NU160 | NU160 Mental Health Concepts Final Exam
v3 | Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is caring for a client who is experiencing a panic attack. Which of the
following actions should the nurse take first?
A. Instruct the client to use deep-breathing techniques.
B. Ask the client to explain what triggered the attack.
C. Administer an ordered PRN antianxiety medication.
D. Stay with the client and remain calm.
Correct Answer: D
Expert Explanation: Safety and presence are the priority during a panic attack to
ensure the client does not feel abandoned. Staying with the client provides a sense
of security and helps decrease the level of anxiety through a calming presence. Other
interventions like teaching or questioning are ineffective until the acute phase of
panic has subsided.
2. A client with schizophrenia is experiencing auditory hallucinations. Which response
by the nurse is therapeutic?
A. I don’t hear any voices, but I understand they are real to you.
B. Why do you think the voices are talking to you right now?
,C. You know that those voices are just a part of your illness.
D. I will turn up the radio so you can’t hear them anymore.
Correct Answer: A
Expert Explanation: This response acknowledges the client’s experience without
validating the hallucination as reality. It presents reality in a non-confrontational
way which helps build trust in the nurse-client relationship. Using ‘why’ questions
or dismissing the experience can increase the client’s defensive behavior or anxiety.
3. A nurse is monitoring a client who is taking lithium carbonate for bipolar disorder.
Which of the following findings should the nurse identify as a sign of lithium toxicity?
A. Polyuria and mild thirst
B. Fine hand tremors
C. Weight gain of 2 pounds
D. Blurred vision and ataxia
Correct Answer: D
Expert Explanation: Blurred vision, ataxia, and severe diarrhea are advanced signs
of lithium toxicity that require immediate medical attention. Fine tremors and mild
thirst are common side effects often seen at therapeutic levels. It is critical for the
,nurse to distinguish between expected side effects and toxic manifestations to
prevent permanent neurological damage.
4. A client is admitted for alcohol detoxification. Which medication should the nurse
expect the provider to prescribe to manage acute withdrawal symptoms?
A. Disulfiram
B. Methadone
C. Chlordiazepoxide
D. Varenicline
Correct Answer: C
Expert Explanation: Benzodiazepines like chlordiazepoxide are the gold standard
for managing acute alcohol withdrawal to prevent seizures and delirium tremens.
Disulfiram is used for maintenance of sobriety after detox, not during the acute
phase. Methadone is specifically used for opioid use disorder rather than alcohol
withdrawal.
5. Which of the following defense mechanisms is a client using when they say, ‘I only
drink because my spouse is so stressful to live with’?
A. Projection
B. Sublimation
, C. Displacement
D. Rationalization
Correct Answer: D
Expert Explanation: Rationalization involves creating logical-sounding excuses to
justify unacceptable behavior or feelings. In this case, the client is blaming an
external factor to justify their substance use. This differs from projection, where one
attributes their own unacceptable impulses to others.
6. A nurse is caring for a client with anorexia nervosa. Which of the following is a
priority nursing intervention during the first week of treatment?
A. Monitoring the client’s weight daily in only a gown.
B. Discussing the client’s distorted body image.
C. Promoting a high-intensity exercise routine.
D. Encouraging the client to lead group therapy.
Correct Answer: A
Expert Explanation: Accurate daily weights are essential to monitor the physical
stability of a client with anorexia nervosa. Weighing the client in a gown prevents
them from hiding objects to artificially increase weight. Physiological stability must
v3 | Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is caring for a client who is experiencing a panic attack. Which of the
following actions should the nurse take first?
A. Instruct the client to use deep-breathing techniques.
B. Ask the client to explain what triggered the attack.
C. Administer an ordered PRN antianxiety medication.
D. Stay with the client and remain calm.
Correct Answer: D
Expert Explanation: Safety and presence are the priority during a panic attack to
ensure the client does not feel abandoned. Staying with the client provides a sense
of security and helps decrease the level of anxiety through a calming presence. Other
interventions like teaching or questioning are ineffective until the acute phase of
panic has subsided.
2. A client with schizophrenia is experiencing auditory hallucinations. Which response
by the nurse is therapeutic?
A. I don’t hear any voices, but I understand they are real to you.
B. Why do you think the voices are talking to you right now?
,C. You know that those voices are just a part of your illness.
D. I will turn up the radio so you can’t hear them anymore.
Correct Answer: A
Expert Explanation: This response acknowledges the client’s experience without
validating the hallucination as reality. It presents reality in a non-confrontational
way which helps build trust in the nurse-client relationship. Using ‘why’ questions
or dismissing the experience can increase the client’s defensive behavior or anxiety.
3. A nurse is monitoring a client who is taking lithium carbonate for bipolar disorder.
Which of the following findings should the nurse identify as a sign of lithium toxicity?
A. Polyuria and mild thirst
B. Fine hand tremors
C. Weight gain of 2 pounds
D. Blurred vision and ataxia
Correct Answer: D
Expert Explanation: Blurred vision, ataxia, and severe diarrhea are advanced signs
of lithium toxicity that require immediate medical attention. Fine tremors and mild
thirst are common side effects often seen at therapeutic levels. It is critical for the
,nurse to distinguish between expected side effects and toxic manifestations to
prevent permanent neurological damage.
4. A client is admitted for alcohol detoxification. Which medication should the nurse
expect the provider to prescribe to manage acute withdrawal symptoms?
A. Disulfiram
B. Methadone
C. Chlordiazepoxide
D. Varenicline
Correct Answer: C
Expert Explanation: Benzodiazepines like chlordiazepoxide are the gold standard
for managing acute alcohol withdrawal to prevent seizures and delirium tremens.
Disulfiram is used for maintenance of sobriety after detox, not during the acute
phase. Methadone is specifically used for opioid use disorder rather than alcohol
withdrawal.
5. Which of the following defense mechanisms is a client using when they say, ‘I only
drink because my spouse is so stressful to live with’?
A. Projection
B. Sublimation
, C. Displacement
D. Rationalization
Correct Answer: D
Expert Explanation: Rationalization involves creating logical-sounding excuses to
justify unacceptable behavior or feelings. In this case, the client is blaming an
external factor to justify their substance use. This differs from projection, where one
attributes their own unacceptable impulses to others.
6. A nurse is caring for a client with anorexia nervosa. Which of the following is a
priority nursing intervention during the first week of treatment?
A. Monitoring the client’s weight daily in only a gown.
B. Discussing the client’s distorted body image.
C. Promoting a high-intensity exercise routine.
D. Encouraging the client to lead group therapy.
Correct Answer: A
Expert Explanation: Accurate daily weights are essential to monitor the physical
stability of a client with anorexia nervosa. Weighing the client in a gown prevents
them from hiding objects to artificially increase weight. Physiological stability must
