NUR 175 Final Exam Actual Exam V2 | NUR 175 Mental Health
(NUR175 Final Exam) | Joyce University
1. A nurse is caring for a client with schizophrenia who is experiencing auditory
hallucinations. What is the most appropriate initial nursing intervention?
A. Leave the client alone in a quiet room to decrease stimulation.
B. Tell the client that there are no voices and it is just their imagination.
C. Ask the client, ‘What are the voices telling you to do?’
D. Turn up the volume on the television to drown out the voices.
Answer: C
Rationale: Safety is the priority when a client is experiencing command hallucinations. The
nurse must determine if the voices are instructing the client to harm themselves or others.
Validating the client’s experience while clarifying the content of the hallucination helps in
risk assessment and planning care.
2. A client has been prescribed Lithium Carbonate for Bipolar I Disorder. Which of the
following findings should the nurse report to the provider immediately?
A. Fine hand tremors and mild thirst.
B. Sexual dysfunction and metallic taste.
C. Polyuria and weight gain of 2 lbs.
D. Diarrhea, vomiting, and blurred vision.
Answer: D
Rationale: Diarrhea, vomiting, and blurred vision are early signs of lithium toxicity, which
can be life-threatening. Fine tremors and mild thirst are common side effects that often
resolve with time. The nurse must monitor serum lithium levels closely, as the therapeutic
range is narrow, typically between 0.6 and 1.2 mEq/L.
3. A client is admitted to the psychiatric unit with a diagnosis of Major Depressive Disorder.
Which nursing action is most effective for a client who is severely withdrawn?
A. Encourage the client to join a large group therapy session immediately.
B. Ask the client open-ended questions about their childhood.
C. Sit in silence with the client for short periods of time.
D. Give the client a list of unit rules and expectations.
Answer: C
,Rationale: Sitting in silence conveys acceptance and builds trust with a severely
withdrawn client without placing demands on them. This therapeutic use of self shows the
client that the nurse is available and cares about their presence. As the client begins to feel
safer, they may gradually start to communicate verbally.
4. Which legal principle is being applied when a nurse reports a client’s threat to harm a
specific individual to the treatment team and the authorities?
A. Duty to Warn
B. Beneficence
C. Autonomy
D. Fidelity
Answer: A
Rationale: The Duty to Warn, established by the Tarasoff v. Regents of the University of
California case, requires mental health professionals to protect third parties from a client’s
threats of violence. This duty overrides the client’s right to confidentiality when a specific
threat is made against an identifiable person. Failure to report such threats can lead to legal
liability for the healthcare provider.
5. A nurse is teaching a client about a new prescription for Phenelzine (Nardil). Which food
choice by the client indicates a need for further teaching?
A. Fresh grilled chicken and broccoli.
B. Aged cheddar cheese and pepperoni pizza.
C. Scrambled eggs and whole wheat toast.
D. Apple slices and peanut butter.
Answer: B
Rationale: Phenelzine is an MAOI (Monoamine Oxidase Inhibitor) and requires a low-
tyramine diet to prevent a hypertensive crisis. Aged cheeses, cured meats like pepperoni,
and fermented products are high in tyramine and must be avoided. The nurse must educate
the client on the signs of a hypertensive crisis, such as a severe headache and stiff neck.
6. A client is experiencing a manic episode and is pacing the hallway, interrupting others, and
not eating. Which intervention should the nurse prioritize?
A. Set strict limits on the client’s behavior and isolate them.
B. Ask the client to sit down and explain their feelings.
C. Invite the client to a competitive game of basketball.
D. Provide high-protein, high-calorie finger foods.
, Answer: D
Rationale: A client in a manic state has high energy and low focus, making it difficult for
them to sit down for regular meals. Finger foods allow the client to eat while moving,
ensuring they receive necessary nutrition and hydration. Safety and physiological stability
are the primary nursing concerns during acute mania.
7. During an intake assessment, a client reports feeling ‘jittery’ and ‘having a racing heart’
after starting Haloperidol. The nurse notes the client’s neck is twisted to one side. What is the
nurse’s priority action?
A. Apply a warm compress to the client’s neck muscles.
B. Reassure the client that these are normal side effects.
C. Administer the PRN dose of Benztropine (Cogentin).
D. Request an immediate EKG to check for arrhythmias.
Answer: C
Rationale: The client is experiencing an acute dystonic reaction, which is an
extrapyramidal side effect (EPS) of typical antipsychotics like Haloperidol. Benztropine is
an anticholinergic medication used to treat and reverse EPS symptoms quickly. If left
untreated, severe dystonia can progress to laryngospasm and respiratory distress.
8. A nurse is assessing a client for potential suicide risk. Which statement by the client
represents the highest level of lethality?
A. ‘I’ve been feeling really down lately and don’t know if things will get better.’
B. ‘Sometimes I wish I could just go to sleep and never wake up.’
C. ‘I’ve started giving away some of my favorite books to my friends.’
D. ‘I have a loaded gun in my garage and I plan to use it tonight.’
Answer: D
Rationale: This statement indicates a specific plan, a highly lethal method (firearm), and
immediate intent (tonight). When assessing suicide risk, the nurse must look for the plan,
the means, and the timeframe. The more specific and lethal the plan, the higher the
immediate risk to the client’s safety.
9. A client with Borderline Personality Disorder is praising one nurse while telling another
nurse that they are ‘incompetent and mean.’ This behavior is known as:
A. Regression
B. Projection
C. Splitting
(NUR175 Final Exam) | Joyce University
1. A nurse is caring for a client with schizophrenia who is experiencing auditory
hallucinations. What is the most appropriate initial nursing intervention?
A. Leave the client alone in a quiet room to decrease stimulation.
B. Tell the client that there are no voices and it is just their imagination.
C. Ask the client, ‘What are the voices telling you to do?’
D. Turn up the volume on the television to drown out the voices.
Answer: C
Rationale: Safety is the priority when a client is experiencing command hallucinations. The
nurse must determine if the voices are instructing the client to harm themselves or others.
Validating the client’s experience while clarifying the content of the hallucination helps in
risk assessment and planning care.
2. A client has been prescribed Lithium Carbonate for Bipolar I Disorder. Which of the
following findings should the nurse report to the provider immediately?
A. Fine hand tremors and mild thirst.
B. Sexual dysfunction and metallic taste.
C. Polyuria and weight gain of 2 lbs.
D. Diarrhea, vomiting, and blurred vision.
Answer: D
Rationale: Diarrhea, vomiting, and blurred vision are early signs of lithium toxicity, which
can be life-threatening. Fine tremors and mild thirst are common side effects that often
resolve with time. The nurse must monitor serum lithium levels closely, as the therapeutic
range is narrow, typically between 0.6 and 1.2 mEq/L.
3. A client is admitted to the psychiatric unit with a diagnosis of Major Depressive Disorder.
Which nursing action is most effective for a client who is severely withdrawn?
A. Encourage the client to join a large group therapy session immediately.
B. Ask the client open-ended questions about their childhood.
C. Sit in silence with the client for short periods of time.
D. Give the client a list of unit rules and expectations.
Answer: C
,Rationale: Sitting in silence conveys acceptance and builds trust with a severely
withdrawn client without placing demands on them. This therapeutic use of self shows the
client that the nurse is available and cares about their presence. As the client begins to feel
safer, they may gradually start to communicate verbally.
4. Which legal principle is being applied when a nurse reports a client’s threat to harm a
specific individual to the treatment team and the authorities?
A. Duty to Warn
B. Beneficence
C. Autonomy
D. Fidelity
Answer: A
Rationale: The Duty to Warn, established by the Tarasoff v. Regents of the University of
California case, requires mental health professionals to protect third parties from a client’s
threats of violence. This duty overrides the client’s right to confidentiality when a specific
threat is made against an identifiable person. Failure to report such threats can lead to legal
liability for the healthcare provider.
5. A nurse is teaching a client about a new prescription for Phenelzine (Nardil). Which food
choice by the client indicates a need for further teaching?
A. Fresh grilled chicken and broccoli.
B. Aged cheddar cheese and pepperoni pizza.
C. Scrambled eggs and whole wheat toast.
D. Apple slices and peanut butter.
Answer: B
Rationale: Phenelzine is an MAOI (Monoamine Oxidase Inhibitor) and requires a low-
tyramine diet to prevent a hypertensive crisis. Aged cheeses, cured meats like pepperoni,
and fermented products are high in tyramine and must be avoided. The nurse must educate
the client on the signs of a hypertensive crisis, such as a severe headache and stiff neck.
6. A client is experiencing a manic episode and is pacing the hallway, interrupting others, and
not eating. Which intervention should the nurse prioritize?
A. Set strict limits on the client’s behavior and isolate them.
B. Ask the client to sit down and explain their feelings.
C. Invite the client to a competitive game of basketball.
D. Provide high-protein, high-calorie finger foods.
, Answer: D
Rationale: A client in a manic state has high energy and low focus, making it difficult for
them to sit down for regular meals. Finger foods allow the client to eat while moving,
ensuring they receive necessary nutrition and hydration. Safety and physiological stability
are the primary nursing concerns during acute mania.
7. During an intake assessment, a client reports feeling ‘jittery’ and ‘having a racing heart’
after starting Haloperidol. The nurse notes the client’s neck is twisted to one side. What is the
nurse’s priority action?
A. Apply a warm compress to the client’s neck muscles.
B. Reassure the client that these are normal side effects.
C. Administer the PRN dose of Benztropine (Cogentin).
D. Request an immediate EKG to check for arrhythmias.
Answer: C
Rationale: The client is experiencing an acute dystonic reaction, which is an
extrapyramidal side effect (EPS) of typical antipsychotics like Haloperidol. Benztropine is
an anticholinergic medication used to treat and reverse EPS symptoms quickly. If left
untreated, severe dystonia can progress to laryngospasm and respiratory distress.
8. A nurse is assessing a client for potential suicide risk. Which statement by the client
represents the highest level of lethality?
A. ‘I’ve been feeling really down lately and don’t know if things will get better.’
B. ‘Sometimes I wish I could just go to sleep and never wake up.’
C. ‘I’ve started giving away some of my favorite books to my friends.’
D. ‘I have a loaded gun in my garage and I plan to use it tonight.’
Answer: D
Rationale: This statement indicates a specific plan, a highly lethal method (firearm), and
immediate intent (tonight). When assessing suicide risk, the nurse must look for the plan,
the means, and the timeframe. The more specific and lethal the plan, the higher the
immediate risk to the client’s safety.
9. A client with Borderline Personality Disorder is praising one nurse while telling another
nurse that they are ‘incompetent and mean.’ This behavior is known as:
A. Regression
B. Projection
C. Splitting
