WILKES UNIVERSITY NUR 303 MENTAL
HEALTH NURSING FINAL EXAM 4 QUESTIONS
AND CORRECT ANSWER 2026 UPDATE
COMPLETE SOLUTION
1. Client with schizophrenia hears voices instructing self-harm. Priority nursing action:
A. Ensure immediate safety and remove means
B. Discuss past trauma
C. Focus on long-term coping
D. Ignore hallucinations
Answer: A. Ensure immediate safety
Rationale: Safety is the highest priority when voices instruct self-harm.
2. Client with bipolar disorder exhibits mania and refuses to sleep. Nursing intervention:
A. Provide calm environment and structured routine
B. Encourage stimulating activities
C. Ignore sleep deprivation
D. Force sleep
Answer: A. Calm environment and structure
Rationale: Promotes rest and prevents exhaustion.
3. Early signs of lithium toxicity include:
A. Nausea, vomiting, tremors, diarrhea
B. Weight gain only
C. Sedation
D. Dry mouth
Answer: A. Nausea, vomiting, tremors
Rationale: Early detection prevents progression to severe, life-threatening toxicity.
4. Client taking MAOI eats aged cheese and develops headache and palpitations. Nursing
priority:
A. Assess for hypertensive crisis and notify provider
B. Encourage hydration
,C. Give acetaminophen
D. Ignore
Answer: A. Assess hypertensive crisis
Rationale: Tyramine-rich foods can trigger dangerous hypertension with MAOIs.
5. Nursing intervention for adolescent with depression refusing school:
A. Assess for suicidal ideation and support coping
B. Force attendance immediately
C. Punish avoidance
D. Ignore
Answer: A. Assess suicide risk
Rationale: Withdrawal and isolation may indicate high self-harm risk.
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 reduces 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 mania spends excessive money impulsively. Nursing intervention:
A. Set limits and provide supervision
B. Allow impulsive spending
C. Ignore behavior
D. Punish financially
Answer: A. Set limits
Rationale: Prevents financial harm and promotes safety.
10. 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.
11. Client with panic disorder hyperventilates. Nursing intervention:
A. Encourage slow, deep breathing and reassurance
B. Ignore
C. Criticize rapid breathing
D. Leave alone
Answer: A. Slow, deep breathing
Rationale: Reduces physiological symptoms and panic.
12. Client with major depressive disorder refuses to eat. Nursing priority:
A. Assess for physical health and suicide risk
B. Focus on therapy only
C. Ignore refusal
D. Encourage fasting
Answer: A. Assess health and suicide risk
Rationale: Malnutrition and withdrawal can be life-threatening.
HEALTH NURSING FINAL EXAM 4 QUESTIONS
AND CORRECT ANSWER 2026 UPDATE
COMPLETE SOLUTION
1. Client with schizophrenia hears voices instructing self-harm. Priority nursing action:
A. Ensure immediate safety and remove means
B. Discuss past trauma
C. Focus on long-term coping
D. Ignore hallucinations
Answer: A. Ensure immediate safety
Rationale: Safety is the highest priority when voices instruct self-harm.
2. Client with bipolar disorder exhibits mania and refuses to sleep. Nursing intervention:
A. Provide calm environment and structured routine
B. Encourage stimulating activities
C. Ignore sleep deprivation
D. Force sleep
Answer: A. Calm environment and structure
Rationale: Promotes rest and prevents exhaustion.
3. Early signs of lithium toxicity include:
A. Nausea, vomiting, tremors, diarrhea
B. Weight gain only
C. Sedation
D. Dry mouth
Answer: A. Nausea, vomiting, tremors
Rationale: Early detection prevents progression to severe, life-threatening toxicity.
4. Client taking MAOI eats aged cheese and develops headache and palpitations. Nursing
priority:
A. Assess for hypertensive crisis and notify provider
B. Encourage hydration
,C. Give acetaminophen
D. Ignore
Answer: A. Assess hypertensive crisis
Rationale: Tyramine-rich foods can trigger dangerous hypertension with MAOIs.
5. Nursing intervention for adolescent with depression refusing school:
A. Assess for suicidal ideation and support coping
B. Force attendance immediately
C. Punish avoidance
D. Ignore
Answer: A. Assess suicide risk
Rationale: Withdrawal and isolation may indicate high self-harm risk.
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 reduces 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 mania spends excessive money impulsively. Nursing intervention:
A. Set limits and provide supervision
B. Allow impulsive spending
C. Ignore behavior
D. Punish financially
Answer: A. Set limits
Rationale: Prevents financial harm and promotes safety.
10. 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.
11. Client with panic disorder hyperventilates. Nursing intervention:
A. Encourage slow, deep breathing and reassurance
B. Ignore
C. Criticize rapid breathing
D. Leave alone
Answer: A. Slow, deep breathing
Rationale: Reduces physiological symptoms and panic.
12. Client with major depressive disorder refuses to eat. Nursing priority:
A. Assess for physical health and suicide risk
B. Focus on therapy only
C. Ignore refusal
D. Encourage fasting
Answer: A. Assess health and suicide risk
Rationale: Malnutrition and withdrawal can be life-threatening.
