Mental Health CMS Prep Part 2 2025–2026
| Questions & Answers with Verified
Solutions and Detailed Rationales |
Complete Study Guide PDF
1. A charge nurse is discussing mental status examinations with a newly licensed
nurse. Which of the following statements by the newly licensed nurse indicates an
understanding of the teaching?
A. “To assess cognitive ability, I should ask the client to count backward by
sevens.”
B. “To assess affect, I should obscure the client’s facial expression.”
C. “To assess language ability, I should instruct the client to write a sentence.”
D. “To assess judgment, I should ask the client to recall the current president.”
Correct answer✓✓A – Serial subtraction (e.g., counting backward by sevens) is a
standard test of cognitive ability and attention.
2. A charge nurse is discussing the characteristics of a nurse-client relationship
with a newly licensed nurse. Which of the following characteristics should the
nurse include in the discussion?
A. It is goal oriented.
B. Behavioral change is encouraged.
C. A termination date is established.
D. The nurse’s personal needs take priority.
Correct answer✓✓A, B, C – The therapeutic relationship is goal oriented, focuses
on client behavioral change, and includes planned termination.
,3. A nurse is caring for a client with major depressive disorder who started taking
an SSRI 1 week ago. Which of the following statements by the client indicates a
need for immediate intervention?
A. “I’m feeling a little less sad today.”
B. “I’ve been having headaches since starting this medication.”
C. “I have more energy now, and I’ve been thinking about how to end things.”
D. “I’m having trouble falling asleep.”
Correct answer✓✓C – Increased energy combined with suicidal ideation raises
risk for suicide; immediate safety measures are required.
4. A nurse is assessing a client with bipolar disorder who is experiencing acute
mania. Which of the following findings should the nurse expect?
A. Anhedonia
B. Pressured speech
C. Psychomotor retardation
D. Flat affect
Correct answer✓✓B – Pressured speech, grandiosity, decreased need for sleep,
and flight of ideas are hallmark symptoms of mania.
5. A nurse is teaching a client about lithium therapy. Which of the following
statements indicates the client understands the teaching?
A. “I should take ibuprofen if I get a headache.”
B. “I need to drink about 2 liters of fluid every day.”
C. “I can skip doses when I feel stable.”
D. “I should take my lithium on an empty stomach.”
Correct answer✓✓B – Consistent fluid intake (approximately 2–3 L/day) is
essential to maintain therapeutic lithium levels and prevent toxicity.
6. A nurse is caring for a client who is experiencing alcohol withdrawal. Which of
the following medications should the nurse anticipate administering?
, A. Lorazepam
B. Naltrexone
C. Disulfiram
D. Acamprosate
Correct answer✓✓A – Benzodiazepines (e.g., lorazepam) are first-line for alcohol
withdrawal to prevent seizures and delirium tremens.
7. A nurse is assessing a client with post-traumatic stress disorder (PTSD). Which
of the following symptoms is consistent with hyperarousal?
A. Flashbacks
B. Hypervigilance
C. Avoidance of crowds
D. Amnesia for the traumatic event
Correct answer✓✓B – Hypervigilance, exaggerated startle response, insomnia,
and irritability are hyperarousal symptoms.
8. A client with schizophrenia tells the nurse, “The CIA is poisoning my food.”
Which of the following responses is most therapeutic?
A. “That’s not true; you are safe here.”
B. “I understand you believe that, but I don’t see any evidence of that.”
C. “Let’s talk about something else.”
D. “What makes you think the CIA would do that?”
Correct answer✓✓B – This response acknowledges the client’s feelings while
presenting reality without arguing.
9. A nurse is providing education to a client who has a new prescription for
clozapine. Which of the following adverse effects should the nurse instruct the
client to report immediately?
A. Dry mouth
B. Sore throat and fever
| Questions & Answers with Verified
Solutions and Detailed Rationales |
Complete Study Guide PDF
1. A charge nurse is discussing mental status examinations with a newly licensed
nurse. Which of the following statements by the newly licensed nurse indicates an
understanding of the teaching?
A. “To assess cognitive ability, I should ask the client to count backward by
sevens.”
B. “To assess affect, I should obscure the client’s facial expression.”
C. “To assess language ability, I should instruct the client to write a sentence.”
D. “To assess judgment, I should ask the client to recall the current president.”
Correct answer✓✓A – Serial subtraction (e.g., counting backward by sevens) is a
standard test of cognitive ability and attention.
2. A charge nurse is discussing the characteristics of a nurse-client relationship
with a newly licensed nurse. Which of the following characteristics should the
nurse include in the discussion?
A. It is goal oriented.
B. Behavioral change is encouraged.
C. A termination date is established.
D. The nurse’s personal needs take priority.
Correct answer✓✓A, B, C – The therapeutic relationship is goal oriented, focuses
on client behavioral change, and includes planned termination.
,3. A nurse is caring for a client with major depressive disorder who started taking
an SSRI 1 week ago. Which of the following statements by the client indicates a
need for immediate intervention?
A. “I’m feeling a little less sad today.”
B. “I’ve been having headaches since starting this medication.”
C. “I have more energy now, and I’ve been thinking about how to end things.”
D. “I’m having trouble falling asleep.”
Correct answer✓✓C – Increased energy combined with suicidal ideation raises
risk for suicide; immediate safety measures are required.
4. A nurse is assessing a client with bipolar disorder who is experiencing acute
mania. Which of the following findings should the nurse expect?
A. Anhedonia
B. Pressured speech
C. Psychomotor retardation
D. Flat affect
Correct answer✓✓B – Pressured speech, grandiosity, decreased need for sleep,
and flight of ideas are hallmark symptoms of mania.
5. A nurse is teaching a client about lithium therapy. Which of the following
statements indicates the client understands the teaching?
A. “I should take ibuprofen if I get a headache.”
B. “I need to drink about 2 liters of fluid every day.”
C. “I can skip doses when I feel stable.”
D. “I should take my lithium on an empty stomach.”
Correct answer✓✓B – Consistent fluid intake (approximately 2–3 L/day) is
essential to maintain therapeutic lithium levels and prevent toxicity.
6. A nurse is caring for a client who is experiencing alcohol withdrawal. Which of
the following medications should the nurse anticipate administering?
, A. Lorazepam
B. Naltrexone
C. Disulfiram
D. Acamprosate
Correct answer✓✓A – Benzodiazepines (e.g., lorazepam) are first-line for alcohol
withdrawal to prevent seizures and delirium tremens.
7. A nurse is assessing a client with post-traumatic stress disorder (PTSD). Which
of the following symptoms is consistent with hyperarousal?
A. Flashbacks
B. Hypervigilance
C. Avoidance of crowds
D. Amnesia for the traumatic event
Correct answer✓✓B – Hypervigilance, exaggerated startle response, insomnia,
and irritability are hyperarousal symptoms.
8. A client with schizophrenia tells the nurse, “The CIA is poisoning my food.”
Which of the following responses is most therapeutic?
A. “That’s not true; you are safe here.”
B. “I understand you believe that, but I don’t see any evidence of that.”
C. “Let’s talk about something else.”
D. “What makes you think the CIA would do that?”
Correct answer✓✓B – This response acknowledges the client’s feelings while
presenting reality without arguing.
9. A nurse is providing education to a client who has a new prescription for
clozapine. Which of the following adverse effects should the nurse instruct the
client to report immediately?
A. Dry mouth
B. Sore throat and fever
