate the client's
, privacy. Encouraging a detailed discussion of the assault is not recommended
immediately as it can be re-traumatizing.
7. A client experiencing alcohol withdrawal is prescribed chlordiazepoxide. The nurse
understands that the primary purpose of this medication is to: A. Decrease the client's
craving for alcohol. B. Prevent the development of Wernicke-Korsakoff syndrome. C.
Prevent and treat withdrawal seizures and delirium tremens. D. Treat underlying
depression that may be contributing to alcohol use. Answer: C. Rationale:
Benzodiazepines like chlordiazepoxide are the standard treatment for alcohol
withdrawal. They work by central nervous system depression, preventing and treating
potentially life-threatening complications such as seizures and delirium tremens (DTs).
Option A is incorrect; medications like naltrexone or acamprosate are used for craving
reduction. Option B is incorrect; thiamine is administered to prevent Wernicke-
Korsakoff syndrome. Option D is incorrect; while clients may have co-occurring
depression, chlordiazepoxide is specifically for withdrawal symptoms.
8. The nurse is assessing a client with dementia who is experiencing "sundowning." Which
of the following behavioral manifestations is most consistent with this phenomenon? A.
Increased confusion, agitation, and restlessness in the late afternoon and evening. B.
Wandering and getting lost while trying to find their way home. C. Episodic memory loss
for recent events. D. Difficulty with complex tasks such as managing finances. Answer: A.
Rationale: Sundowning refers to a state of increased confusion, agitation, and
restlessness that typically occurs in the late afternoon and evening hours in individuals
with dementia. It is a well-documented phenomenon. Options B, C, and D describe
general symptoms of dementia but are not specifically the "sundowning" syndrome.
9. Which client statement is most consistent with a diagnosis of body dysmorphic disorder?
A. "I feel like my nose is hideous and it dominates my face. I obsess about it for hours."
B. "I hate my thighs; they are so fat that I can barely stand to look at them." C.
"Sometimes I think my skin looks pale, but other people tell me I look fine." D. "I am
constantly worried that I am going to have a serious illness like cancer." Answer: A.
Rationale: Body dysmorphic disorder involves a preoccupation with an imagined or
slight defect in physical appearance that causes significant distress and impairment.
The focus is often on the face, skin, or hair. Option A describes a preoccupation with a
specific facial feature (nose) and significant distress. Option B describes a common
concern but doesn't necessarily indicate a clinical preoccupation. Option C suggests
mild concern. Option D describes illness anxiety disorder (hypochondriasis).
10. A client on the psychiatric unit is placed in seclusion after becoming violent. What is the
nurse's priority intervention during this seclusion episode? A. Ensure the client is
, comfortable and has water. B. Frequently assess the client's physical and emotional
status. C. Document the need for seclusion and the client's behavior. D. Use the time to
encourage the client to reflect on their behavior. Answer: B. Rationale: The priority
during seclusion is the client's safety. This requires frequent, systematic assessment of
the client's physical condition, emotional state, and vital signs to identify any signs of
distress or medical emergency. Comfort and documentation are important but
secondary to safety. Encouraging reflection is not appropriate during the seclusion
episode, as the client is likely highly agitated and may not be able to process
information.
11. The therapeutic nurse-client relationship is best characterized by: A. A social friendship
based on mutual support and trust. B. A professional relationship with clear boundaries
and goals. C. An asymmetrical relationship where the nurse has all the power. D. A brief
relationship focused only on symptom reduction. Answer: B. Rationale: The therapeutic
relationship is a professional, goal-directed, and time-limited relationship with clear
boundaries, roles, and responsibilities. It is not a social friendship (Option A). While
there is an inherent power differential, the goal is to empower the client, not
dominate (Option C). It is not solely focused on symptom reduction but on overall
growth and functioning (Option D).
12. A client is prescribed fluoxetine for depression. The nurse should include which essential
teaching point regarding this medication? A. "You may notice an improvement in your
mood within the first 24-48 hours." B. "It is safe to take this medication with St. John's
Wort." C. "You should avoid foods high in tyramine while taking this medication." D. "It
may take 4 to 6 weeks to experience the full therapeutic effect." Answer: D. Rationale:
SSRIs like fluoxetine typically take 4 to 6 weeks to achieve full therapeutic effect.
Option A is incorrect; the onset of action is weeks, not days. Option B is incorrect;
combining SSRIs with St. John's Wort can increase the risk of serotonin syndrome.
Option C is a guideline for MAOIs, not SSRIs.
13. A nurse is preparing a client for electroconvulsive therapy (ECT). Which client statement
indicates a need for further teaching? A. "I will be given a muscle relaxant and general
anesthesia for the procedure." B. "I may have some memory loss for events around the
time of the treatment." C. "This treatment is a first-line therapy for most types of
depression." D. "I will be closely monitored during and after the procedure." Answer: C.
Rationale: ECT is typically used for severe, treatment-resistant depression, major
depression with psychotic features, or when there is a significant risk of suicide. It is
generally not considered a first-line therapy for most types of depression;
