NSG 221
Mental Health Nursing
Pre-Assessment Version 3
Questions & Answers
2025
1. A client with depression remains in bed most of the day, declines
activities and refuses meals. Which nursing problem has the greatest
priority for this client?
a. Loss of interest in diversional activity.
b. Social isolation
c. Refusal to address nutritional needs
d. Low self-esteem.
2. The nurse is preparing medications for a client with bipolar disorder
and notices that the antipsychotic medication was discontinued several
days ago. Which medication should also be discontinued?
a. Lithium (lithotabs )
b. Benztropine (Cogentin)
c. Alprazolam (Xanax)
d. Magnesium (milk of magnesia)
3. A female client request that her husband be allowed to stay in the
room during the admission assessment. While interviewing the client,
the nurse notes a discrepancy between the client’s verbal and
nonverbal communication. What action should the nurse take?
a. Pay close attention and docum ent the nonverbal messages
b. Ask the client’s husband to interpret the discrepancy
c. Ignore the nonverbal behavior and focus on the client’s verbal
messages.
d. Integrate the verbal and nonverbal messages and interpret them
as one.
4. A male client approaches the nurse with an angry expression on his
face and raises his voice, saying, “My roommate is the most selfish,
self-centered, angry person I have ever met. If he loses his temper one
more time with me, I am going to punch him out!” the nurse
recognizes that the client is using which defense mechanism?
a. Denial
b. Projection
c. Rationalization
d. Splitting
5. A male client with bipolar disorder who began taking lithium carbonate
five days ago is complaining of excessive thirst, and the nurse finds
P a g e 1 | 28
, him attempting to drink water from the bathroom sink faucet. Which
intervention should the nurse implement?
a. Report the client’s serum lithium level to the healthcare provider
b. Encourage the client to suck on hard candy to relieve the
symptoms
c. No actions is needed since polydipsia is a common side effect
d. Tell the client that drinking from the faucet is not allowed
3
6. The nurse is teaching a client about the initiation of a prescribed
abstinence therapy using disulfiram (Antabuse). What information
should the client acknowledge understanding?
a. Completely abstain from heroin or cocaine use
b. Remain alcohol free from 12 hours prior to the first dose
c. Attend monthly meetings of alcoholics anonymous
d. Admit to others that he is a substance abuser
7. A male client with schizophrenia is admitted to the mental health unit
after abruptly stopping his prescription for ziprasidone (Geodon) one
month ago. Which question is most important for the nurse to ask the
client
a. Have you lost interest in the things that you used to enjoy?
b. Is your ability to think or concentrate decreased?
c. How many continuous hours do you sleep at night
d. Do you hear sounds or voices that others do not hear?
8. During an annual physical by the occupational nurse working in a
corporate clinic, a male employee tells the nurse that his high-stress
job is causing trouble in his personal life. He further explains the he
often gets so angry while driving to and from work that he has
considered “getting even” with other drivers, how should the nurse
respond?
a. “anger is contagious and could result in major confrontation”
b. “Try not to let your anger cause you to act impulsively”
c. “expressing your anger to a stranger could result in an unsafe”
d. It sound as if there are many situations that make you feel
angry”
9. A client who has agoraphobia (a fear of crowds) is beginning
desensitization with the therapist, and the nurse is reinforcing the
process. Which intervention has the highest priority for this client's
plan of care?
a. Encourage substitution of positive thoughts for negative ones
b. Establish trust by providing a calm, safe environment
c. Progressively expose the client to larger crowds
d. Encourage deep breathing when anxiety escalates in a crowd
10. A male client is admitted to the psychiatric unit for recurrent
P a g e 2 | 28
,negative symptoms of chronic schizophrenia and medication
adjustment of risperidone (Risperdal). When the client walks to the
nurse’s station in a literally contracted position, he states that
something has made his body confort into a monster. What action
should the nurse take?
a) Medicate the client with the prescribed antipsychotic thioridazine
mellaril)
4
b) Offer the client a prescribed physical therapy hot pack for muscle
spasms.
c) Direct client to occupational therapy to distract him from somatic
complaints.
d) Administer the prescribed anticholinergic benztropine (Cogentin)
for dystonia.
11. A mental health worker (MHW) is caring for a client with escalating
aggressive behavior. Which action by the MHW warrants immediate
intervention by the nurse?
A) Is attempting to physically restrain the client.
B) Tells the client to go to the quiet area of the unit.
C) Is using a loud voice to talk to the client.
D) Remains at a distance of 4 feet from the client.
12. A client on the mental health unit is becoming more agitated,
shouting at the staff, and pacing in the hallway. When a PRN
medication is offered, the client refuses the medication and defiantly
sits on the floor in the middle of the unit hallway. What nursing
intervention should the nurse implement first?
A) Transport of the client to the seclusion room
B) Quietly approach the client with additional staff members.
C) Take other client in the area to the client lounge.
D) Administer medication to chemically restrain the client.
13. A client is admitted to the mental health unit and reports taking
extra antianxiety medication because, “I’m so stressed out. I just
wanted to go sleep” the nurse should plan one-on- one observation of
the client based on which statement?
A) What should I do? Nothing seems to help.”
B) I have been so tired lately and needed to sleep.”
C) I really think that I don’t need to be here.”
D) I don’t want to talk. Nothing matters anymore.”
P a g e 3 | 28
, 14. A male hospital employee is pushed out of the way by a female
employee because of an oncoming gurney. The pushed employee
becomes very angry and swings at the female employee. Both
employees are referred for counseling with the staff psychiatric nurse.
Which factor in the pushed employee’s history is most related to the
reaction that occurred?
A) Is worried about losing his job to a woman
5
B) Tortured animals as a child.
C) Was physically abused by his mother
D) Hates to be touched by anyone
15. The nurse documents the mental status of a female client who has
been hospitalized for several days by court order. The client state, “I
don’t need to be here” and tells the nurse that she believes that the
television talks to her. The nurse should document these assessment
findings in which section of the mental status exam?
A) Level of concentration
B) Insight and judgment
C) Remote memory
D) Mood and affect
16. The nurse on the evening shift receives report that a client is
scheduled for electroconvulsive treatment (ECT) in the morning. Which
intervention should the nurse implement the evening before the
scheduled ECT?
A) Hold all bedtime medication.
B) Keep the client NPO after midnight.
C) Implement elopement precautions.
D) Give client an enema at bedtime.
17. A client who is admitted to the mental health unit report shortness
of breath and dizziness. The client tells the nurse, “I feel like I’m going
to die” which nursing problem should the nurse include in this client’s
plan of care?
A) Mood disturbance
B) Moderate anxiety
C) Altered thoughts
D) Social isolation
18. A female client is brought to the emergency department after
police officers found her disoriented, disorganized, and confuse. The
nurse also determines that the client is homeless and slightly
suspicious. This client’s treatment plan should include what priority
problem?
A) Self-care deficit.
P a g e 4 | 28
Mental Health Nursing
Pre-Assessment Version 3
Questions & Answers
2025
1. A client with depression remains in bed most of the day, declines
activities and refuses meals. Which nursing problem has the greatest
priority for this client?
a. Loss of interest in diversional activity.
b. Social isolation
c. Refusal to address nutritional needs
d. Low self-esteem.
2. The nurse is preparing medications for a client with bipolar disorder
and notices that the antipsychotic medication was discontinued several
days ago. Which medication should also be discontinued?
a. Lithium (lithotabs )
b. Benztropine (Cogentin)
c. Alprazolam (Xanax)
d. Magnesium (milk of magnesia)
3. A female client request that her husband be allowed to stay in the
room during the admission assessment. While interviewing the client,
the nurse notes a discrepancy between the client’s verbal and
nonverbal communication. What action should the nurse take?
a. Pay close attention and docum ent the nonverbal messages
b. Ask the client’s husband to interpret the discrepancy
c. Ignore the nonverbal behavior and focus on the client’s verbal
messages.
d. Integrate the verbal and nonverbal messages and interpret them
as one.
4. A male client approaches the nurse with an angry expression on his
face and raises his voice, saying, “My roommate is the most selfish,
self-centered, angry person I have ever met. If he loses his temper one
more time with me, I am going to punch him out!” the nurse
recognizes that the client is using which defense mechanism?
a. Denial
b. Projection
c. Rationalization
d. Splitting
5. A male client with bipolar disorder who began taking lithium carbonate
five days ago is complaining of excessive thirst, and the nurse finds
P a g e 1 | 28
, him attempting to drink water from the bathroom sink faucet. Which
intervention should the nurse implement?
a. Report the client’s serum lithium level to the healthcare provider
b. Encourage the client to suck on hard candy to relieve the
symptoms
c. No actions is needed since polydipsia is a common side effect
d. Tell the client that drinking from the faucet is not allowed
3
6. The nurse is teaching a client about the initiation of a prescribed
abstinence therapy using disulfiram (Antabuse). What information
should the client acknowledge understanding?
a. Completely abstain from heroin or cocaine use
b. Remain alcohol free from 12 hours prior to the first dose
c. Attend monthly meetings of alcoholics anonymous
d. Admit to others that he is a substance abuser
7. A male client with schizophrenia is admitted to the mental health unit
after abruptly stopping his prescription for ziprasidone (Geodon) one
month ago. Which question is most important for the nurse to ask the
client
a. Have you lost interest in the things that you used to enjoy?
b. Is your ability to think or concentrate decreased?
c. How many continuous hours do you sleep at night
d. Do you hear sounds or voices that others do not hear?
8. During an annual physical by the occupational nurse working in a
corporate clinic, a male employee tells the nurse that his high-stress
job is causing trouble in his personal life. He further explains the he
often gets so angry while driving to and from work that he has
considered “getting even” with other drivers, how should the nurse
respond?
a. “anger is contagious and could result in major confrontation”
b. “Try not to let your anger cause you to act impulsively”
c. “expressing your anger to a stranger could result in an unsafe”
d. It sound as if there are many situations that make you feel
angry”
9. A client who has agoraphobia (a fear of crowds) is beginning
desensitization with the therapist, and the nurse is reinforcing the
process. Which intervention has the highest priority for this client's
plan of care?
a. Encourage substitution of positive thoughts for negative ones
b. Establish trust by providing a calm, safe environment
c. Progressively expose the client to larger crowds
d. Encourage deep breathing when anxiety escalates in a crowd
10. A male client is admitted to the psychiatric unit for recurrent
P a g e 2 | 28
,negative symptoms of chronic schizophrenia and medication
adjustment of risperidone (Risperdal). When the client walks to the
nurse’s station in a literally contracted position, he states that
something has made his body confort into a monster. What action
should the nurse take?
a) Medicate the client with the prescribed antipsychotic thioridazine
mellaril)
4
b) Offer the client a prescribed physical therapy hot pack for muscle
spasms.
c) Direct client to occupational therapy to distract him from somatic
complaints.
d) Administer the prescribed anticholinergic benztropine (Cogentin)
for dystonia.
11. A mental health worker (MHW) is caring for a client with escalating
aggressive behavior. Which action by the MHW warrants immediate
intervention by the nurse?
A) Is attempting to physically restrain the client.
B) Tells the client to go to the quiet area of the unit.
C) Is using a loud voice to talk to the client.
D) Remains at a distance of 4 feet from the client.
12. A client on the mental health unit is becoming more agitated,
shouting at the staff, and pacing in the hallway. When a PRN
medication is offered, the client refuses the medication and defiantly
sits on the floor in the middle of the unit hallway. What nursing
intervention should the nurse implement first?
A) Transport of the client to the seclusion room
B) Quietly approach the client with additional staff members.
C) Take other client in the area to the client lounge.
D) Administer medication to chemically restrain the client.
13. A client is admitted to the mental health unit and reports taking
extra antianxiety medication because, “I’m so stressed out. I just
wanted to go sleep” the nurse should plan one-on- one observation of
the client based on which statement?
A) What should I do? Nothing seems to help.”
B) I have been so tired lately and needed to sleep.”
C) I really think that I don’t need to be here.”
D) I don’t want to talk. Nothing matters anymore.”
P a g e 3 | 28
, 14. A male hospital employee is pushed out of the way by a female
employee because of an oncoming gurney. The pushed employee
becomes very angry and swings at the female employee. Both
employees are referred for counseling with the staff psychiatric nurse.
Which factor in the pushed employee’s history is most related to the
reaction that occurred?
A) Is worried about losing his job to a woman
5
B) Tortured animals as a child.
C) Was physically abused by his mother
D) Hates to be touched by anyone
15. The nurse documents the mental status of a female client who has
been hospitalized for several days by court order. The client state, “I
don’t need to be here” and tells the nurse that she believes that the
television talks to her. The nurse should document these assessment
findings in which section of the mental status exam?
A) Level of concentration
B) Insight and judgment
C) Remote memory
D) Mood and affect
16. The nurse on the evening shift receives report that a client is
scheduled for electroconvulsive treatment (ECT) in the morning. Which
intervention should the nurse implement the evening before the
scheduled ECT?
A) Hold all bedtime medication.
B) Keep the client NPO after midnight.
C) Implement elopement precautions.
D) Give client an enema at bedtime.
17. A client who is admitted to the mental health unit report shortness
of breath and dizziness. The client tells the nurse, “I feel like I’m going
to die” which nursing problem should the nurse include in this client’s
plan of care?
A) Mood disturbance
B) Moderate anxiety
C) Altered thoughts
D) Social isolation
18. A female client is brought to the emergency department after
police officers found her disoriented, disorganized, and confuse. The
nurse also determines that the client is homeless and slightly
suspicious. This client’s treatment plan should include what priority
problem?
A) Self-care deficit.
P a g e 4 | 28
