NUR 2488 Final Exam: Mental Health Nursing Questions and Correct
Answers with Explanation | Latest Update | Rasmussen University
1. A patient with schizophrenia is hearing voices telling him to hurt himself.
Which nursing action is the priority?
A. Encourage the patient to express his feelings.
B. Tell the patient that the voices are not real.
C. Redirect the patient to a group activity.
D. Ask the patient if he has a specific plan to carry out the command.
Answer: D
Explanation: Safety is the priority. Command hallucinations require immediate
assessment for intent and plan to prevent self-harm or harm to others.
2. A nurse is caring for a client who is taking lithium for bipolar disorder. Which
lab value should the nurse report to the provider?
A. Sodium level of 140 mEq/L
B. BUN level of 15 mg/dL
C. Potassium level of 4.2 mEq/L
D. Lithium level of 1.8 mEq/L
Answer: D
,Explanation: A lithium level of 1.8 mEq/L is above the therapeutic range (0.6-1.2 mEq/L)
and indicates toxicity.
3. Which therapeutic communication technique is being used when the nurse
says, ‘Tell me more about that’?
A. Restating
B. Exploring
C. Summarizing
D. Offering self
Answer: B
Explanation: Exploring is a technique that encourages the client to provide more detail
about a specific topic or feeling.
4. A patient is prescribed phenelzine (an MAOI). Which food should the nurse
instruct the patient to avoid?
A. Fresh strawberries
B. Aged cheddar cheese
C. Grilled chicken breast
D. Whole grain bread
Answer: B
Explanation: Aged cheeses contain tyramine, which can cause a hypertensive crisis when
taken with Monoamine Oxidase Inhibitors (MAOIs).
,5. During the termination phase of the nurse-patient relationship, which activity
is expected?
A. The nurse establishes the boundaries of the relationship.
B. The nurse identifies the patient’s strengths and weaknesses.
C. The patient discusses goals and tasks for the future.
D. The patient tests the nurse’s commitment.
Answer: C
Explanation: The termination phase focuses on summarizing progress and planning for
the transition to other resources or independent care.
6. Which defense mechanism involves a person’s refusal to acknowledge a
painful reality?
A. Projection
B. Displacement
C. Denial
D. Sublimation
Answer: C
Explanation: Denial is the refusal to accept reality or facts, acting as if a painful event,
thought, or feeling doesn’t exist.
, 7. A client with obsessive-compulsive disorder (OCD) is performing a hand-
washing ritual. How should the nurse respond initially?
A. Allow the client enough time to complete the ritual.
B. Stop the client from washing their hands immediately.
C. Tell the client that their hands are already clean.
D. Place the client in seclusion until the behavior stops.
Answer: A
Explanation: Initially, the nurse should allow the ritual to prevent overwhelming anxiety;
later, the nurse works on limiting the time spent on rituals.
8. A client is experiencing an acute panic attack. What is the priority nursing
intervention?
A. Ask the client to explain what triggered the attack.
B. Teach the client deep breathing exercises.
C. Administer an oral antidepressant.
D. Stay with the client and maintain a calm demeanor.
Answer: D
Explanation: During an acute panic attack, the priority is to ensure the client’s safety and
reduce anxiety by staying with them in a calm manner.
Answers with Explanation | Latest Update | Rasmussen University
1. A patient with schizophrenia is hearing voices telling him to hurt himself.
Which nursing action is the priority?
A. Encourage the patient to express his feelings.
B. Tell the patient that the voices are not real.
C. Redirect the patient to a group activity.
D. Ask the patient if he has a specific plan to carry out the command.
Answer: D
Explanation: Safety is the priority. Command hallucinations require immediate
assessment for intent and plan to prevent self-harm or harm to others.
2. A nurse is caring for a client who is taking lithium for bipolar disorder. Which
lab value should the nurse report to the provider?
A. Sodium level of 140 mEq/L
B. BUN level of 15 mg/dL
C. Potassium level of 4.2 mEq/L
D. Lithium level of 1.8 mEq/L
Answer: D
,Explanation: A lithium level of 1.8 mEq/L is above the therapeutic range (0.6-1.2 mEq/L)
and indicates toxicity.
3. Which therapeutic communication technique is being used when the nurse
says, ‘Tell me more about that’?
A. Restating
B. Exploring
C. Summarizing
D. Offering self
Answer: B
Explanation: Exploring is a technique that encourages the client to provide more detail
about a specific topic or feeling.
4. A patient is prescribed phenelzine (an MAOI). Which food should the nurse
instruct the patient to avoid?
A. Fresh strawberries
B. Aged cheddar cheese
C. Grilled chicken breast
D. Whole grain bread
Answer: B
Explanation: Aged cheeses contain tyramine, which can cause a hypertensive crisis when
taken with Monoamine Oxidase Inhibitors (MAOIs).
,5. During the termination phase of the nurse-patient relationship, which activity
is expected?
A. The nurse establishes the boundaries of the relationship.
B. The nurse identifies the patient’s strengths and weaknesses.
C. The patient discusses goals and tasks for the future.
D. The patient tests the nurse’s commitment.
Answer: C
Explanation: The termination phase focuses on summarizing progress and planning for
the transition to other resources or independent care.
6. Which defense mechanism involves a person’s refusal to acknowledge a
painful reality?
A. Projection
B. Displacement
C. Denial
D. Sublimation
Answer: C
Explanation: Denial is the refusal to accept reality or facts, acting as if a painful event,
thought, or feeling doesn’t exist.
, 7. A client with obsessive-compulsive disorder (OCD) is performing a hand-
washing ritual. How should the nurse respond initially?
A. Allow the client enough time to complete the ritual.
B. Stop the client from washing their hands immediately.
C. Tell the client that their hands are already clean.
D. Place the client in seclusion until the behavior stops.
Answer: A
Explanation: Initially, the nurse should allow the ritual to prevent overwhelming anxiety;
later, the nurse works on limiting the time spent on rituals.
8. A client is experiencing an acute panic attack. What is the priority nursing
intervention?
A. Ask the client to explain what triggered the attack.
B. Teach the client deep breathing exercises.
C. Administer an oral antidepressant.
D. Stay with the client and maintain a calm demeanor.
Answer: D
Explanation: During an acute panic attack, the priority is to ensure the client’s safety and
reduce anxiety by staying with them in a calm manner.
