PRN 1562/PRN1562 Exam 4 V2 | Principles
of Mental Health Nursing Q&A with
Rationale | Rasmussen University
1. A nurse is caring for a client with Bipolar I Disorder experiencing acute mania. What is the
priority nursing intervention for this client?
A. Ensuring the client’s physical safety and nutritional intake.
B. Engaging the client in group therapy activities.
C. Teaching the client about long-term medication side effects.
D. Encouraging the client to lead a discussion group.
Answer: A
Rationale: In the acute manic phase, safety is the highest priority due to hyperactivity and
poor judgment. Clients often neglect basic needs like food and sleep, so maintaining
physical health is essential. The nurse must provide high-calorie finger foods and a
structured, low-stimulation environment.
2. A client is prescribed Lithium Carbonate. Which of the following serum lithium levels is
within the therapeutic range for maintenance?
A. 0.2 mEq/L
B. 0.8 mEq/L
C. 1.8 mEq/L
,D. 2.5 mEq/L
Answer: B
Rationale: The therapeutic maintenance range for lithium is generally 0.6 to 1.2 mEq/L.
Values below 0.6 are subtherapeutic and may result in a relapse of symptoms. Values above
1.5 indicate toxicity and require immediate medical intervention.
3. A patient is taking Clozapine for treatment-resistant schizophrenia. Which laboratory result
must the nurse monitor most closely?
A. Serum potassium levels
B. Blood urea nitrogen (BUN)
C. White blood cell (WBC) count
D. Thyroid stimulating hormone (TSH)
Answer: C
Rationale: Clozapine is associated with a high risk of agranulocytosis, which is a life-
threatening reduction in white blood cells. Patients must undergo regular blood monitoring
to ensure the WBC and Absolute Neutrophil Count remain within safe limits. If the count
drops too low, the medication must be discontinued immediately to prevent severe
infection.
4. The nurse observes a client repeating the exact words spoken by the nurse. How should
the nurse document this behavior?
A. Neologisms
, B. Echolalia
C. Word salad
D. Echopraxia
Answer: B
Rationale: Echolalia is the pathological repeating of words or phrases spoken by another
person. It is often seen in individuals with schizophrenia or autism spectrum disorders.
This differs from echopraxia, which involves mimicking another person’s movements.
5. Which defense mechanism involves a client blaming others for their own unacceptable
feelings or impulses?
A. Sublimation
B. Projection
C. Rationalization
D. Reaction Formation
Answer: B
Rationale: Projection is a defense mechanism where individuals attribute their own
unwanted thoughts or feelings to someone else. For example, a client who feels angry might
accuse the nurse of being angry with them. This process helps the individual avoid facing
their own internal conflicts.
of Mental Health Nursing Q&A with
Rationale | Rasmussen University
1. A nurse is caring for a client with Bipolar I Disorder experiencing acute mania. What is the
priority nursing intervention for this client?
A. Ensuring the client’s physical safety and nutritional intake.
B. Engaging the client in group therapy activities.
C. Teaching the client about long-term medication side effects.
D. Encouraging the client to lead a discussion group.
Answer: A
Rationale: In the acute manic phase, safety is the highest priority due to hyperactivity and
poor judgment. Clients often neglect basic needs like food and sleep, so maintaining
physical health is essential. The nurse must provide high-calorie finger foods and a
structured, low-stimulation environment.
2. A client is prescribed Lithium Carbonate. Which of the following serum lithium levels is
within the therapeutic range for maintenance?
A. 0.2 mEq/L
B. 0.8 mEq/L
C. 1.8 mEq/L
,D. 2.5 mEq/L
Answer: B
Rationale: The therapeutic maintenance range for lithium is generally 0.6 to 1.2 mEq/L.
Values below 0.6 are subtherapeutic and may result in a relapse of symptoms. Values above
1.5 indicate toxicity and require immediate medical intervention.
3. A patient is taking Clozapine for treatment-resistant schizophrenia. Which laboratory result
must the nurse monitor most closely?
A. Serum potassium levels
B. Blood urea nitrogen (BUN)
C. White blood cell (WBC) count
D. Thyroid stimulating hormone (TSH)
Answer: C
Rationale: Clozapine is associated with a high risk of agranulocytosis, which is a life-
threatening reduction in white blood cells. Patients must undergo regular blood monitoring
to ensure the WBC and Absolute Neutrophil Count remain within safe limits. If the count
drops too low, the medication must be discontinued immediately to prevent severe
infection.
4. The nurse observes a client repeating the exact words spoken by the nurse. How should
the nurse document this behavior?
A. Neologisms
, B. Echolalia
C. Word salad
D. Echopraxia
Answer: B
Rationale: Echolalia is the pathological repeating of words or phrases spoken by another
person. It is often seen in individuals with schizophrenia or autism spectrum disorders.
This differs from echopraxia, which involves mimicking another person’s movements.
5. Which defense mechanism involves a client blaming others for their own unacceptable
feelings or impulses?
A. Sublimation
B. Projection
C. Rationalization
D. Reaction Formation
Answer: B
Rationale: Projection is a defense mechanism where individuals attribute their own
unwanted thoughts or feelings to someone else. For example, a client who feels angry might
accuse the nurse of being angry with them. This process helps the individual avoid facing
their own internal conflicts.
