PNR 200/PNR200 Final Exam V3 | Mental Health
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client with Bipolar Disorder who is prescribed Lithium Carbonate.
Which of the following findings should the nurse identify as a priority to report to the
provider?
A. Fine hand tremors
B. Polyuria
C. Blurred vision
D. Mild nausea
Correct Answer: C
Explanation: Blurred vision is a sign of advanced lithium toxicity and requires immediate
medical attention. Fine hand tremors and mild nausea are common expected side effects
when starting lithium therapy. The nurse must monitor for more severe symptoms like
ataxia, persistent gastrointestinal upset, and confusion to ensure patient safety.
2. A client is admitted to the psychiatric unit after a suicide attempt. Which of the following is
the priority nursing intervention?
A. Initiate one-on-one constant observation.
B. Encourage the client to attend group therapy.
C. Assess the client’s support system.
,D. Administer prescribed antidepressant medication.
Correct Answer: A
Explanation: The immediate priority is the safety of the client to prevent further self-
harm. One-on-one observation ensures that the nurse can intervene immediately if the
client attempts to harm themselves again. While group therapy and social support are
important for long-term recovery, they do not address the immediate life-threatening risk.
3. A nurse is assessing a client for Neuroleptic Malignant Syndrome (NMS). Which of the
following symptoms should the nurse expect to find?
A. Hypotension and bradycardia
B. Hyporeflexia and diarrhea
C. Respiratory depression and miosis
D. Muscle rigidity and hyperpyrexia
Correct Answer: D
Explanation: Neuroleptic Malignant Syndrome is a life-threatening reaction to
antipsychotic drugs characterized by high fever (hyperpyrexia), muscle rigidity, and
autonomic instability. This condition requires immediate discontinuation of the medication
and supportive care. It is often confused with serotonin syndrome, but the lead-pipe
rigidity is a hallmark of NMS.
, 4. A nurse is providing teaching to a client starting Phenelzine. Which of the following foods
should the nurse instruct the client to avoid?
A. Cottage cheese
B. Fresh chicken breast
C. Pepperoni pizza
D. Green leafy vegetables
Correct Answer: C
Explanation: Phenelzine is an MAOI, which interacts with tyramine-rich foods to cause a
hypertensive crisis. Pepperoni and other cured meats are high in tyramine and must be
strictly avoided. Fresh meats and unaged cheeses like cottage cheese are generally safe for
consumption on this medication.
5. A client with schizophrenia is experiencing auditory hallucinations. Which is the most
appropriate therapeutic response by the nurse?
A. ‘I don’t see anyone else in the room.’
B. ‘I understand the voices are real to you, but I do not hear them.’
C. ‘You should ignore the voices; they aren’t real.’
D. ‘What are the voices saying to you?’
Correct Answer: B
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client with Bipolar Disorder who is prescribed Lithium Carbonate.
Which of the following findings should the nurse identify as a priority to report to the
provider?
A. Fine hand tremors
B. Polyuria
C. Blurred vision
D. Mild nausea
Correct Answer: C
Explanation: Blurred vision is a sign of advanced lithium toxicity and requires immediate
medical attention. Fine hand tremors and mild nausea are common expected side effects
when starting lithium therapy. The nurse must monitor for more severe symptoms like
ataxia, persistent gastrointestinal upset, and confusion to ensure patient safety.
2. A client is admitted to the psychiatric unit after a suicide attempt. Which of the following is
the priority nursing intervention?
A. Initiate one-on-one constant observation.
B. Encourage the client to attend group therapy.
C. Assess the client’s support system.
,D. Administer prescribed antidepressant medication.
Correct Answer: A
Explanation: The immediate priority is the safety of the client to prevent further self-
harm. One-on-one observation ensures that the nurse can intervene immediately if the
client attempts to harm themselves again. While group therapy and social support are
important for long-term recovery, they do not address the immediate life-threatening risk.
3. A nurse is assessing a client for Neuroleptic Malignant Syndrome (NMS). Which of the
following symptoms should the nurse expect to find?
A. Hypotension and bradycardia
B. Hyporeflexia and diarrhea
C. Respiratory depression and miosis
D. Muscle rigidity and hyperpyrexia
Correct Answer: D
Explanation: Neuroleptic Malignant Syndrome is a life-threatening reaction to
antipsychotic drugs characterized by high fever (hyperpyrexia), muscle rigidity, and
autonomic instability. This condition requires immediate discontinuation of the medication
and supportive care. It is often confused with serotonin syndrome, but the lead-pipe
rigidity is a hallmark of NMS.
, 4. A nurse is providing teaching to a client starting Phenelzine. Which of the following foods
should the nurse instruct the client to avoid?
A. Cottage cheese
B. Fresh chicken breast
C. Pepperoni pizza
D. Green leafy vegetables
Correct Answer: C
Explanation: Phenelzine is an MAOI, which interacts with tyramine-rich foods to cause a
hypertensive crisis. Pepperoni and other cured meats are high in tyramine and must be
strictly avoided. Fresh meats and unaged cheeses like cottage cheese are generally safe for
consumption on this medication.
5. A client with schizophrenia is experiencing auditory hallucinations. Which is the most
appropriate therapeutic response by the nurse?
A. ‘I don’t see anyone else in the room.’
B. ‘I understand the voices are real to you, but I do not hear them.’
C. ‘You should ignore the voices; they aren’t real.’
D. ‘What are the voices saying to you?’
Correct Answer: B
