NUR 384 Exam 4 – Mental Health Nursing (2026)
Concordia University | Practice Questions &
Rationales
1. A client tells the nurse, "I am going to kill my brother as soon
as I get out of here." According to the Tarasoff ruling, what is
the nurse's legal obligation?
A) Document the statement in the client's medical record.
B) Inform the client's brother and law enforcement of the
threat.
C) Increase the client's antipsychotic medication dose.
D) Place the client in physical restraints immediately.
<span style="color:red;">Answer: B) Inform the client's brother
and law enforcement of the threat.</span>
Rationale: The Tarasoff ruling (duty to warn/protect) requires
mental health professionals to breach confidentiality and warn
a specific, identifiable potential victim if a client makes a serious
threat of homicide.
2. A client is brought to the emergency department
involuntarily by police after threatening to jump off a bridge.
Which legal criterion justifies this involuntary commitment?
,A) The client has a diagnosed mental illness.
B) The client poses an imminent danger to self or others.
C) The client is unable to afford outpatient treatment.
D) The client refuses to take prescribed medications.
<span style="color:red;">Answer: B) The client poses an
imminent danger to self or others.</span>
Rationale: Involuntary commitment requires that the individual
poses an imminent, physical danger to themselves (suicidal) or
others (homicidal), or is gravely disabled and unable to meet
basic survival needs (food, clothing, shelter).
3. A nurse is caring for a client with severe Alzheimer’s disease
who is admitted for pneumonia. The client repeatedly tries to
pull out their IV line. Which intervention is the least restrictive
and should be tried first?
A) Apply soft wrist restraints.
B) Administer a PRN sedative.
C) Ask a family member to stay with the client.
D) Hide the IV tubing under clothing and distract the client.
<span style="color:red;">Answer: D) Hide the IV tubing under
clothing and distract the client.</span>
,Rationale: The least restrictive intervention must always be
attempted first. Environmental modification, camouflaging the
IV, and distraction are non-pharmacological, non-restrictive
interventions. Restraints and sedatives are more restrictive and
require a provider order.
4. A client with schizophrenia is prescribed clozapine. The
client's Absolute Neutrophil Count (ANC) is 1,200/mm³. What is
the nurse's priority action?
A) Administer the medication as prescribed.
B) Hold the medication and notify the provider.
C) Administer half the prescribed dose.
D) Administer an antibiotic before the clozapine.
<span style="color:red;">Answer: B) Hold the medication and
notify the provider.</span>
Rationale: Clozapine carries a black box warning for
agranulocytosis. An ANC below 1,500/mm³ requires
interrupting the medication immediately and contacting the
provider to prevent fatal infections.
, 5. A client taking phenelzine (Nardil), an MAOI, consumes a
meal of aged cheese and red wine. The nurse should monitor
the client for which life-threatening emergency?
A) Serotonin syndrome
B) Hypertensive crisis
C) Neuroleptic malignant syndrome
D) Acute dystonic reaction
<span style="color:red;">Answer: B) Hypertensive crisis</span>
Rationale: MAOIs inhibit the breakdown of tyramine.
Consuming tyramine-rich foods (aged cheese, red wine, smoked
meats) causes a massive release of norepinephrine, leading to a
potentially fatal hypertensive crisis (severe headache,
hypertension, sweating).
6. A client on the psychiatric unit becomes violently aggressive.
After all de-escalation attempts fail, the client is placed in
physical restraints. How often must the nurse assess the client's
circulation, range of motion, and vital signs while in restraints?
A) Every 15 minutes
B) Every 30 minutes
C) Every 1 hour
Concordia University | Practice Questions &
Rationales
1. A client tells the nurse, "I am going to kill my brother as soon
as I get out of here." According to the Tarasoff ruling, what is
the nurse's legal obligation?
A) Document the statement in the client's medical record.
B) Inform the client's brother and law enforcement of the
threat.
C) Increase the client's antipsychotic medication dose.
D) Place the client in physical restraints immediately.
<span style="color:red;">Answer: B) Inform the client's brother
and law enforcement of the threat.</span>
Rationale: The Tarasoff ruling (duty to warn/protect) requires
mental health professionals to breach confidentiality and warn
a specific, identifiable potential victim if a client makes a serious
threat of homicide.
2. A client is brought to the emergency department
involuntarily by police after threatening to jump off a bridge.
Which legal criterion justifies this involuntary commitment?
,A) The client has a diagnosed mental illness.
B) The client poses an imminent danger to self or others.
C) The client is unable to afford outpatient treatment.
D) The client refuses to take prescribed medications.
<span style="color:red;">Answer: B) The client poses an
imminent danger to self or others.</span>
Rationale: Involuntary commitment requires that the individual
poses an imminent, physical danger to themselves (suicidal) or
others (homicidal), or is gravely disabled and unable to meet
basic survival needs (food, clothing, shelter).
3. A nurse is caring for a client with severe Alzheimer’s disease
who is admitted for pneumonia. The client repeatedly tries to
pull out their IV line. Which intervention is the least restrictive
and should be tried first?
A) Apply soft wrist restraints.
B) Administer a PRN sedative.
C) Ask a family member to stay with the client.
D) Hide the IV tubing under clothing and distract the client.
<span style="color:red;">Answer: D) Hide the IV tubing under
clothing and distract the client.</span>
,Rationale: The least restrictive intervention must always be
attempted first. Environmental modification, camouflaging the
IV, and distraction are non-pharmacological, non-restrictive
interventions. Restraints and sedatives are more restrictive and
require a provider order.
4. A client with schizophrenia is prescribed clozapine. The
client's Absolute Neutrophil Count (ANC) is 1,200/mm³. What is
the nurse's priority action?
A) Administer the medication as prescribed.
B) Hold the medication and notify the provider.
C) Administer half the prescribed dose.
D) Administer an antibiotic before the clozapine.
<span style="color:red;">Answer: B) Hold the medication and
notify the provider.</span>
Rationale: Clozapine carries a black box warning for
agranulocytosis. An ANC below 1,500/mm³ requires
interrupting the medication immediately and contacting the
provider to prevent fatal infections.
, 5. A client taking phenelzine (Nardil), an MAOI, consumes a
meal of aged cheese and red wine. The nurse should monitor
the client for which life-threatening emergency?
A) Serotonin syndrome
B) Hypertensive crisis
C) Neuroleptic malignant syndrome
D) Acute dystonic reaction
<span style="color:red;">Answer: B) Hypertensive crisis</span>
Rationale: MAOIs inhibit the breakdown of tyramine.
Consuming tyramine-rich foods (aged cheese, red wine, smoked
meats) causes a massive release of norepinephrine, leading to a
potentially fatal hypertensive crisis (severe headache,
hypertension, sweating).
6. A client on the psychiatric unit becomes violently aggressive.
After all de-escalation attempts fail, the client is placed in
physical restraints. How often must the nurse assess the client's
circulation, range of motion, and vital signs while in restraints?
A) Every 15 minutes
B) Every 30 minutes
C) Every 1 hour
