WILKES UNIVERSITY NUR 303 MENTAL HEALTH
NURSING EXAM 2 QUESTIONS AND CORRECT
ANSWER 2026 UPDATE COMPLETE SOLUTION
1. A client with borderline personality disorder expresses intense anger toward staff. The
nurse’s best response:
A. Maintain calm, set clear boundaries, and ensure safety
B. Match the client’s anger to gain control
C. Ignore the behavior completely
D. Punish the client
Answer: A. Maintain calm and set boundaries
Rationale: Consistent, calm limits prevent escalation and maintain therapeutic relationship.
2. Client taking MAOI complains of severe headache after eating fermented sausage.
Nursing priority:
A. Assess for hypertensive crisis and notify provider
B. Encourage hydration only
C. Give acetaminophen and discharge
D. Ignore the complaint
Answer: A. Assess for hypertensive crisis
Rationale: Tyramine-rich foods can trigger life-threatening hypertension with MAOIs.
3. Early signs of lithium toxicity include:
A. Nausea, vomiting, diarrhea, tremors
B. Weight gain only
C. Dry mouth
D. Sedation only
Answer: A. Nausea, vomiting, tremors
Rationale: Early recognition allows prompt intervention before severe toxicity.
4. Client in acute manic episode is hyperverbal and distractible. Nursing priority:
A. Reduce environmental stimuli and provide structured activities
B. Encourage multitasking
,C. Allow unlimited visitors
D. Ignore hyperactivity
Answer: A. Reduce stimuli
Rationale: Prevents exhaustion and promotes focus.
5. Client with schizophrenia demonstrates auditory hallucinations. Best nursing approach:
A. Acknowledge experience but focus on reality
B. Agree with hallucinations
C. Ignore the client
D. Confront aggressively
Answer: A. Acknowledge and focus on reality
Rationale: Therapeutic communication validates feelings without reinforcing delusions.
6. Client with panic disorder hyperventilating. Nursing intervention:
A. Encourage slow, deep breathing and calm reassurance
B. Ignore symptoms
C. Criticize rapid breathing
D. Leave alone
Answer: A. Encourage slow breathing
Rationale: Reduces physiological symptoms and anxiety.
7. Priority nursing action for a client expressing suicidal ideation with a plan:
A. Ensure immediate safety and remove means
B. Discuss diet
C. Encourage long-term planning
D. Delay intervention
Answer: A. Ensure safety
Rationale: Suicide risk requires immediate crisis management.
8. Client with PTSD experiences nightmares and flashbacks. Nursing intervention:
A. Provide grounding techniques and safety
B. Encourage reliving trauma
C. Ignore symptoms
D. Punish avoidance
, Answer: A. Grounding techniques
Rationale: Helps client regain control and reduce anxiety.
9. Nursing assessment for antisocial personality disorder:
A. Disregard for others’ rights, impulsivity, lack of remorse
B. Hallucinations
C. Obsessive rituals
D. Hyperactivity only
Answer: A. Disregard for rights and impulsivity
Rationale: Core traits of antisocial personality disorder.
10. Client on clozapine develops sudden fever and sore throat. Nursing priority:
A. Monitor WBC and notify provider for potential agranulocytosis
B. Ignore mild symptoms
C. Encourage exercise
D. Increase dose
Answer: A. Monitor WBC and notify provider
Rationale: Clozapine can cause life-threatening leukopenia.
11. Client with major depression reports feeling hopeless. Nursing priority:
A. Assess for suicidal ideation
B. Discuss nutrition only
C. Encourage long-term planning
D. Avoid discussing feelings
Answer: A. Assess for suicide
Rationale: Hopelessness is a strong predictor of self-harm.
12. Child with ADHD demonstrates inattention and impulsivity in school. Best nursing
intervention:
A. Break tasks into small steps and provide positive reinforcement
B. Punish for inattentiveness
C. Expect full attention for long periods
D. Ignore inattention
NURSING EXAM 2 QUESTIONS AND CORRECT
ANSWER 2026 UPDATE COMPLETE SOLUTION
1. A client with borderline personality disorder expresses intense anger toward staff. The
nurse’s best response:
A. Maintain calm, set clear boundaries, and ensure safety
B. Match the client’s anger to gain control
C. Ignore the behavior completely
D. Punish the client
Answer: A. Maintain calm and set boundaries
Rationale: Consistent, calm limits prevent escalation and maintain therapeutic relationship.
2. Client taking MAOI complains of severe headache after eating fermented sausage.
Nursing priority:
A. Assess for hypertensive crisis and notify provider
B. Encourage hydration only
C. Give acetaminophen and discharge
D. Ignore the complaint
Answer: A. Assess for hypertensive crisis
Rationale: Tyramine-rich foods can trigger life-threatening hypertension with MAOIs.
3. Early signs of lithium toxicity include:
A. Nausea, vomiting, diarrhea, tremors
B. Weight gain only
C. Dry mouth
D. Sedation only
Answer: A. Nausea, vomiting, tremors
Rationale: Early recognition allows prompt intervention before severe toxicity.
4. Client in acute manic episode is hyperverbal and distractible. Nursing priority:
A. Reduce environmental stimuli and provide structured activities
B. Encourage multitasking
,C. Allow unlimited visitors
D. Ignore hyperactivity
Answer: A. Reduce stimuli
Rationale: Prevents exhaustion and promotes focus.
5. Client with schizophrenia demonstrates auditory hallucinations. Best nursing approach:
A. Acknowledge experience but focus on reality
B. Agree with hallucinations
C. Ignore the client
D. Confront aggressively
Answer: A. Acknowledge and focus on reality
Rationale: Therapeutic communication validates feelings without reinforcing delusions.
6. Client with panic disorder hyperventilating. Nursing intervention:
A. Encourage slow, deep breathing and calm reassurance
B. Ignore symptoms
C. Criticize rapid breathing
D. Leave alone
Answer: A. Encourage slow breathing
Rationale: Reduces physiological symptoms and anxiety.
7. Priority nursing action for a client expressing suicidal ideation with a plan:
A. Ensure immediate safety and remove means
B. Discuss diet
C. Encourage long-term planning
D. Delay intervention
Answer: A. Ensure safety
Rationale: Suicide risk requires immediate crisis management.
8. Client with PTSD experiences nightmares and flashbacks. Nursing intervention:
A. Provide grounding techniques and safety
B. Encourage reliving trauma
C. Ignore symptoms
D. Punish avoidance
, Answer: A. Grounding techniques
Rationale: Helps client regain control and reduce anxiety.
9. Nursing assessment for antisocial personality disorder:
A. Disregard for others’ rights, impulsivity, lack of remorse
B. Hallucinations
C. Obsessive rituals
D. Hyperactivity only
Answer: A. Disregard for rights and impulsivity
Rationale: Core traits of antisocial personality disorder.
10. Client on clozapine develops sudden fever and sore throat. Nursing priority:
A. Monitor WBC and notify provider for potential agranulocytosis
B. Ignore mild symptoms
C. Encourage exercise
D. Increase dose
Answer: A. Monitor WBC and notify provider
Rationale: Clozapine can cause life-threatening leukopenia.
11. Client with major depression reports feeling hopeless. Nursing priority:
A. Assess for suicidal ideation
B. Discuss nutrition only
C. Encourage long-term planning
D. Avoid discussing feelings
Answer: A. Assess for suicide
Rationale: Hopelessness is a strong predictor of self-harm.
12. Child with ADHD demonstrates inattention and impulsivity in school. Best nursing
intervention:
A. Break tasks into small steps and provide positive reinforcement
B. Punish for inattentiveness
C. Expect full attention for long periods
D. Ignore inattention
