NUR 175 Exam 2 Actual Exam V2 | NUR 175 Mental Health (NUR175
Exam 2) | Joyce University
1. A nurse is caring for a client experiencing a panic attack. Which of the following is the
priority nursing intervention?
A. Instruct the client to practice deep breathing techniques.
B. Stay with the client and remain calm.
C. Ask the client to describe what triggered the attack.
D. Administer a PRN dose of a selective serotonin reuptake inhibitor (SSRI).
Answer: B
Rationale: During a panic attack, the client’s safety and sense of security are the highest
priority. Staying with the client provides a calming presence and ensures they are not alone
during a frightening physical experience. Other interventions, like teaching or exploration,
are ineffective until the level of anxiety decreases.
2. A client is diagnosed with Generalized Anxiety Disorder (GAD). Which symptom is most
characteristic of this condition?
A. Persistent, excessive worry about various life circumstances for at least 6 months.
B. Flashbacks related to a specific traumatic event.
C. Sudden episodes of intense fear accompanied by physical symptoms like palpitations.
D. Ritualistic behaviors performed to reduce anxiety levels.
Answer: A
Rationale: Generalized Anxiety Disorder is characterized by chronic, unrealistic, and
excessive anxiety and worry. The symptoms must have occurred more days than not for at
least 6 months and involve multiple events or activities. This distinguishes GAD from panic
disorder or specific phobias which have different clinical presentations.
3. A nurse is teaching a client about the dietary restrictions associated with Monoamine
Oxidase Inhibitors (MAOIs). Which food choice indicates a need for further teaching?
A. Grilled chicken breast
B. Aged cheddar cheese
C. Fresh steamed broccoli
D. Sliced apples
Answer: B
,Rationale: Aged cheddar cheese is high in tyramine, which must be avoided when taking
MAOIs. Consuming tyramine-rich foods while on MAOIs can lead to a hypertensive crisis, a
potentially fatal medical emergency. The nurse must ensure the client understands to avoid
aged, cured, or fermented foods to maintain safety.
4. A client with Major Depressive Disorder (MDD) is started on Fluoxetine. The nurse should
instruct the client to monitor for which early side effect?
A. Urinary retention
B. Nausea and agitation
C. Severe muscle rigidity
D. Hypertensive crisis
Answer: B
Rationale: Fluoxetine is an SSRI, and common early side effects include nausea, agitation,
and insomnia. These symptoms often subside after a few weeks of treatment as the body
adjusts to the medication. It is important to educate the client about these possibilities to
encourage adherence to the treatment plan.
5. Which assessment finding is the most critical to report for a client diagnosed with Bipolar I
Disorder currently in a manic episode?
A. The client is wearing brightly colored, mismatched clothing.
B. The client has not slept for 48 hours.
C. The client is speaking very rapidly and jumping from topic to topic.
D. The client reports a decreased appetite.
Answer: B
Rationale: Prolonged lack of sleep in a manic client is a priority because it can lead to
physical exhaustion and even death from cardiac collapse. While rapid speech and
mismatched clothes are typical signs of mania, they are not immediately life-threatening.
The nurse must prioritize physiological stability and safety in this acute phase.
6. A nurse is performing a suicide risk assessment. Which client statement represents the
highest level of lethality?
A. I wish I could just go to sleep and never wake up.
B. I have a loaded gun at home and I plan to use it tonight.
C. Sometimes I think everyone would be better off without me.
D. I’ve been feeling really down lately and don’t see a way out.
Answer: B
, Rationale: This statement shows a specific plan, a highly lethal method, and immediate
intent. In suicide assessment, the more specific and lethal the plan, the higher the risk for
completed suicide. The nurse must take immediate action to ensure the client’s safety,
typically involving constant observation.
7. A client is diagnosed with Obsessive-Compulsive Disorder (OCD) and spends hours washing
their hands. What is the primary purpose of this ritualistic behavior?
A. To get attention from the staff.
B. To increase self-esteem.
C. To reduce anxiety levels.
D. To control the behavior of others.
Answer: C
Rationale: Compulsions in OCD are repetitive behaviors that the individual feels driven to
perform in response to an obsession or according to rules that must be applied rigidly. The
primary goal of these behaviors is to prevent or reduce anxiety or distress. Although the
relief is only temporary, the client feels compelled to repeat the act to manage their
internal tension.
8. A client is prescribed Lithium Carbonate for Bipolar Disorder. The nurse knows that which
of the following serum levels is within the therapeutic range for acute mania?
A. 1.0 - 1.5 mEq/L
B. 0.2 - 0.5 mEq/L
C. 2.0 - 2.5 mEq/L
D. 3.0 - 3.5 mEq/L
Answer: A
Rationale: For acute mania, the therapeutic lithium level is typically between 1.0 and 1.5
mEq/L. Levels above 1.5 mEq/L can indicate toxicity, which requires immediate
intervention. Regular blood monitoring is essential for clients on lithium due to its narrow
therapeutic index.
9. A client with PTSD reports experiencing ‘flashbacks.’ The nurse understands that a
flashback is an example of which type of symptom?
A. Avoidance symptom
B. Hyperarousal symptom
C. Intrusive symptom
D. Negative alteration in mood
Exam 2) | Joyce University
1. A nurse is caring for a client experiencing a panic attack. Which of the following is the
priority nursing intervention?
A. Instruct the client to practice deep breathing techniques.
B. Stay with the client and remain calm.
C. Ask the client to describe what triggered the attack.
D. Administer a PRN dose of a selective serotonin reuptake inhibitor (SSRI).
Answer: B
Rationale: During a panic attack, the client’s safety and sense of security are the highest
priority. Staying with the client provides a calming presence and ensures they are not alone
during a frightening physical experience. Other interventions, like teaching or exploration,
are ineffective until the level of anxiety decreases.
2. A client is diagnosed with Generalized Anxiety Disorder (GAD). Which symptom is most
characteristic of this condition?
A. Persistent, excessive worry about various life circumstances for at least 6 months.
B. Flashbacks related to a specific traumatic event.
C. Sudden episodes of intense fear accompanied by physical symptoms like palpitations.
D. Ritualistic behaviors performed to reduce anxiety levels.
Answer: A
Rationale: Generalized Anxiety Disorder is characterized by chronic, unrealistic, and
excessive anxiety and worry. The symptoms must have occurred more days than not for at
least 6 months and involve multiple events or activities. This distinguishes GAD from panic
disorder or specific phobias which have different clinical presentations.
3. A nurse is teaching a client about the dietary restrictions associated with Monoamine
Oxidase Inhibitors (MAOIs). Which food choice indicates a need for further teaching?
A. Grilled chicken breast
B. Aged cheddar cheese
C. Fresh steamed broccoli
D. Sliced apples
Answer: B
,Rationale: Aged cheddar cheese is high in tyramine, which must be avoided when taking
MAOIs. Consuming tyramine-rich foods while on MAOIs can lead to a hypertensive crisis, a
potentially fatal medical emergency. The nurse must ensure the client understands to avoid
aged, cured, or fermented foods to maintain safety.
4. A client with Major Depressive Disorder (MDD) is started on Fluoxetine. The nurse should
instruct the client to monitor for which early side effect?
A. Urinary retention
B. Nausea and agitation
C. Severe muscle rigidity
D. Hypertensive crisis
Answer: B
Rationale: Fluoxetine is an SSRI, and common early side effects include nausea, agitation,
and insomnia. These symptoms often subside after a few weeks of treatment as the body
adjusts to the medication. It is important to educate the client about these possibilities to
encourage adherence to the treatment plan.
5. Which assessment finding is the most critical to report for a client diagnosed with Bipolar I
Disorder currently in a manic episode?
A. The client is wearing brightly colored, mismatched clothing.
B. The client has not slept for 48 hours.
C. The client is speaking very rapidly and jumping from topic to topic.
D. The client reports a decreased appetite.
Answer: B
Rationale: Prolonged lack of sleep in a manic client is a priority because it can lead to
physical exhaustion and even death from cardiac collapse. While rapid speech and
mismatched clothes are typical signs of mania, they are not immediately life-threatening.
The nurse must prioritize physiological stability and safety in this acute phase.
6. A nurse is performing a suicide risk assessment. Which client statement represents the
highest level of lethality?
A. I wish I could just go to sleep and never wake up.
B. I have a loaded gun at home and I plan to use it tonight.
C. Sometimes I think everyone would be better off without me.
D. I’ve been feeling really down lately and don’t see a way out.
Answer: B
, Rationale: This statement shows a specific plan, a highly lethal method, and immediate
intent. In suicide assessment, the more specific and lethal the plan, the higher the risk for
completed suicide. The nurse must take immediate action to ensure the client’s safety,
typically involving constant observation.
7. A client is diagnosed with Obsessive-Compulsive Disorder (OCD) and spends hours washing
their hands. What is the primary purpose of this ritualistic behavior?
A. To get attention from the staff.
B. To increase self-esteem.
C. To reduce anxiety levels.
D. To control the behavior of others.
Answer: C
Rationale: Compulsions in OCD are repetitive behaviors that the individual feels driven to
perform in response to an obsession or according to rules that must be applied rigidly. The
primary goal of these behaviors is to prevent or reduce anxiety or distress. Although the
relief is only temporary, the client feels compelled to repeat the act to manage their
internal tension.
8. A client is prescribed Lithium Carbonate for Bipolar Disorder. The nurse knows that which
of the following serum levels is within the therapeutic range for acute mania?
A. 1.0 - 1.5 mEq/L
B. 0.2 - 0.5 mEq/L
C. 2.0 - 2.5 mEq/L
D. 3.0 - 3.5 mEq/L
Answer: A
Rationale: For acute mania, the therapeutic lithium level is typically between 1.0 and 1.5
mEq/L. Levels above 1.5 mEq/L can indicate toxicity, which requires immediate
intervention. Regular blood monitoring is essential for clients on lithium due to its narrow
therapeutic index.
9. A client with PTSD reports experiencing ‘flashbacks.’ The nurse understands that a
flashback is an example of which type of symptom?
A. Avoidance symptom
B. Hyperarousal symptom
C. Intrusive symptom
D. Negative alteration in mood
