Mental Health NCLEX practice
The serum lithium blood level of a client with a mood disorder, manic episode, is 2.3 mEq/L. What
should the nurse expect when assessing this client?
a) Elevation in mood
b) Nausea, thirst, and fine hand tremor
c) Decrease in manic signs and symptoms
d) Vomiting, diarrhea, and decreased coordination - ANS d) Vomiting, diarrhea, and decreased
coordination
Vomiting, diarrhea, and decreased coordination are reflective of lithium toxicity. During the active phase
of a manic episode a lithium level of 2.3 mEq/L is more than the therapeutic range of 0.8 to 1.4 mEq/L.
An improvement in mood may occur when the therapeutic level is approached early in lithium therapy.
Nausea, thirst, and fine hand tremor are common early side effects of lithium treatment. They are not
related to lithium toxicity, which is indicated by a 2.3 mEq/L lithium level. During the acute phase of
mania the therapeutic serum level of lithium should be between 0.8 and 1.4 mEq/L. The maintenance
therapeutic serum level ranges from 0.4 to 1.0 mEq/L. A reduction in symptoms is expected when the
therapeutic level of lithium is reached.
The nurse is caring for a female client who is confused and delirious. What is the most therapeutic
intervention when the nurse is interacting with this client?
a) Reassuring the client that she will get better
b) Directing the client's daily activities on the unit
c) Helping the client clarify her experience and gain insight into her behavior
d) Providing the client with solutions to past and current problems she has experienced - ANS b)
Directing the client's daily activities on the unit
The client needs to have her activities decided and directed until delirium and confusion clear.
Reassuring the client that she will get better is false reassurance. Clients who are delirious are unable to
,develop insight into their behavior. Providing the client with solutions to past and current problems
experienced is not therapeutic and does not help the client develop insight.
A male client with cyclothymic disorder with hypomanic symptoms is admitted to the psychiatric unit.
He has progressively lost weight and does not take the time to eat his food. How can the nurse best
respond to this situation?
a) By providing a tray for him in his room
b) By assuring him that he is deserving of food
c) By ordering food that he can hold in his hand to eat while moving around
d) By pointing out that he must replace the energy that he is burning up by eating - ANS c) By ordering
food that he can hold in his hand to eat while moving around
The client with hypomanic symptoms cannot tolerate sitting still long enough to eat an adequate meal;
handheld foods will help meet the client's nutritional needs and do not require the client to sit down.
This client will most likely ignore the tray. Unworthy feelings are related to a depressive, not manic,
episode. It is unlikely that this client will understand or care about the need to replace energy with food.
A client who has a diagnosis of paranoid schizophrenia and has been violent in the past is admitted to
the psychiatric unit. What should the nurse do before conducting an admission interview?
a) Move to the client's side and sit down.
b) Alert the assault response team about the client's history.
c) Have two other staff members present when talking with the client.
d) Enter the room with another staff member while remaining between the client and the door. - ANS d)
Enter the room with another staff member while remaining between the client and the door.
Making sure to stay between the client and the door provides safety for the nurse and the other staff
member because it will enable them to make a rapid exit. Moving to the client and sitting down invades
the client's territory and may precipitate an aggressive client response. Alerting the assault response
, team is premature; the team is alerted when a client is out of control, harming self or others, and cannot
be managed by the staff on the unit. Having two other staff members present may be viewed by the
client as confrontational and may precipitate an aggressive response.
The nurse is caring for a client with a somatoform disorder, conversion-type paralysis. What is the best
nursing approach?
a) Discussing topics other than the paralysis
b) Explaining the reason for the physical problem
c) Asking how the client feels about being paralyzed
d) Encouraging the client to slowly walk around the room - ANS a) Discussing topics other than the
paralysis
Discussion of signs and symptoms should not be initiated by the nurse; the signs and symptoms should
be accepted by the nurse. Discussion should be focused on the client's feelings and current situation.
Explaining the reason for the physical problem may take away the client's unconscious defense and
increase anxiety. Asking how the client feels about being paralyzed focuses on the paralysis rather than
feelings. Encouraging the client to slowly walk around the room denies the client's symptoms; in reality
this client cannot make the legs move to walk.
During the intake interview at a mental health clinic, a client in withdrawal reveals to the nurse long-
term, high-dose cocaine use. Which signs and symptoms support the conclusion that the client has been
abusing cocaine for a prolonged time? Select all that apply.
a) Sadness
b) Euphoria
c) Loss of appetite
d) Impaired judgment
e) Psychomotor retardation - ANS a) Sadness
e) Psychomotor retardation
The serum lithium blood level of a client with a mood disorder, manic episode, is 2.3 mEq/L. What
should the nurse expect when assessing this client?
a) Elevation in mood
b) Nausea, thirst, and fine hand tremor
c) Decrease in manic signs and symptoms
d) Vomiting, diarrhea, and decreased coordination - ANS d) Vomiting, diarrhea, and decreased
coordination
Vomiting, diarrhea, and decreased coordination are reflective of lithium toxicity. During the active phase
of a manic episode a lithium level of 2.3 mEq/L is more than the therapeutic range of 0.8 to 1.4 mEq/L.
An improvement in mood may occur when the therapeutic level is approached early in lithium therapy.
Nausea, thirst, and fine hand tremor are common early side effects of lithium treatment. They are not
related to lithium toxicity, which is indicated by a 2.3 mEq/L lithium level. During the acute phase of
mania the therapeutic serum level of lithium should be between 0.8 and 1.4 mEq/L. The maintenance
therapeutic serum level ranges from 0.4 to 1.0 mEq/L. A reduction in symptoms is expected when the
therapeutic level of lithium is reached.
The nurse is caring for a female client who is confused and delirious. What is the most therapeutic
intervention when the nurse is interacting with this client?
a) Reassuring the client that she will get better
b) Directing the client's daily activities on the unit
c) Helping the client clarify her experience and gain insight into her behavior
d) Providing the client with solutions to past and current problems she has experienced - ANS b)
Directing the client's daily activities on the unit
The client needs to have her activities decided and directed until delirium and confusion clear.
Reassuring the client that she will get better is false reassurance. Clients who are delirious are unable to
,develop insight into their behavior. Providing the client with solutions to past and current problems
experienced is not therapeutic and does not help the client develop insight.
A male client with cyclothymic disorder with hypomanic symptoms is admitted to the psychiatric unit.
He has progressively lost weight and does not take the time to eat his food. How can the nurse best
respond to this situation?
a) By providing a tray for him in his room
b) By assuring him that he is deserving of food
c) By ordering food that he can hold in his hand to eat while moving around
d) By pointing out that he must replace the energy that he is burning up by eating - ANS c) By ordering
food that he can hold in his hand to eat while moving around
The client with hypomanic symptoms cannot tolerate sitting still long enough to eat an adequate meal;
handheld foods will help meet the client's nutritional needs and do not require the client to sit down.
This client will most likely ignore the tray. Unworthy feelings are related to a depressive, not manic,
episode. It is unlikely that this client will understand or care about the need to replace energy with food.
A client who has a diagnosis of paranoid schizophrenia and has been violent in the past is admitted to
the psychiatric unit. What should the nurse do before conducting an admission interview?
a) Move to the client's side and sit down.
b) Alert the assault response team about the client's history.
c) Have two other staff members present when talking with the client.
d) Enter the room with another staff member while remaining between the client and the door. - ANS d)
Enter the room with another staff member while remaining between the client and the door.
Making sure to stay between the client and the door provides safety for the nurse and the other staff
member because it will enable them to make a rapid exit. Moving to the client and sitting down invades
the client's territory and may precipitate an aggressive client response. Alerting the assault response
, team is premature; the team is alerted when a client is out of control, harming self or others, and cannot
be managed by the staff on the unit. Having two other staff members present may be viewed by the
client as confrontational and may precipitate an aggressive response.
The nurse is caring for a client with a somatoform disorder, conversion-type paralysis. What is the best
nursing approach?
a) Discussing topics other than the paralysis
b) Explaining the reason for the physical problem
c) Asking how the client feels about being paralyzed
d) Encouraging the client to slowly walk around the room - ANS a) Discussing topics other than the
paralysis
Discussion of signs and symptoms should not be initiated by the nurse; the signs and symptoms should
be accepted by the nurse. Discussion should be focused on the client's feelings and current situation.
Explaining the reason for the physical problem may take away the client's unconscious defense and
increase anxiety. Asking how the client feels about being paralyzed focuses on the paralysis rather than
feelings. Encouraging the client to slowly walk around the room denies the client's symptoms; in reality
this client cannot make the legs move to walk.
During the intake interview at a mental health clinic, a client in withdrawal reveals to the nurse long-
term, high-dose cocaine use. Which signs and symptoms support the conclusion that the client has been
abusing cocaine for a prolonged time? Select all that apply.
a) Sadness
b) Euphoria
c) Loss of appetite
d) Impaired judgment
e) Psychomotor retardation - ANS a) Sadness
e) Psychomotor retardation
