NUR 175 Final Exam Actual Exam V1 | NUR 175 Mental Health
(NUR175 Final Exam) | Joyce University
1. A client is admitted to the psychiatric unit after a suicide attempt. Which of the following
nursing actions is the highest priority?
A. Encouraging the client to participate in group therapy.
B. Administering prescribed antidepressant medications.
C. Implementing one-to-one observation to ensure safety.
D. Teaching the client healthy coping mechanisms.
Answer: C
Rationale: Safety is always the primary concern in psychiatric nursing, especially following
a suicide attempt. One-to-one observation ensures the client is physically safe and prevents
further self-harm. Other interventions like therapy and education are secondary to
immediate stabilization.
2. A nurse is caring for a client who has a lithium level of 1.8 mEq/L. Which assessment
finding should the nurse prioritize?
A. Confusion, coarse hand tremors, and ataxia.
B. Increased thirst and mild nausea.
C. Weight gain of 2 pounds in one week.
D. Fine resting hand tremors.
Answer: A
Rationale: A lithium level of 1.8 mEq/L indicates moderate toxicity, as the therapeutic
range is generally 0.6 to 1.2 mEq/L. Symptoms such as confusion, coarse tremors, and lack
of coordination are serious indicators of toxicity that require immediate intervention. Fine
tremors and mild thirst are common side effects, but not signs of acute toxicity.
3. A client with schizophrenia tells the nurse, ‘The FBI is listening to my thoughts through the
television.’ How should the nurse respond?
A. I don’t believe the FBI has the technology to do that.
B. Let’s turn off the television so they can’t hear you.
C. Why do you think the FBI is interested in you?
D. It sounds like you are feeling very frightened right now.
Answer: D
,Rationale: The nurse should focus on the underlying feeling of the delusion rather than
arguing about the logic or validating the false belief. Acknowledging the client’s fear shows
empathy and helps build a therapeutic relationship. Arguing or asking ‘why’ can increase
the client’s defensiveness and paranoia.
4. A client is experiencing alcohol withdrawal and exhibits diaphoresis, tachycardia, and
tremors. Which medication is most appropriate to administer?
A. Lorazepam
B. Disulfiram
C. Methadone
D. Haloperidol
Answer: A
Rationale: Benzodiazepines like Lorazepam are the gold standard for managing acute
alcohol withdrawal symptoms. They help stabilize vital signs and prevent the progression
to seizures or delirium tremens. Disulfiram is used for maintenance of sobriety, not acute
withdrawal management.
5. A client with Borderline Personality Disorder frequently uses splitting behavior. Which
behavior by the staff is the best way to manage this?
A. Allowing the client to choose which nurse they work with.
B. Holding frequent staff meetings to ensure a consistent approach.
C. Confronting the client immediately about their manipulative behavior.
D. Assigning different nurses each shift to prevent attachment.
Answer: B
Rationale: Splitting involves categorizing people as all good or all bad, which can cause
conflict among staff members. Consistency and limit-setting are vital when working with
personality disorders to maintain the milieu. Frequent communication prevents the client
from playing one staff member against another.
6. A nurse is assessing a client for Neuroleptic Malignant Syndrome (NMS). Which symptoms
are characteristic of this condition?
A. High fever, muscle rigidity, and autonomic instability.
B. Facial grimacing and involuntary tongue movements.
C. Extreme restlessness and an inability to sit still.
D. Hypotension and bradycardia.
Answer: A
, Rationale: Neuroleptic Malignant Syndrome is a life-threatening reaction to antipsychotic
drugs characterized by ‘lead-pipe’ muscle rigidity and hyperpyrexia. It also involves
tachycardia and fluctuating blood pressure, requiring immediate medical attention.
Involuntary tongue movements are associated with tardive dyskinesia, not NMS.
7. Which therapeutic communication technique is being used when the nurse states, ‘Tell me
more about how you felt when that happened’?
A. Summarizing
B. Exploring
C. Restating
D. Offering self
Answer: B
Rationale: Exploring is a technique used to encourage the client to delve deeper into a
specific subject or feeling. This helps the nurse gather more information and allows the
client to process their experiences. It is more focused than simple broad openings but less
directive than questioning.
8. A client with Major Depressive Disorder has been taking Phenelzine (an MAOI) for one
week. The nurse should instruct the client to avoid which food?
A. Fresh apples and oranges.
B. Whole grain bread and brown rice.
C. Aged cheddar cheese and red wine.
D. Skim milk and boiled eggs.
Answer: C
Rationale: MAOIs interact with tyramine-rich foods to cause a hypertensive crisis, which
can be fatal. Aged cheeses, cured meats, and fermented beverages like red wine are high in
tyramine and must be strictly avoided. The nurse must provide a comprehensive list of safe
and unsafe foods to the client.
9. A nurse is caring for an older adult client with Delirium. Which of the following is a key
characteristic of this condition?
A. Slow, progressive decline in memory over several years.
B. Stable level of consciousness throughout the day.
C. Sudden onset with fluctuating levels of consciousness.
D. Irreversible cognitive impairment.
Answer: C
(NUR175 Final Exam) | Joyce University
1. A client is admitted to the psychiatric unit after a suicide attempt. Which of the following
nursing actions is the highest priority?
A. Encouraging the client to participate in group therapy.
B. Administering prescribed antidepressant medications.
C. Implementing one-to-one observation to ensure safety.
D. Teaching the client healthy coping mechanisms.
Answer: C
Rationale: Safety is always the primary concern in psychiatric nursing, especially following
a suicide attempt. One-to-one observation ensures the client is physically safe and prevents
further self-harm. Other interventions like therapy and education are secondary to
immediate stabilization.
2. A nurse is caring for a client who has a lithium level of 1.8 mEq/L. Which assessment
finding should the nurse prioritize?
A. Confusion, coarse hand tremors, and ataxia.
B. Increased thirst and mild nausea.
C. Weight gain of 2 pounds in one week.
D. Fine resting hand tremors.
Answer: A
Rationale: A lithium level of 1.8 mEq/L indicates moderate toxicity, as the therapeutic
range is generally 0.6 to 1.2 mEq/L. Symptoms such as confusion, coarse tremors, and lack
of coordination are serious indicators of toxicity that require immediate intervention. Fine
tremors and mild thirst are common side effects, but not signs of acute toxicity.
3. A client with schizophrenia tells the nurse, ‘The FBI is listening to my thoughts through the
television.’ How should the nurse respond?
A. I don’t believe the FBI has the technology to do that.
B. Let’s turn off the television so they can’t hear you.
C. Why do you think the FBI is interested in you?
D. It sounds like you are feeling very frightened right now.
Answer: D
,Rationale: The nurse should focus on the underlying feeling of the delusion rather than
arguing about the logic or validating the false belief. Acknowledging the client’s fear shows
empathy and helps build a therapeutic relationship. Arguing or asking ‘why’ can increase
the client’s defensiveness and paranoia.
4. A client is experiencing alcohol withdrawal and exhibits diaphoresis, tachycardia, and
tremors. Which medication is most appropriate to administer?
A. Lorazepam
B. Disulfiram
C. Methadone
D. Haloperidol
Answer: A
Rationale: Benzodiazepines like Lorazepam are the gold standard for managing acute
alcohol withdrawal symptoms. They help stabilize vital signs and prevent the progression
to seizures or delirium tremens. Disulfiram is used for maintenance of sobriety, not acute
withdrawal management.
5. A client with Borderline Personality Disorder frequently uses splitting behavior. Which
behavior by the staff is the best way to manage this?
A. Allowing the client to choose which nurse they work with.
B. Holding frequent staff meetings to ensure a consistent approach.
C. Confronting the client immediately about their manipulative behavior.
D. Assigning different nurses each shift to prevent attachment.
Answer: B
Rationale: Splitting involves categorizing people as all good or all bad, which can cause
conflict among staff members. Consistency and limit-setting are vital when working with
personality disorders to maintain the milieu. Frequent communication prevents the client
from playing one staff member against another.
6. A nurse is assessing a client for Neuroleptic Malignant Syndrome (NMS). Which symptoms
are characteristic of this condition?
A. High fever, muscle rigidity, and autonomic instability.
B. Facial grimacing and involuntary tongue movements.
C. Extreme restlessness and an inability to sit still.
D. Hypotension and bradycardia.
Answer: A
, Rationale: Neuroleptic Malignant Syndrome is a life-threatening reaction to antipsychotic
drugs characterized by ‘lead-pipe’ muscle rigidity and hyperpyrexia. It also involves
tachycardia and fluctuating blood pressure, requiring immediate medical attention.
Involuntary tongue movements are associated with tardive dyskinesia, not NMS.
7. Which therapeutic communication technique is being used when the nurse states, ‘Tell me
more about how you felt when that happened’?
A. Summarizing
B. Exploring
C. Restating
D. Offering self
Answer: B
Rationale: Exploring is a technique used to encourage the client to delve deeper into a
specific subject or feeling. This helps the nurse gather more information and allows the
client to process their experiences. It is more focused than simple broad openings but less
directive than questioning.
8. A client with Major Depressive Disorder has been taking Phenelzine (an MAOI) for one
week. The nurse should instruct the client to avoid which food?
A. Fresh apples and oranges.
B. Whole grain bread and brown rice.
C. Aged cheddar cheese and red wine.
D. Skim milk and boiled eggs.
Answer: C
Rationale: MAOIs interact with tyramine-rich foods to cause a hypertensive crisis, which
can be fatal. Aged cheeses, cured meats, and fermented beverages like red wine are high in
tyramine and must be strictly avoided. The nurse must provide a comprehensive list of safe
and unsafe foods to the client.
9. A nurse is caring for an older adult client with Delirium. Which of the following is a key
characteristic of this condition?
A. Slow, progressive decline in memory over several years.
B. Stable level of consciousness throughout the day.
C. Sudden onset with fluctuating levels of consciousness.
D. Irreversible cognitive impairment.
Answer: C
