NSG 205 — Mental Health Nursing exam
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1. A nurse is assessing a client who has depression. Which finding
requires the nurse's immediate attention?
A. Loss of appetite
B. Difficulty sleeping
C. Feelings of worthlessness
D. A specific plan to commit suicide
Rationale: A specific suicide plan indicates an immediate risk of self-
harm and requires prompt safety interventions. Although appetite
changes, insomnia, and feelings of worthlessness are common
depressive symptoms, a formulated suicide plan represents a potentially
imminent danger.
, 2. Which nursing response is most therapeutic when a client says, “I
feel like nobody cares about me”?
A. “You should try to think more positively.”
B. “Everyone feels that way sometimes.”
C. “It sounds like you are feeling very alone right now.”
D. “Your family probably cares more than you realize.”
Rationale: Restating the client's feelings demonstrates empathy and
encourages further communication. The response avoids minimizing the
client's concerns or offering premature advice.
3. A client with schizophrenia reports hearing voices that tell the
client to hurt another person. What should the nurse do first?
A. Tell the client that the voices are not real.
B. Encourage the client to ignore the voices.
C. Assess the content of the hallucinations and determine whether the
client intends to act on them.
D. Place the client in a quiet room and leave the client alone.
Rationale: Command hallucinations involving harm require immediate
assessment of the client's intent, plan, and ability to act. Safety of the
client and others is the priority.
4. Which statement best describes a hallucination?
,A. A false belief that is firmly held
B. An exaggerated interpretation of reality
C. A sensory perception that occurs without an external stimulus
D. A misinterpretation of an actual external stimulus
Rationale: A hallucination is a perception experienced through one or
more senses in the absence of an external stimulus. A delusion is a fixed
false belief, while an illusion is a misinterpretation of an actual stimulus.
5. A client experiencing acute mania is extremely active and has not
slept for two days. Which nursing intervention is most
appropriate?
A. Encourage participation in group activities.
B. Provide lengthy explanations about treatment.
C. Provide a calm, low-stimulation environment and set clear limits.
D. Encourage the client to make important financial decisions.
Rationale: Clients experiencing mania benefit from reduced
environmental stimulation, consistent limits, and structured care.
Excessive stimulation can worsen agitation and impulsivity.
6. Which behavior is characteristic of mania?
A. Social withdrawal
B. Psychomotor retardation
, C. Decreased need for sleep with increased energy
D. Persistent sadness with loss of interest
Rationale: Mania commonly involves elevated or irritable mood,
increased energy, decreased need for sleep, rapid speech, distractibility,
and increased goal-directed activity.
7. A client taking lithium reports severe diarrhea, vomiting, coarse
hand tremors, and confusion. What should the nurse suspect?
A. Therapeutic lithium effects
B. Mild dehydration
C. Lithium toxicity
D. Serotonin deficiency
Rationale: Severe gastrointestinal symptoms, coarse tremors, confusion,
and neurological changes can indicate lithium toxicity. The medication
should be withheld and the healthcare provider notified promptly
according to the clinical situation.
8. Which laboratory value is particularly important for a client
receiving lithium therapy?
A. Hemoglobin
B. Platelet count
Questions and Correct Answers (Verified
Answers) Plus Rationale 2027 Q&A| Instant
Download Pdf
1. A nurse is assessing a client who has depression. Which finding
requires the nurse's immediate attention?
A. Loss of appetite
B. Difficulty sleeping
C. Feelings of worthlessness
D. A specific plan to commit suicide
Rationale: A specific suicide plan indicates an immediate risk of self-
harm and requires prompt safety interventions. Although appetite
changes, insomnia, and feelings of worthlessness are common
depressive symptoms, a formulated suicide plan represents a potentially
imminent danger.
, 2. Which nursing response is most therapeutic when a client says, “I
feel like nobody cares about me”?
A. “You should try to think more positively.”
B. “Everyone feels that way sometimes.”
C. “It sounds like you are feeling very alone right now.”
D. “Your family probably cares more than you realize.”
Rationale: Restating the client's feelings demonstrates empathy and
encourages further communication. The response avoids minimizing the
client's concerns or offering premature advice.
3. A client with schizophrenia reports hearing voices that tell the
client to hurt another person. What should the nurse do first?
A. Tell the client that the voices are not real.
B. Encourage the client to ignore the voices.
C. Assess the content of the hallucinations and determine whether the
client intends to act on them.
D. Place the client in a quiet room and leave the client alone.
Rationale: Command hallucinations involving harm require immediate
assessment of the client's intent, plan, and ability to act. Safety of the
client and others is the priority.
4. Which statement best describes a hallucination?
,A. A false belief that is firmly held
B. An exaggerated interpretation of reality
C. A sensory perception that occurs without an external stimulus
D. A misinterpretation of an actual external stimulus
Rationale: A hallucination is a perception experienced through one or
more senses in the absence of an external stimulus. A delusion is a fixed
false belief, while an illusion is a misinterpretation of an actual stimulus.
5. A client experiencing acute mania is extremely active and has not
slept for two days. Which nursing intervention is most
appropriate?
A. Encourage participation in group activities.
B. Provide lengthy explanations about treatment.
C. Provide a calm, low-stimulation environment and set clear limits.
D. Encourage the client to make important financial decisions.
Rationale: Clients experiencing mania benefit from reduced
environmental stimulation, consistent limits, and structured care.
Excessive stimulation can worsen agitation and impulsivity.
6. Which behavior is characteristic of mania?
A. Social withdrawal
B. Psychomotor retardation
, C. Decreased need for sleep with increased energy
D. Persistent sadness with loss of interest
Rationale: Mania commonly involves elevated or irritable mood,
increased energy, decreased need for sleep, rapid speech, distractibility,
and increased goal-directed activity.
7. A client taking lithium reports severe diarrhea, vomiting, coarse
hand tremors, and confusion. What should the nurse suspect?
A. Therapeutic lithium effects
B. Mild dehydration
C. Lithium toxicity
D. Serotonin deficiency
Rationale: Severe gastrointestinal symptoms, coarse tremors, confusion,
and neurological changes can indicate lithium toxicity. The medication
should be withheld and the healthcare provider notified promptly
according to the clinical situation.
8. Which laboratory value is particularly important for a client
receiving lithium therapy?
A. Hemoglobin
B. Platelet count
