PNR 200/PNR200 Exam 3 V3 | Mental Health
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client with a history of alcohol use disorder who is experiencing
tremors, tachycardia, and diaphoresis. Which of the following is the priority nursing action?
A. Administer a prescribed benzodiazepine.
B. Encourage oral fluid intake.
C. Provide a quiet, low-stimulus environment.
D. Assess the client’s blood alcohol level.
Correct Answer: A
Explanation: The client is exhibiting signs of acute alcohol withdrawal, which can progress
to life-threatening seizures or delirium tremens. Benzodiazepines like lorazepam are the
first-line treatment to stabilize vital signs and prevent progression. Safety is the priority,
and pharmacological intervention is necessary to manage these physiological symptoms.
2. A client is admitted to the unit for treatment of Obsessive-Compulsive Disorder (OCD).
Which nursing intervention should be implemented during the initial phase of treatment?
A. Prevent the client from performing rituals.
B. Allow the client enough time to perform rituals.
C. Limit the client’s handwashing to twice daily.
D. Confront the client about the absurdity of the rituals.
,Correct Answer: B
Explanation: In the initial phase of OCD treatment, the nurse should allow the client to
perform rituals to avoid extreme anxiety. Abruptly stopping rituals can cause the client’s
anxiety to escalate to panic levels. Over time, the nurse will work with the client to develop
coping mechanisms and gradually decrease the time spent on rituals.
3. The nurse is reviewing the lab results for a client taking Lithium carbonate for Bipolar
Disorder. The lithium level is 1.8 mEq/L. Which action should the nurse take first?
A. Hold the dose and notify the provider.
B. Request an increase in the dosage.
C. Administer the next dose as scheduled.
D. Encourage the client to increase sodium intake.
Correct Answer: A
Explanation: The therapeutic range for lithium is 0.6 to 1.2 mEq/L, and levels above 1.5
mEq/L indicate toxicity. A level of 1.8 mEq/L requires immediate intervention to prevent
severe neurological damage or cardiac issues. The nurse must hold the medication and
report the finding to the physician immediately.
4. A client diagnosed with schizophrenia is experiencing auditory hallucinations. Which is the
most therapeutic response by the nurse?
A. “I don’t hear the voices, but I understand they are real to you.”
B. “You know those voices are just a symptom of your illness.”
, C. “What are the voices telling you to do right now?”
D. “I will turn up the radio to drown out the voices for you.”
Correct Answer: C
Explanation: The priority is to assess for ‘command hallucinations’ which might instruct
the client to harm themselves or others. By asking what the voices are saying, the nurse can
assess for safety risks. Validating the client’s experience while stating reality is also
important, but safety assessment comes first.
5. Which of the following foods should a nurse instruct a client taking Phenelzine (Nardil) to
avoid?
A. Fresh chicken and broccoli.
B. Whole grain bread and butter.
C. Aged cheddar cheese and red wine.
D. Apples and orange juice.
Correct Answer: C
Explanation: Phenelzine is a Monoamine Oxidase Inhibitor (MAOI) that interacts with
tyramine-rich foods. Consumption of aged cheeses, cured meats, and fermented beverages
can lead to a hypertensive crisis. This is a life-threatening emergency characterized by
severe headache and extreme blood pressure elevation.
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client with a history of alcohol use disorder who is experiencing
tremors, tachycardia, and diaphoresis. Which of the following is the priority nursing action?
A. Administer a prescribed benzodiazepine.
B. Encourage oral fluid intake.
C. Provide a quiet, low-stimulus environment.
D. Assess the client’s blood alcohol level.
Correct Answer: A
Explanation: The client is exhibiting signs of acute alcohol withdrawal, which can progress
to life-threatening seizures or delirium tremens. Benzodiazepines like lorazepam are the
first-line treatment to stabilize vital signs and prevent progression. Safety is the priority,
and pharmacological intervention is necessary to manage these physiological symptoms.
2. A client is admitted to the unit for treatment of Obsessive-Compulsive Disorder (OCD).
Which nursing intervention should be implemented during the initial phase of treatment?
A. Prevent the client from performing rituals.
B. Allow the client enough time to perform rituals.
C. Limit the client’s handwashing to twice daily.
D. Confront the client about the absurdity of the rituals.
,Correct Answer: B
Explanation: In the initial phase of OCD treatment, the nurse should allow the client to
perform rituals to avoid extreme anxiety. Abruptly stopping rituals can cause the client’s
anxiety to escalate to panic levels. Over time, the nurse will work with the client to develop
coping mechanisms and gradually decrease the time spent on rituals.
3. The nurse is reviewing the lab results for a client taking Lithium carbonate for Bipolar
Disorder. The lithium level is 1.8 mEq/L. Which action should the nurse take first?
A. Hold the dose and notify the provider.
B. Request an increase in the dosage.
C. Administer the next dose as scheduled.
D. Encourage the client to increase sodium intake.
Correct Answer: A
Explanation: The therapeutic range for lithium is 0.6 to 1.2 mEq/L, and levels above 1.5
mEq/L indicate toxicity. A level of 1.8 mEq/L requires immediate intervention to prevent
severe neurological damage or cardiac issues. The nurse must hold the medication and
report the finding to the physician immediately.
4. A client diagnosed with schizophrenia is experiencing auditory hallucinations. Which is the
most therapeutic response by the nurse?
A. “I don’t hear the voices, but I understand they are real to you.”
B. “You know those voices are just a symptom of your illness.”
, C. “What are the voices telling you to do right now?”
D. “I will turn up the radio to drown out the voices for you.”
Correct Answer: C
Explanation: The priority is to assess for ‘command hallucinations’ which might instruct
the client to harm themselves or others. By asking what the voices are saying, the nurse can
assess for safety risks. Validating the client’s experience while stating reality is also
important, but safety assessment comes first.
5. Which of the following foods should a nurse instruct a client taking Phenelzine (Nardil) to
avoid?
A. Fresh chicken and broccoli.
B. Whole grain bread and butter.
C. Aged cheddar cheese and red wine.
D. Apples and orange juice.
Correct Answer: C
Explanation: Phenelzine is a Monoamine Oxidase Inhibitor (MAOI) that interacts with
tyramine-rich foods. Consumption of aged cheeses, cured meats, and fermented beverages
can lead to a hypertensive crisis. This is a life-threatening emergency characterized by
severe headache and extreme blood pressure elevation.
