PNR 200/PNR200 Final Exam V1 | Mental Health
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client who is experiencing a manic episode. Which of the following is
the priority nursing intervention?
A. Encouraging the client to participate in a group volleyball game.
B. Setting strict disciplinary rules for the client’s behavior.
C. Asking the client to lead a peer support group session.
D. Providing the client with high-calorie finger foods and fluids.
Correct Answer: D
Explanation: During a manic episode, the client is at risk for exhaustion and malnutrition
due to hyperactivity and inability to sit for meals. Providing finger foods allows the client to
consume nutrients while moving around safely. This intervention addresses physiological
needs according to Maslow’s hierarchy of needs. Group sports are often too stimulating and
competitive for a manic client.
2. A client is prescribed Lithium Carbonate for the treatment of Bipolar Disorder. The nurse
should identify that which of the following serum levels is within the therapeutic range?
A. 0.2 mEq/L
B. 0.9 mEq/L
C. 1.8 mEq/L
,D. 2.5 mEq/L
Correct Answer: B
Explanation: The therapeutic serum lithium level for maintenance is generally between
0.6 and 1.2 mEq/L. A level of 0.9 mEq/L is within this safe and effective window for mood
stabilization. Levels above 1.5 mEq/L are considered toxic and require immediate
intervention. Levels below 0.6 mEq/L are usually sub-therapeutic and may lead to
symptom relapse.
3. A client with Schizophrenia reports hearing voices telling them to ‘hurt the people around
you.’ Which of the following actions should the nurse take first?
A. Tell the client that the voices are not real and they should ignore them.
B. Ask the client to describe exactly what the voices are saying.
C. Administer a PRN dose of Haloperidol immediately.
D. Initiate one-on-one observation to ensure safety.
Correct Answer: D
Explanation: Safety is the absolute priority when a client reports command hallucinations
that involve harming others. Initiating one-on-one observation prevents the client from
acting on the voices until the crisis is stabilized. While assessing the content of the
hallucination is important, the immediate physical safety of the milieu must come first.
Dismissing the voices as not real is non-therapeutic and may cause the client to withdraw.
,4. Which of the following findings is an example of a ‘negative’ symptom of Schizophrenia?
A. Auditory hallucinations
B. Delusions of grandeur
C. Flat affect and social withdrawal
D. Disorganized speech patterns
Correct Answer: C
Explanation: Negative symptoms represent a loss or deficit in normal functioning, such as
flat affect, alogia, and avolition. Flat affect refers to a lack of emotional expression, which
significantly impacts social interaction. Hallucinations and delusions are considered
‘positive’ symptoms because they are additions to normal perception and thought.
Recognizing the difference is crucial for choosing appropriate pharmacological and
behavioral interventions.
5. A nurse is performing an admission assessment for a client with Anorexia Nervosa. Which
physical finding should the nurse expect?
A. Tachycardia and hypertension
B. Lanugo and bradycardia
C. Warm, flushed skin
D. Elevated serum potassium levels
Correct Answer: B
, Explanation: Clients with Anorexia Nervosa often exhibit lanugo (fine, downy hair) as the
body attempts to insulate itself due to low body fat. Bradycardia and hypotension are also
common compensatory mechanisms for malnutrition and starvation. Hypokalemia, not
hyperkalemia, is more likely due to purging or starvation. The skin is typically cold and
pale rather than warm and flushed.
6. A client is experiencing Alcohol Withdrawal Delirium (Delirium Tremens). Which of the
following medications is commonly used to manage these symptoms?
A. Lithium
B. Disulfiram
C. Fluoxetine
D. Lorazepam
Correct Answer: D
Explanation: Benzodiazepines like Lorazepam are the gold standard for treating alcohol
withdrawal because they stabilize vital signs and prevent seizures. They work by
enhancing the effects of GABA in the central nervous system to reduce neuronal over-
excitation. Disulfiram is used for maintenance of sobriety, not for acute withdrawal
management. Fluoxetine and Lithium have no role in the acute management of alcohol
withdrawal symptoms.
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client who is experiencing a manic episode. Which of the following is
the priority nursing intervention?
A. Encouraging the client to participate in a group volleyball game.
B. Setting strict disciplinary rules for the client’s behavior.
C. Asking the client to lead a peer support group session.
D. Providing the client with high-calorie finger foods and fluids.
Correct Answer: D
Explanation: During a manic episode, the client is at risk for exhaustion and malnutrition
due to hyperactivity and inability to sit for meals. Providing finger foods allows the client to
consume nutrients while moving around safely. This intervention addresses physiological
needs according to Maslow’s hierarchy of needs. Group sports are often too stimulating and
competitive for a manic client.
2. A client is prescribed Lithium Carbonate for the treatment of Bipolar Disorder. The nurse
should identify that which of the following serum levels is within the therapeutic range?
A. 0.2 mEq/L
B. 0.9 mEq/L
C. 1.8 mEq/L
,D. 2.5 mEq/L
Correct Answer: B
Explanation: The therapeutic serum lithium level for maintenance is generally between
0.6 and 1.2 mEq/L. A level of 0.9 mEq/L is within this safe and effective window for mood
stabilization. Levels above 1.5 mEq/L are considered toxic and require immediate
intervention. Levels below 0.6 mEq/L are usually sub-therapeutic and may lead to
symptom relapse.
3. A client with Schizophrenia reports hearing voices telling them to ‘hurt the people around
you.’ Which of the following actions should the nurse take first?
A. Tell the client that the voices are not real and they should ignore them.
B. Ask the client to describe exactly what the voices are saying.
C. Administer a PRN dose of Haloperidol immediately.
D. Initiate one-on-one observation to ensure safety.
Correct Answer: D
Explanation: Safety is the absolute priority when a client reports command hallucinations
that involve harming others. Initiating one-on-one observation prevents the client from
acting on the voices until the crisis is stabilized. While assessing the content of the
hallucination is important, the immediate physical safety of the milieu must come first.
Dismissing the voices as not real is non-therapeutic and may cause the client to withdraw.
,4. Which of the following findings is an example of a ‘negative’ symptom of Schizophrenia?
A. Auditory hallucinations
B. Delusions of grandeur
C. Flat affect and social withdrawal
D. Disorganized speech patterns
Correct Answer: C
Explanation: Negative symptoms represent a loss or deficit in normal functioning, such as
flat affect, alogia, and avolition. Flat affect refers to a lack of emotional expression, which
significantly impacts social interaction. Hallucinations and delusions are considered
‘positive’ symptoms because they are additions to normal perception and thought.
Recognizing the difference is crucial for choosing appropriate pharmacological and
behavioral interventions.
5. A nurse is performing an admission assessment for a client with Anorexia Nervosa. Which
physical finding should the nurse expect?
A. Tachycardia and hypertension
B. Lanugo and bradycardia
C. Warm, flushed skin
D. Elevated serum potassium levels
Correct Answer: B
, Explanation: Clients with Anorexia Nervosa often exhibit lanugo (fine, downy hair) as the
body attempts to insulate itself due to low body fat. Bradycardia and hypotension are also
common compensatory mechanisms for malnutrition and starvation. Hypokalemia, not
hyperkalemia, is more likely due to purging or starvation. The skin is typically cold and
pale rather than warm and flushed.
6. A client is experiencing Alcohol Withdrawal Delirium (Delirium Tremens). Which of the
following medications is commonly used to manage these symptoms?
A. Lithium
B. Disulfiram
C. Fluoxetine
D. Lorazepam
Correct Answer: D
Explanation: Benzodiazepines like Lorazepam are the gold standard for treating alcohol
withdrawal because they stabilize vital signs and prevent seizures. They work by
enhancing the effects of GABA in the central nervous system to reduce neuronal over-
excitation. Disulfiram is used for maintenance of sobriety, not for acute withdrawal
management. Fluoxetine and Lithium have no role in the acute management of alcohol
withdrawal symptoms.
