NU 160 Exam 2 V1 | NU 160 Mental Health
Concepts | NCLEX (NGN) Q&A with
Rationale (NU160 Exam 2)
1. A nurse is caring for a client experiencing a panic attack. Which of the following nursing
interventions is the priority?
A. Stay with the client and maintain a calm, quiet demeanor.
B. Encourage the client to describe their feelings in detail.
C. Administer a prescribed PRN dose of an SSRI medication.
D. Place the client in a room with other patients for distraction.
Correct Answer: A
Explanation: During a panic attack, the client’s safety and the reduction of immediate
anxiety are the nursing priorities. Staying with the client provides a sense of security and
prevents the client from feeling abandoned during a terrifying experience. A calm, quiet
demeanor helps prevent further escalation of the client’s physiological and psychological
symptoms.
2. A client diagnosed with Bipolar I Disorder is in the manic phase and is moving rapidly
around the unit. What is the most appropriate snack to provide?
A. A bowl of chicken noodle soup.
B. An apple and a peanut butter sandwich.
,C. A cheese quesadilla cut into small pieces.
D. A cup of vanilla yogurt.
Correct Answer: B
Explanation: Clients in a manic phase often have high energy levels and cannot sit still
long enough to eat a full meal. Providing ‘finger foods’ that are high in protein and calories
allows the client to eat while remaining mobile. An apple and a sandwich are portable and
provide the necessary nutrients to prevent exhaustion and weight loss during mania.
3. A nurse is assessing a client for Lithium toxicity. Which of the following findings should the
nurse report to the provider immediately?
A. Fine hand tremors and mild thirst.
B. Polyuria and a metallic taste in the mouth.
C. Ataxia, blurred vision, and severe diarrhea.
D. Weight gain of 2 pounds in one week.
Correct Answer: C
Explanation: Ataxia, blurred vision, and severe diarrhea are classic signs of moderate to
severe lithium toxicity. These symptoms indicate that lithium levels may be approaching or
exceeding 2.0 mEq/L, which requires immediate medical intervention. Early signs like fine
tremors and mild thirst are common side effects and usually do not indicate toxicity.
, 4. A client is prescribed Clozapine for treatment-resistant schizophrenia. Which laboratory
value is the most critical for the nurse to monitor?
A. Serum potassium levels.
B. White blood cell (WBC) count.
C. Blood urea nitrogen (BUN).
D. Liver function tests (ALT/AST).
Correct Answer: B
Explanation: Clozapine carries a high risk for agranulocytosis, which is a life-threatening
decrease in the white blood cell count. Regular monitoring of the WBC and Absolute
Neutrophil Count (ANC) is mandatory per FDA protocols to prevent severe infection. If the
WBC count falls below specific thresholds, the medication must be discontinued
immediately.
5. A nurse is communicating with a client who is hearing auditory hallucinations. Which
statement by the nurse is therapeutic?
A. Just ignore them; they aren’t real and cannot hurt you.
B. Why do you think you are hearing those voices right now?
C. I don’t hear the voices, but I understand that they are real to you.
D. What are the voices telling you to do?
Correct Answer: C
Concepts | NCLEX (NGN) Q&A with
Rationale (NU160 Exam 2)
1. A nurse is caring for a client experiencing a panic attack. Which of the following nursing
interventions is the priority?
A. Stay with the client and maintain a calm, quiet demeanor.
B. Encourage the client to describe their feelings in detail.
C. Administer a prescribed PRN dose of an SSRI medication.
D. Place the client in a room with other patients for distraction.
Correct Answer: A
Explanation: During a panic attack, the client’s safety and the reduction of immediate
anxiety are the nursing priorities. Staying with the client provides a sense of security and
prevents the client from feeling abandoned during a terrifying experience. A calm, quiet
demeanor helps prevent further escalation of the client’s physiological and psychological
symptoms.
2. A client diagnosed with Bipolar I Disorder is in the manic phase and is moving rapidly
around the unit. What is the most appropriate snack to provide?
A. A bowl of chicken noodle soup.
B. An apple and a peanut butter sandwich.
,C. A cheese quesadilla cut into small pieces.
D. A cup of vanilla yogurt.
Correct Answer: B
Explanation: Clients in a manic phase often have high energy levels and cannot sit still
long enough to eat a full meal. Providing ‘finger foods’ that are high in protein and calories
allows the client to eat while remaining mobile. An apple and a sandwich are portable and
provide the necessary nutrients to prevent exhaustion and weight loss during mania.
3. A nurse is assessing a client for Lithium toxicity. Which of the following findings should the
nurse report to the provider immediately?
A. Fine hand tremors and mild thirst.
B. Polyuria and a metallic taste in the mouth.
C. Ataxia, blurred vision, and severe diarrhea.
D. Weight gain of 2 pounds in one week.
Correct Answer: C
Explanation: Ataxia, blurred vision, and severe diarrhea are classic signs of moderate to
severe lithium toxicity. These symptoms indicate that lithium levels may be approaching or
exceeding 2.0 mEq/L, which requires immediate medical intervention. Early signs like fine
tremors and mild thirst are common side effects and usually do not indicate toxicity.
, 4. A client is prescribed Clozapine for treatment-resistant schizophrenia. Which laboratory
value is the most critical for the nurse to monitor?
A. Serum potassium levels.
B. White blood cell (WBC) count.
C. Blood urea nitrogen (BUN).
D. Liver function tests (ALT/AST).
Correct Answer: B
Explanation: Clozapine carries a high risk for agranulocytosis, which is a life-threatening
decrease in the white blood cell count. Regular monitoring of the WBC and Absolute
Neutrophil Count (ANC) is mandatory per FDA protocols to prevent severe infection. If the
WBC count falls below specific thresholds, the medication must be discontinued
immediately.
5. A nurse is communicating with a client who is hearing auditory hallucinations. Which
statement by the nurse is therapeutic?
A. Just ignore them; they aren’t real and cannot hurt you.
B. Why do you think you are hearing those voices right now?
C. I don’t hear the voices, but I understand that they are real to you.
D. What are the voices telling you to do?
Correct Answer: C
