PNR 200/PNR200 Exam 4 V2 | Mental Health
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client with a history of lithium carbonate use for bipolar disorder.
The client’s current lithium level is 2.1 mEq/L. Which action should the nurse take first?
A. Administer the next scheduled dose as prescribed.
B. Request a repeat lab test to verify the results.
C. Immediately notify the healthcare provider and hold the medication.
D. Increase the client’s daily fluid intake to 3,000 mL.
Correct Answer: C
Explanation: A lithium level of 2.1 mEq/L is considered toxic as the therapeutic range is
generally 0.6 to 1.2 mEq/L. The nurse must prioritize patient safety by withholding the
medication to prevent further toxicity. Immediate notification of the provider is necessary
to initiate medical interventions such as gastric lavage or hemodialysis if required.
2. A client is experiencing a manic episode and is pacing the hallway, shouting, and disrupting
other clients. Which nursing intervention is most appropriate?
A. Place the client in a quiet area with low stimuli.
B. Encourage the client to join a group therapy session.
C. Ask the client to explain why they are feeling upset.
D. Provide the client with a complex puzzle to focus their energy.
,Correct Answer: A
Explanation: During a manic episode, clients are easily overstimulated and can become
aggressive or exhausted. Moving the client to a low-stimulus environment helps decrease
agitation and promotes safety for the client and others. Directing them to group activities
or complex tasks would likely increase their frustration and escalate the mania.
3. The nurse is assessing a client prescribed Clozapine for treatment-resistant schizophrenia.
Which laboratory value should the nurse monitor most closely?
A. Serum potassium levels
B. Liver enzymes
C. Hemoglobin and Hematocrit
D. White blood cell (WBC) count
Correct Answer: D
Explanation: Clozapine is associated with a high risk of agranulocytosis, a life-threatening
decrease in white blood cells. National protocols require regular monitoring of the absolute
neutrophil count (ANC) and WBC count to detect this condition early. If the count falls
below a specific threshold, the medication must be discontinued immediately to prevent
severe infection.
4. Which statement by a client with a history of Major Depressive Disorder indicates a
possible transition from suicidal ideation to a suicide plan?
A. ‘I’ve decided to give my favorite guitar to my nephew tomorrow.’
, B. ‘I don’t think things will ever get better for me.’
C. ‘I am feeling very tired and just want to sleep all day.’
D. ‘My family would be better off if I wasn’t around.’
Correct Answer: A
Explanation: Giving away prized possessions is a red flag indicating the client may have
finalized a suicide plan and is settling their affairs. While the other statements reflect
hopelessness and passive ideation, the act of distributing belongings suggests imminent
intent. The nurse must perform a lethality assessment and implement suicide precautions
immediately.
5. A client diagnosed with Obsessive-Compulsive Disorder (OCD) spends two hours washing
their hands every morning. What is the nurse’s initial goal?
A. Prohibit the client from using the sink for the first hour of the day.
B. Provide the client with skin lotion to prevent breakdown.
C. Explain to the client that their hands are already clean.
D. Allow the client time to perform the ritual to decrease anxiety.
Correct Answer: D
Explanation: In the initial phase of treatment for OCD, preventing the ritual can lead to
overwhelming anxiety and panic. The nurse should allow the client to perform the ritual
while gradually working on a schedule to limit the time spent. Forcing the client to stop
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client with a history of lithium carbonate use for bipolar disorder.
The client’s current lithium level is 2.1 mEq/L. Which action should the nurse take first?
A. Administer the next scheduled dose as prescribed.
B. Request a repeat lab test to verify the results.
C. Immediately notify the healthcare provider and hold the medication.
D. Increase the client’s daily fluid intake to 3,000 mL.
Correct Answer: C
Explanation: A lithium level of 2.1 mEq/L is considered toxic as the therapeutic range is
generally 0.6 to 1.2 mEq/L. The nurse must prioritize patient safety by withholding the
medication to prevent further toxicity. Immediate notification of the provider is necessary
to initiate medical interventions such as gastric lavage or hemodialysis if required.
2. A client is experiencing a manic episode and is pacing the hallway, shouting, and disrupting
other clients. Which nursing intervention is most appropriate?
A. Place the client in a quiet area with low stimuli.
B. Encourage the client to join a group therapy session.
C. Ask the client to explain why they are feeling upset.
D. Provide the client with a complex puzzle to focus their energy.
,Correct Answer: A
Explanation: During a manic episode, clients are easily overstimulated and can become
aggressive or exhausted. Moving the client to a low-stimulus environment helps decrease
agitation and promotes safety for the client and others. Directing them to group activities
or complex tasks would likely increase their frustration and escalate the mania.
3. The nurse is assessing a client prescribed Clozapine for treatment-resistant schizophrenia.
Which laboratory value should the nurse monitor most closely?
A. Serum potassium levels
B. Liver enzymes
C. Hemoglobin and Hematocrit
D. White blood cell (WBC) count
Correct Answer: D
Explanation: Clozapine is associated with a high risk of agranulocytosis, a life-threatening
decrease in white blood cells. National protocols require regular monitoring of the absolute
neutrophil count (ANC) and WBC count to detect this condition early. If the count falls
below a specific threshold, the medication must be discontinued immediately to prevent
severe infection.
4. Which statement by a client with a history of Major Depressive Disorder indicates a
possible transition from suicidal ideation to a suicide plan?
A. ‘I’ve decided to give my favorite guitar to my nephew tomorrow.’
, B. ‘I don’t think things will ever get better for me.’
C. ‘I am feeling very tired and just want to sleep all day.’
D. ‘My family would be better off if I wasn’t around.’
Correct Answer: A
Explanation: Giving away prized possessions is a red flag indicating the client may have
finalized a suicide plan and is settling their affairs. While the other statements reflect
hopelessness and passive ideation, the act of distributing belongings suggests imminent
intent. The nurse must perform a lethality assessment and implement suicide precautions
immediately.
5. A client diagnosed with Obsessive-Compulsive Disorder (OCD) spends two hours washing
their hands every morning. What is the nurse’s initial goal?
A. Prohibit the client from using the sink for the first hour of the day.
B. Provide the client with skin lotion to prevent breakdown.
C. Explain to the client that their hands are already clean.
D. Allow the client time to perform the ritual to decrease anxiety.
Correct Answer: D
Explanation: In the initial phase of treatment for OCD, preventing the ritual can lead to
overwhelming anxiety and panic. The nurse should allow the client to perform the ritual
while gradually working on a schedule to limit the time spent. Forcing the client to stop
