QUESTIONS WITH 100% ACCURATE ANSWERS
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Overview:
This section focuses on mental health nursing concepts, covering client care across a range of
psychiatric disorders, including depression, bipolar disorder, schizophrenia, anxiety disorders, OCD,
PTSD, personality disorders, substance use disorders, and dementia.
Key areas tested include:
1. Therapeutic Communication:
o Using empathy, active listening, and appropriate responses to hallucinations, delusions,
or emotional distress.
o Techniques like grounding, reflection, and validation without reinforcing psychosis.
2. Safety & Crisis Intervention:
o Suicide risk assessment, aggression management, and de-escalation strategies.
o Use of least restrictive interventions (verbal de-escalation, chemical restraint if
necessary).
3. Psychopharmacology:
o Common psychiatric medications: SSRIs, SNRIs, MAOIs, antipsychotics (typical &
atypical), mood stabilizers (lithium, valproic acid), anxiolytics, and substance withdrawal
medications.
o Identification of side effects, toxicities, and teaching points (e.g., lithium toxicity,
serotonin syndrome, agranulocytosis with clozapine, hypertensive crisis with MAOIs).
4. Psychiatric Disorders & Nursing Diagnosis:
o Differentiation of positive vs. negative symptoms in schizophrenia.
o Recognition of mania, depression, PTSD, OCD, panic attacks, and dementia-related
behaviors.
o Nursing diagnoses: low self-esteem, self-care deficits, risk for violence, impaired social
interaction.
5. Client Education & Recovery:
o Teaching clients about medication adherence, side effects, coping strategies, relapse
prevention, and safe withdrawal from substances.
o Promoting structured routines, small achievable tasks, and engagement in activities for
depressed or cognitively impaired clients.
6. Assessment & Monitoring:
o Observation of behavioral cues, cognitive function, affect, thought patterns, and
physiological signs.
o Prioritizing immediate threats to life (suicidal ideation, alcohol withdrawal seizures,
NMS, lithium toxicity).
,NB QUESTIONS NOT WELL ARRANGED
51. A client with schizophrenia is taking clozapine. The nurse reviews today’s
labs and notes a WBC count of 2,900/mm³. Which action is PRIORITY?
A) Encourage fluid intake
B) Monitor temperature only
C) Give medication as scheduled
D) Hold the medication and notify the provider immediately
Answer: D
Rationale: Clozapine can cause agranulocytosis. A WBC <3,000 is dangerous and requires
immediate discontinuation and provider notification.
52. A client in acute mania interrupts others, talks loudly, and becomes irritable
when redirected. Which nursing intervention is MOST therapeutic?
A) Ask the client to explain their behavior
B) Allow them to lead the group
C) Escort the client to a quiet area with minimal stimulation
D) Tell them to be quiet
Answer: C
Rationale: Decreasing stimulation helps manage irritability and prevents escalation.
53. A client with severe depression states, “I’m tired of being a burden.” The
nurse should FIRST:
A) Give a medication teaching sheet
B) Tell the client they are not a burden
C) Encourage the client to talk with family
D) Assess for suicidal thoughts, intent, or plan
Answer: D
Rationale: Feeling like a burden is a major suicide red flag requiring direct assessment.
54. A client with panic disorder experiences chest tightness, dizziness, and fear of
dying. Which nursing action is PRIORITY?
A) Ask the client about their past panic attacks
B) Educate about long-term therapy
C) Stay with the client and guide slow, deep breathing
, D) Provide water
Answer: C
Rationale: Staying present and controlling breathing reduces hyperventilation and panic
escalation.
55. A client on sertraline states they took St. John’s wort last night for sleep. The
nurse should be MOST concerned about:
A) Weight gain
B) Drowsiness
C) Serotonin syndrome
D) Dry mouth
Answer: C
Rationale: SSRIs + St. John’s wort = dangerous serotonin syndrome, requiring immediate
assessment.
56. A client with anorexia nervosa has a potassium level of 2.8 mEq/L. The
nurse’s FIRST action is to:
A) Encourage a meal
B) Provide educational pamphlets
C) Let the client rest
D) Notify the provider due to risk of cardiac dysrhythmias
Answer: D
Rationale: Severe hypokalemia is life-threatening and requires urgent intervention.
57. A client with dementia repeatedly asks, “When can I go home?” even though
they live in the facility. The BEST nursing response is:
A) “You live here now.”
B) “You’re safe here. Tell me about the home you’re thinking of.”
C) “We just talked about this.”
D) “Stop worrying about that.”
Answer: B
Rationale: Validation therapy lowers anxiety and promotes dignity.