Psychiatric mENTAl
HEALTH NURSING
QUESTIONS & ANSWERS WITH
RATIONALES
, PSYCHIATRIC MENTAL HEALTH NURSING MIDTERM EXAM
1. A client with major depressive disorder says, "I'm a burden to everyone and my family would be
better off without me." Which response by the nurse is most therapeutic?
A. "Why do you feel that way?"
B. "You have a lot to live for, don't say that."
C. "You feel like your family would be better off without you?"
D. "I'm sure your family loves you very much."
Answer: C
Rationale: This is a reflective response that encourages the client to elaborate on their feelings
without judgment. "Why" questions (Option A) can make the client feel defensive. False reassurance
(Options B and D) is non-therapeutic because it dismisses and invalidates the client's feelings.
2. A client with bipolar disorder is prescribed lithium carbonate. Which of the following laboratory
values should the nurse monitor closely to prevent lithium toxicity?
A. Serum calcium
B. Serum sodium
C. Serum potassium
D. Serum magnesium
Answer: B
Rationale: Lithium is a salt, and the body handles it similarly to sodium. Low serum sodium levels can
lead to lithium retention and subsequent toxicity. The nurse should monitor serum sodium and
encourage adequate fluid and consistent salt intake.
3. A client with schizophrenia is experiencing command hallucinations telling them to harm others.
What is the priority nursing intervention?
A. Administer PRN antipsychotic medication.
B. Place the client in a quiet, isolated room.
C. Assess the client's intent and plan to act on the hallucinations.
D. Engage the client in a distracting activity.
Answer: C
Rationale: Safety is always the absolute priority. The nurse must first assess the client's intent and
specific plan to determine the level of risk and the need for immediate, escalated interventions (e.g.,
one-to-one observation, notifying the provider).
4. A client is experiencing a severe panic attack. Which of the following actions should the nurse take
first?
A. Teach the client deep breathing exercises.
B. Stay with the client and speak in calm, short, simple sentences.
C. Ask the client to identify the trigger for the panic attack.
D. Administer an ordered benzodiazepine immediately.
Answer: B
,Rationale: During a severe panic attack, the client's cognitive ability to process information is severely
diminished. The nurse's presence and a calm, simple environment provide safety and grounding.
Teaching (Option A) or asking analytical questions (Option C) is ineffective until the panic subsides.
5. A client with anorexia nervosa is involuntarily admitted to the psychiatric unit. Which of the
following statements by the client indicates an understanding of their rights regarding involuntary
admission?
A. "I can leave the hospital whenever I want."
B. "I have the right to refuse all medications, even in an emergency."
C. "I can request a hearing to contest my admission."
D. "My family can make all medical decisions for me without my input."
Answer: C
Rationale: Clients who are involuntarily admitted retain their civil rights, including the right to due
process, which means they can request a legal hearing to contest the admission. They do not have the
right to leave at will (Option A). In life-threatening emergencies, medication can be given over refusal
(Option B). Competent clients retain the right to make their own medical decisions (Option D).
6. A client with major depressive disorder has been on a selective serotonin reuptake inhibitor (SSRI)
for two weeks. The client's mood appears to have improved, and they have more energy. What is the
most important action for the nurse to take?
A. Document the improvement and continue the current care plan.
B. Assess the client for suicidal ideation.
C. Encourage the client to participate in more group activities.
D. Prepare the client for discharge.
Answer: B
Rationale: As depression begins to lift and physical energy returns, the client may gain the energy
required to act on pre-existing suicidal thoughts. The risk of suicide can actually increase during the
initial weeks of antidepressant therapy before the mood fully and safely stabilizes.
7. A client with borderline personality disorder says, "The night nurse is so mean, but you are the only
nurse who really understands me." What is the best response by the nurse?
A. "Thank you, I always try to be the best nurse I can be."
B. "It sounds like you are having difficulty with the night nurse. Let's talk about it."
C. "All of the nurses on this unit are here to help you and provide good care."
D. "Why do you think the night nurse is mean?"
Answer: C
Rationale: This response sets a professional boundary and actively avoids "splitting," a common
defense mechanism in borderline personality disorder where staff are viewed as either "all good" or
"all bad." It reinforces the unity and consistency of the treatment team.
8. A client is prescribed phenelzine, a monoamine oxidase inhibitor (MAOI). Which of the following
foods should the nurse instruct the client to avoid?
A. Fresh fruits and vegetables
B. Aged cheese and cured meats
C. Whole grain bread and pasta
D. Lean poultry and fish
, Answer: B
Rationale: MAOIs can cause a life-threatening hypertensive crisis if the client consumes foods high in
tyramine. Aged cheeses, cured or smoked meats, draft beer, and certain wines are high in tyramine
and must be strictly avoided.
9. A client is admitted to the detoxification unit with a history of heavy alcohol use. The client's last
drink was 12 hours ago. Which of the following symptoms should the nurse monitor for as an early
sign of alcohol withdrawal?
A. Bradycardia and hypotension
B. Diaphoresis, tremors, and anxiety
C. Hypothermia and lethargy
D. Decreased respiratory rate
Answer: B
Rationale: Early signs of alcohol withdrawal (typically occurring within 6–24 hours after the last drink)
include autonomic nervous system hyperactivity, such as diaphoresis (sweating), tremors,
tachycardia, hypertension, and anxiety.
10. What is the primary goal of the therapeutic milieu in a psychiatric inpatient setting?
A. To keep clients occupied with activities throughout the day.
B. To provide a safe, structured environment that promotes healing and positive behavioral changes.
C. To ensure that all clients adhere strictly to a rigid schedule.
D. To isolate clients who exhibit disruptive behaviors.
Answer: B
Rationale: The therapeutic milieu is intentionally designed to be a safe, structured, and supportive
environment that encourages positive social interactions, the development of coping skills, and
constructive behavioral changes.
11. A client in a manic episode has not slept for three days and is pacing the hallway, talking rapidly,
and demanding to speak to the hospital administrator. What is the most appropriate nursing
intervention?
A. Allow the client to pace as it expends energy.
B. Provide a quiet environment and offer high-calorie, finger foods.
C. Confront the client about their unrealistic demands.
D. Restrict the client to their room until they calm down.
Answer: B
Rationale: Clients in a manic state have extreme energy expenditure, poor concentration, and a short
attention span. A quiet environment reduces overstimulation, and high-calorie finger foods allow
them to eat while moving, preventing physical exhaustion and malnutrition.
12. A client with post-traumatic stress disorder (PTSD) experiences a flashback. What is the priority
nursing intervention?
A. Ask the client to describe the traumatic event in detail.
B. Leave the client alone to process the experience.
C. Gently orient the client to the present time and place, assuring them they are safe.
D. Administer a PRN sedative immediately.
Answer: C
HEALTH NURSING
QUESTIONS & ANSWERS WITH
RATIONALES
, PSYCHIATRIC MENTAL HEALTH NURSING MIDTERM EXAM
1. A client with major depressive disorder says, "I'm a burden to everyone and my family would be
better off without me." Which response by the nurse is most therapeutic?
A. "Why do you feel that way?"
B. "You have a lot to live for, don't say that."
C. "You feel like your family would be better off without you?"
D. "I'm sure your family loves you very much."
Answer: C
Rationale: This is a reflective response that encourages the client to elaborate on their feelings
without judgment. "Why" questions (Option A) can make the client feel defensive. False reassurance
(Options B and D) is non-therapeutic because it dismisses and invalidates the client's feelings.
2. A client with bipolar disorder is prescribed lithium carbonate. Which of the following laboratory
values should the nurse monitor closely to prevent lithium toxicity?
A. Serum calcium
B. Serum sodium
C. Serum potassium
D. Serum magnesium
Answer: B
Rationale: Lithium is a salt, and the body handles it similarly to sodium. Low serum sodium levels can
lead to lithium retention and subsequent toxicity. The nurse should monitor serum sodium and
encourage adequate fluid and consistent salt intake.
3. A client with schizophrenia is experiencing command hallucinations telling them to harm others.
What is the priority nursing intervention?
A. Administer PRN antipsychotic medication.
B. Place the client in a quiet, isolated room.
C. Assess the client's intent and plan to act on the hallucinations.
D. Engage the client in a distracting activity.
Answer: C
Rationale: Safety is always the absolute priority. The nurse must first assess the client's intent and
specific plan to determine the level of risk and the need for immediate, escalated interventions (e.g.,
one-to-one observation, notifying the provider).
4. A client is experiencing a severe panic attack. Which of the following actions should the nurse take
first?
A. Teach the client deep breathing exercises.
B. Stay with the client and speak in calm, short, simple sentences.
C. Ask the client to identify the trigger for the panic attack.
D. Administer an ordered benzodiazepine immediately.
Answer: B
,Rationale: During a severe panic attack, the client's cognitive ability to process information is severely
diminished. The nurse's presence and a calm, simple environment provide safety and grounding.
Teaching (Option A) or asking analytical questions (Option C) is ineffective until the panic subsides.
5. A client with anorexia nervosa is involuntarily admitted to the psychiatric unit. Which of the
following statements by the client indicates an understanding of their rights regarding involuntary
admission?
A. "I can leave the hospital whenever I want."
B. "I have the right to refuse all medications, even in an emergency."
C. "I can request a hearing to contest my admission."
D. "My family can make all medical decisions for me without my input."
Answer: C
Rationale: Clients who are involuntarily admitted retain their civil rights, including the right to due
process, which means they can request a legal hearing to contest the admission. They do not have the
right to leave at will (Option A). In life-threatening emergencies, medication can be given over refusal
(Option B). Competent clients retain the right to make their own medical decisions (Option D).
6. A client with major depressive disorder has been on a selective serotonin reuptake inhibitor (SSRI)
for two weeks. The client's mood appears to have improved, and they have more energy. What is the
most important action for the nurse to take?
A. Document the improvement and continue the current care plan.
B. Assess the client for suicidal ideation.
C. Encourage the client to participate in more group activities.
D. Prepare the client for discharge.
Answer: B
Rationale: As depression begins to lift and physical energy returns, the client may gain the energy
required to act on pre-existing suicidal thoughts. The risk of suicide can actually increase during the
initial weeks of antidepressant therapy before the mood fully and safely stabilizes.
7. A client with borderline personality disorder says, "The night nurse is so mean, but you are the only
nurse who really understands me." What is the best response by the nurse?
A. "Thank you, I always try to be the best nurse I can be."
B. "It sounds like you are having difficulty with the night nurse. Let's talk about it."
C. "All of the nurses on this unit are here to help you and provide good care."
D. "Why do you think the night nurse is mean?"
Answer: C
Rationale: This response sets a professional boundary and actively avoids "splitting," a common
defense mechanism in borderline personality disorder where staff are viewed as either "all good" or
"all bad." It reinforces the unity and consistency of the treatment team.
8. A client is prescribed phenelzine, a monoamine oxidase inhibitor (MAOI). Which of the following
foods should the nurse instruct the client to avoid?
A. Fresh fruits and vegetables
B. Aged cheese and cured meats
C. Whole grain bread and pasta
D. Lean poultry and fish
, Answer: B
Rationale: MAOIs can cause a life-threatening hypertensive crisis if the client consumes foods high in
tyramine. Aged cheeses, cured or smoked meats, draft beer, and certain wines are high in tyramine
and must be strictly avoided.
9. A client is admitted to the detoxification unit with a history of heavy alcohol use. The client's last
drink was 12 hours ago. Which of the following symptoms should the nurse monitor for as an early
sign of alcohol withdrawal?
A. Bradycardia and hypotension
B. Diaphoresis, tremors, and anxiety
C. Hypothermia and lethargy
D. Decreased respiratory rate
Answer: B
Rationale: Early signs of alcohol withdrawal (typically occurring within 6–24 hours after the last drink)
include autonomic nervous system hyperactivity, such as diaphoresis (sweating), tremors,
tachycardia, hypertension, and anxiety.
10. What is the primary goal of the therapeutic milieu in a psychiatric inpatient setting?
A. To keep clients occupied with activities throughout the day.
B. To provide a safe, structured environment that promotes healing and positive behavioral changes.
C. To ensure that all clients adhere strictly to a rigid schedule.
D. To isolate clients who exhibit disruptive behaviors.
Answer: B
Rationale: The therapeutic milieu is intentionally designed to be a safe, structured, and supportive
environment that encourages positive social interactions, the development of coping skills, and
constructive behavioral changes.
11. A client in a manic episode has not slept for three days and is pacing the hallway, talking rapidly,
and demanding to speak to the hospital administrator. What is the most appropriate nursing
intervention?
A. Allow the client to pace as it expends energy.
B. Provide a quiet environment and offer high-calorie, finger foods.
C. Confront the client about their unrealistic demands.
D. Restrict the client to their room until they calm down.
Answer: B
Rationale: Clients in a manic state have extreme energy expenditure, poor concentration, and a short
attention span. A quiet environment reduces overstimulation, and high-calorie finger foods allow
them to eat while moving, preventing physical exhaustion and malnutrition.
12. A client with post-traumatic stress disorder (PTSD) experiences a flashback. What is the priority
nursing intervention?
A. Ask the client to describe the traumatic event in detail.
B. Leave the client alone to process the experience.
C. Gently orient the client to the present time and place, assuring them they are safe.
D. Administer a PRN sedative immediately.
Answer: C
