WILKES UNIVERSITY NUR 303 MENTAL
HEALTH NURSING EXAM 3 QUESTIONS AND
CORRECT ANSWER 2026 UPDATE COMPLETE
SOLUTION
1. Client with schizophrenia reports hearing voices telling them to harm self. Priority
nursing action:
A. Ensure immediate safety and remove means
B. Explore childhood trauma
C. Discuss long-term coping
D. Ignore the hallucinations
Answer: A. Ensure immediate safety
Rationale: Protects client from imminent self-harm; safety is top priority.
2. Early signs of lithium toxicity include:
A. Nausea, vomiting, diarrhea, tremors
B. Weight gain only
C. Sedation
D. Dry mouth
Answer: A. Nausea, vomiting, tremors
Rationale: Early recognition prevents progression to severe, life-threatening toxicity.
3. Client taking MAOI experiences severe headache and palpitations after eating aged
cheese. 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-containing foods can trigger dangerous hypertension with MAOIs.
4. Nursing intervention for adolescent with depression refusing to attend school:
A. Assess for suicidal ideation and support coping
B. Force attendance immediately
,C. Punish avoidance
D. Ignore behavior
Answer: A. Assess for suicide risk
Rationale: Withdrawal and isolation may indicate self-harm risk.
5. Client with mania 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.
6. Client with PTSD has flashbacks and nightmares. 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.
7. Client with OCD performs repetitive checking. Nursing approach:
A. Gradually limit ritual time and teach coping strategies
B. Punish behavior
C. Allow unlimited rituals
D. Ignore
Answer: A. Gradually limit rituals
Rationale: Supports exposure-response prevention therapy.
8. Client taking clozapine reports fever and sore throat. Nursing priority:
A. Monitor WBC and notify provider
B. Ignore
C. Encourage exercise
D. Increase dose
, Answer: A. Monitor WBC
Rationale: Clozapine can cause life-threatening agranulocytosis.
9. Client with bipolar disorder refuses sleep. Nursing intervention:
A. Provide calm environment and structured routine
B. Encourage stimulation
C. Ignore sleep deprivation
D. Force sleep
Answer: A. Calm environment
Rationale: Supports rest and prevents exhaustion.
10. Teaching about SSRIs:
A. May take 4–6 weeks for full effect
B. Immediate relief expected
C. Abrupt discontinuation is safe
D. Alcohol enhances effect
Answer: A. May take weeks
Rationale: Delayed onset requires patient education and adherence.
11. Client with mania spends excessive money impulsively. Nursing intervention:
A. Set limits and provide supervision
B. Encourage impulsive spending
C. Ignore behavior
D. Punish financially
Answer: A. Set limits
Rationale: Prevents financial harm and promotes safety.
12. Client with schizophrenia exhibits flat affect. This is a:
A. Negative symptom
B. Positive symptom
C. Cognitive symptom
D. Affective disorder
Answer: A. Negative symptom
Rationale: Reflects loss of normal emotional expression.
HEALTH NURSING EXAM 3 QUESTIONS AND
CORRECT ANSWER 2026 UPDATE COMPLETE
SOLUTION
1. Client with schizophrenia reports hearing voices telling them to harm self. Priority
nursing action:
A. Ensure immediate safety and remove means
B. Explore childhood trauma
C. Discuss long-term coping
D. Ignore the hallucinations
Answer: A. Ensure immediate safety
Rationale: Protects client from imminent self-harm; safety is top priority.
2. Early signs of lithium toxicity include:
A. Nausea, vomiting, diarrhea, tremors
B. Weight gain only
C. Sedation
D. Dry mouth
Answer: A. Nausea, vomiting, tremors
Rationale: Early recognition prevents progression to severe, life-threatening toxicity.
3. Client taking MAOI experiences severe headache and palpitations after eating aged
cheese. 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-containing foods can trigger dangerous hypertension with MAOIs.
4. Nursing intervention for adolescent with depression refusing to attend school:
A. Assess for suicidal ideation and support coping
B. Force attendance immediately
,C. Punish avoidance
D. Ignore behavior
Answer: A. Assess for suicide risk
Rationale: Withdrawal and isolation may indicate self-harm risk.
5. Client with mania 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.
6. Client with PTSD has flashbacks and nightmares. 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.
7. Client with OCD performs repetitive checking. Nursing approach:
A. Gradually limit ritual time and teach coping strategies
B. Punish behavior
C. Allow unlimited rituals
D. Ignore
Answer: A. Gradually limit rituals
Rationale: Supports exposure-response prevention therapy.
8. Client taking clozapine reports fever and sore throat. Nursing priority:
A. Monitor WBC and notify provider
B. Ignore
C. Encourage exercise
D. Increase dose
, Answer: A. Monitor WBC
Rationale: Clozapine can cause life-threatening agranulocytosis.
9. Client with bipolar disorder refuses sleep. Nursing intervention:
A. Provide calm environment and structured routine
B. Encourage stimulation
C. Ignore sleep deprivation
D. Force sleep
Answer: A. Calm environment
Rationale: Supports rest and prevents exhaustion.
10. Teaching about SSRIs:
A. May take 4–6 weeks for full effect
B. Immediate relief expected
C. Abrupt discontinuation is safe
D. Alcohol enhances effect
Answer: A. May take weeks
Rationale: Delayed onset requires patient education and adherence.
11. Client with mania spends excessive money impulsively. Nursing intervention:
A. Set limits and provide supervision
B. Encourage impulsive spending
C. Ignore behavior
D. Punish financially
Answer: A. Set limits
Rationale: Prevents financial harm and promotes safety.
12. Client with schizophrenia exhibits flat affect. This is a:
A. Negative symptom
B. Positive symptom
C. Cognitive symptom
D. Affective disorder
Answer: A. Negative symptom
Rationale: Reflects loss of normal emotional expression.
