NUR 175 Exam 4 Actual Exam V3 | NUR 175 Mental Health (NUR175
Exam 4) | Joyce University
1. A nurse is caring for a client with schizophrenia who reports hearing voices telling them to
‘hurt the doctor.’ Which action is the nurse’s priority?
A. Ask the client to describe what the voices look like.
B. Initiate one-to-one observation for the client’s safety.
C. Ask the client to stay in their room to reduce stimulation.
D. Administer an as-needed (PRN) dose of an antipsychotic.
Answer: B
Rationale: The nurse’s priority is the safety of the client and others when command
hallucinations are present. One-to-one observation ensures that the client is supervised at
all times to prevent acting on the harmful command. This intervention takes precedence
over medication or environmental changes in the immediate crisis phase.
2. A client is admitted to the psychiatric unit with a lithium level of 1.8 mEq/L. Which clinical
finding should the nurse expect to observe?
A. Increased appetite and weight gain.
B. Blurred vision and severe gastrointestinal distress.
C. Fine hand tremors and mild thirst.
D. Hyperactivity and flight of ideas.
Answer: B
Rationale: A lithium level of 1.8 mEq/L indicates moderate toxicity, which typically
presents with symptoms like blurred vision, ataxia, and severe diarrhea or vomiting. The
therapeutic range for lithium is 0.6 to 1.2 mEq/L, and levels above 1.5 are considered toxic.
The nurse must recognize these signs immediately and hold the next dose while notifying
the provider.
3. A nurse is teaching a client who has a new prescription for phenelzine. Which food should
the nurse instruct the client to avoid?
A. Whole grain bread.
B. Fresh green beans.
C. Grilled chicken breast.
D. Aged cheddar cheese.
,Answer: D
Rationale: Phenelzine is a Monoamine Oxidase Inhibitor (MAOI) that requires a tyramine-
restricted diet to prevent hypertensive crisis. Aged cheeses, cured meats, and fermented
products are high in tyramine and must be strictly avoided. The nurse must ensure the
client understands that consuming these foods could lead to life-threatening elevations in
blood pressure.
4. Which intervention is most appropriate for a client experiencing a panic-level attack of
anxiety?
A. Teach the client deep breathing techniques.
B. Stay with the client and use short, simple sentences.
C. Encourage the client to discuss the cause of the panic.
D. Place the client in a room with several other peers for support.
Answer: B
Rationale: During a panic attack, the client’s ability to process information is severely
limited, so the nurse should remain present to provide a sense of security. Using short,
simple sentences helps the client understand instructions when their cognitive function is
impaired. High-stimulation environments or complex teaching should be avoided until the
panic subsides.
5. A nurse is assessing a client for Neuroleptic Malignant Syndrome (NMS). Which finding is a
hallmark symptom of this condition?
A. Hypotension and bradycardia.
B. Muscle rigidity and high fever.
C. Increased salivation and diarrhea.
D. Respiratory depression and pinpoint pupils.
Answer: B
Rationale: Neuroleptic Malignant Syndrome (NMS) is a life-threatening reaction to
antipsychotic medications characterized by lead-pipe muscle rigidity and hyperpyrexia. It
is considered a medical emergency that requires immediate discontinuation of the
medication and supportive care. Nurses must monitor for these signs, especially in clients
starting new high-potency antipsychotics.
6. A client with Borderline Personality Disorder is praise-filled toward one nurse while being
hostile to another. What is this behavior called?
A. Projection.
B. Sublimation.
, C. Rationalization.
D. Splitting.
Answer: D
Rationale: Splitting is a common defense mechanism in Borderline Personality Disorder
where individuals view others as all good or all bad. This behavior often creates conflict
among the healthcare team, necessitating a unified approach to care. Nurses must maintain
consistent boundaries and communicate effectively to prevent the client from manipulating
the staff.
7. A client is scheduled for Electroconvulsive Therapy (ECT). Which medication should the
nurse expect to be held prior to the procedure?
A. Acetaminophen.
B. Phenytoin.
C. Multivitamin.
D. Diphenhydramine.
Answer: B
Rationale: Phenytoin is an anticonvulsant that can raise the seizure threshold, potentially
making the ECT treatment ineffective since ECT relies on inducing a controlled seizure. The
nurse must coordinate with the physician to hold medications that interfere with seizure
activity before the procedure. Ensuring the client’s safety and the treatment’s efficacy is the
primary goal during pre-ECT care.
8. A nurse is caring for a client with anorexia nervosa. Which finding should be the nurse’s
priority for reporting to the provider?
A. Potassium level of 2.8 mEq/L.
B. Lanugo on the back and arms.
C. Body mass index (BMI) of 17.
D. Refusal to participate in group therapy.
Answer: A
Rationale: A potassium level of 2.8 mEq/L is critically low and poses a significant risk for
cardiac arrhythmias or arrest. While a low BMI and lanugo are expected findings in
anorexia, physiological stability takes priority in clinical assessment. Electrolyte
imbalances must be corrected immediately to ensure the client’s survival.
9. What is the primary purpose of a ‘therapeutic milieu’ in a mental health setting?
A. To provide a structured and safe environment for behavioral change.
Exam 4) | Joyce University
1. A nurse is caring for a client with schizophrenia who reports hearing voices telling them to
‘hurt the doctor.’ Which action is the nurse’s priority?
A. Ask the client to describe what the voices look like.
B. Initiate one-to-one observation for the client’s safety.
C. Ask the client to stay in their room to reduce stimulation.
D. Administer an as-needed (PRN) dose of an antipsychotic.
Answer: B
Rationale: The nurse’s priority is the safety of the client and others when command
hallucinations are present. One-to-one observation ensures that the client is supervised at
all times to prevent acting on the harmful command. This intervention takes precedence
over medication or environmental changes in the immediate crisis phase.
2. A client is admitted to the psychiatric unit with a lithium level of 1.8 mEq/L. Which clinical
finding should the nurse expect to observe?
A. Increased appetite and weight gain.
B. Blurred vision and severe gastrointestinal distress.
C. Fine hand tremors and mild thirst.
D. Hyperactivity and flight of ideas.
Answer: B
Rationale: A lithium level of 1.8 mEq/L indicates moderate toxicity, which typically
presents with symptoms like blurred vision, ataxia, and severe diarrhea or vomiting. The
therapeutic range for lithium is 0.6 to 1.2 mEq/L, and levels above 1.5 are considered toxic.
The nurse must recognize these signs immediately and hold the next dose while notifying
the provider.
3. A nurse is teaching a client who has a new prescription for phenelzine. Which food should
the nurse instruct the client to avoid?
A. Whole grain bread.
B. Fresh green beans.
C. Grilled chicken breast.
D. Aged cheddar cheese.
,Answer: D
Rationale: Phenelzine is a Monoamine Oxidase Inhibitor (MAOI) that requires a tyramine-
restricted diet to prevent hypertensive crisis. Aged cheeses, cured meats, and fermented
products are high in tyramine and must be strictly avoided. The nurse must ensure the
client understands that consuming these foods could lead to life-threatening elevations in
blood pressure.
4. Which intervention is most appropriate for a client experiencing a panic-level attack of
anxiety?
A. Teach the client deep breathing techniques.
B. Stay with the client and use short, simple sentences.
C. Encourage the client to discuss the cause of the panic.
D. Place the client in a room with several other peers for support.
Answer: B
Rationale: During a panic attack, the client’s ability to process information is severely
limited, so the nurse should remain present to provide a sense of security. Using short,
simple sentences helps the client understand instructions when their cognitive function is
impaired. High-stimulation environments or complex teaching should be avoided until the
panic subsides.
5. A nurse is assessing a client for Neuroleptic Malignant Syndrome (NMS). Which finding is a
hallmark symptom of this condition?
A. Hypotension and bradycardia.
B. Muscle rigidity and high fever.
C. Increased salivation and diarrhea.
D. Respiratory depression and pinpoint pupils.
Answer: B
Rationale: Neuroleptic Malignant Syndrome (NMS) is a life-threatening reaction to
antipsychotic medications characterized by lead-pipe muscle rigidity and hyperpyrexia. It
is considered a medical emergency that requires immediate discontinuation of the
medication and supportive care. Nurses must monitor for these signs, especially in clients
starting new high-potency antipsychotics.
6. A client with Borderline Personality Disorder is praise-filled toward one nurse while being
hostile to another. What is this behavior called?
A. Projection.
B. Sublimation.
, C. Rationalization.
D. Splitting.
Answer: D
Rationale: Splitting is a common defense mechanism in Borderline Personality Disorder
where individuals view others as all good or all bad. This behavior often creates conflict
among the healthcare team, necessitating a unified approach to care. Nurses must maintain
consistent boundaries and communicate effectively to prevent the client from manipulating
the staff.
7. A client is scheduled for Electroconvulsive Therapy (ECT). Which medication should the
nurse expect to be held prior to the procedure?
A. Acetaminophen.
B. Phenytoin.
C. Multivitamin.
D. Diphenhydramine.
Answer: B
Rationale: Phenytoin is an anticonvulsant that can raise the seizure threshold, potentially
making the ECT treatment ineffective since ECT relies on inducing a controlled seizure. The
nurse must coordinate with the physician to hold medications that interfere with seizure
activity before the procedure. Ensuring the client’s safety and the treatment’s efficacy is the
primary goal during pre-ECT care.
8. A nurse is caring for a client with anorexia nervosa. Which finding should be the nurse’s
priority for reporting to the provider?
A. Potassium level of 2.8 mEq/L.
B. Lanugo on the back and arms.
C. Body mass index (BMI) of 17.
D. Refusal to participate in group therapy.
Answer: A
Rationale: A potassium level of 2.8 mEq/L is critically low and poses a significant risk for
cardiac arrhythmias or arrest. While a low BMI and lanugo are expected findings in
anorexia, physiological stability takes priority in clinical assessment. Electrolyte
imbalances must be corrected immediately to ensure the client’s survival.
9. What is the primary purpose of a ‘therapeutic milieu’ in a mental health setting?
A. To provide a structured and safe environment for behavioral change.
