,NUR 208 Exam 4 | Mental Health Nursing (2026)
Actual Q&A PDF | Fortis College
1. A client with schizophrenia is experiencing auditory hallucinations. Which nursing
intervention is most appropriate initially?
A) Tell the client to ignore the voices.
B) Ask the client what the voices are saying.
C) Administer a PRN antipsychotic immediately.
D) Isolate the client to reduce stimulation.
Correct Answer: Ask the client what the voices are saying.
Rationale: Asking what the voices are saying helps assess the content, which may
indicate command hallucinations requiring immediate intervention. Telling the client to
ignore the voices is not therapeutic, administering medication without assessment may
be premature, and isolation may increase anxiety.
2. A nurse is assessing a client with borderline personality disorder who is using
splitting. Which behavior should the nurse expect?
A) The client idealizes one staff member and devalues another.
B) The client withdraws from all social interaction.
C) The client exhibits grandiosity and a need for admiration.
D) The client demonstrates a lack of remorse for harmful actions.
Correct Answer: The client idealizes one staff member and devalues another.
Rationale: Splitting is a defense mechanism common in borderline personality
disorder where the client views people as either all good or all bad. Withdrawal suggests
,schizoid traits, grandiosity is characteristic of narcissistic personality disorder, and lack
of remorse is associated with antisocial personality disorder.
3. A client with major depressive disorder states, "I am a terrible person and everything
is my fault." Which nursing response best reflects the use of cognitive-behavioral
techniques?
A) "You shouldn't say things like that about yourself."
B) "Let's examine the evidence for and against that belief."
C) "Why do you feel that way?"
D) "I'm sure you're a wonderful person."
Correct Answer: "Let's examine the evidence for and against that belief."
Rationale: Cognitive-behavioral therapy involves examining the evidence for and
against maladaptive beliefs. Asking "why" can feel interrogative, reassurance is not
therapeutic, and telling the client not to say negative things dismisses their feelings.
4. A client with bipolar disorder is experiencing acute mania. Which intervention is most
appropriate?
A) Encourage group therapy participation.
B) Provide a calm, low-stimulation environment.
C) Explore childhood conflicts.
D) Administer a stimulant medication.
Correct Answer: Provide a calm, low-stimulation environment.
Rationale: During acute mania, a calm, low-stimulation environment reduces
agitation and supports safety. Group therapy may be overstimulating, exploring
, childhood conflicts is not appropriate during acute mania, and stimulants would worsen
mania.
5. A nurse is teaching a client about lithium therapy. Which instruction should the nurse
include?
A) "Increase your sodium intake to prevent toxicity."
B) "Take the medication on an empty stomach."
C) "Maintain consistent fluid and sodium intake."
D) "Stop the medication if you feel better."
Correct Answer: "Maintain consistent fluid and sodium intake."
Rationale: Lithium levels are affected by sodium and fluid balance. Clients should
maintain consistent fluid and sodium intake to prevent toxicity. Increasing sodium
intake is not recommended, taking lithium on an empty stomach may cause GI upset,
and the medication should not be stopped abruptly.
6. A client with post-traumatic stress disorder is having a flashback. Which intervention
should the nurse implement first?
A) Encourage the client to describe the trauma in detail.
B) Guide the client to the present moment using grounding techniques.
C) Administer a PRN antipsychotic.
D) Turn off the lights to reduce stimulation.
Correct Answer: Guide the client to the present moment using grounding
techniques.
Rationale: During a flashback, the priority is to help the client reorient to the present
using grounding techniques. Encouraging detailed description of the trauma may
Actual Q&A PDF | Fortis College
1. A client with schizophrenia is experiencing auditory hallucinations. Which nursing
intervention is most appropriate initially?
A) Tell the client to ignore the voices.
B) Ask the client what the voices are saying.
C) Administer a PRN antipsychotic immediately.
D) Isolate the client to reduce stimulation.
Correct Answer: Ask the client what the voices are saying.
Rationale: Asking what the voices are saying helps assess the content, which may
indicate command hallucinations requiring immediate intervention. Telling the client to
ignore the voices is not therapeutic, administering medication without assessment may
be premature, and isolation may increase anxiety.
2. A nurse is assessing a client with borderline personality disorder who is using
splitting. Which behavior should the nurse expect?
A) The client idealizes one staff member and devalues another.
B) The client withdraws from all social interaction.
C) The client exhibits grandiosity and a need for admiration.
D) The client demonstrates a lack of remorse for harmful actions.
Correct Answer: The client idealizes one staff member and devalues another.
Rationale: Splitting is a defense mechanism common in borderline personality
disorder where the client views people as either all good or all bad. Withdrawal suggests
,schizoid traits, grandiosity is characteristic of narcissistic personality disorder, and lack
of remorse is associated with antisocial personality disorder.
3. A client with major depressive disorder states, "I am a terrible person and everything
is my fault." Which nursing response best reflects the use of cognitive-behavioral
techniques?
A) "You shouldn't say things like that about yourself."
B) "Let's examine the evidence for and against that belief."
C) "Why do you feel that way?"
D) "I'm sure you're a wonderful person."
Correct Answer: "Let's examine the evidence for and against that belief."
Rationale: Cognitive-behavioral therapy involves examining the evidence for and
against maladaptive beliefs. Asking "why" can feel interrogative, reassurance is not
therapeutic, and telling the client not to say negative things dismisses their feelings.
4. A client with bipolar disorder is experiencing acute mania. Which intervention is most
appropriate?
A) Encourage group therapy participation.
B) Provide a calm, low-stimulation environment.
C) Explore childhood conflicts.
D) Administer a stimulant medication.
Correct Answer: Provide a calm, low-stimulation environment.
Rationale: During acute mania, a calm, low-stimulation environment reduces
agitation and supports safety. Group therapy may be overstimulating, exploring
, childhood conflicts is not appropriate during acute mania, and stimulants would worsen
mania.
5. A nurse is teaching a client about lithium therapy. Which instruction should the nurse
include?
A) "Increase your sodium intake to prevent toxicity."
B) "Take the medication on an empty stomach."
C) "Maintain consistent fluid and sodium intake."
D) "Stop the medication if you feel better."
Correct Answer: "Maintain consistent fluid and sodium intake."
Rationale: Lithium levels are affected by sodium and fluid balance. Clients should
maintain consistent fluid and sodium intake to prevent toxicity. Increasing sodium
intake is not recommended, taking lithium on an empty stomach may cause GI upset,
and the medication should not be stopped abruptly.
6. A client with post-traumatic stress disorder is having a flashback. Which intervention
should the nurse implement first?
A) Encourage the client to describe the trauma in detail.
B) Guide the client to the present moment using grounding techniques.
C) Administer a PRN antipsychotic.
D) Turn off the lights to reduce stimulation.
Correct Answer: Guide the client to the present moment using grounding
techniques.
Rationale: During a flashback, the priority is to help the client reorient to the present
using grounding techniques. Encouraging detailed description of the trauma may
