NU160 | NU160 Mental Health Concepts Exam 2 v3
| Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is caring for a client who is taking lithium carbonate for bipolar disorder.
The nurse should monitor which of the following laboratory values most closely to
prevent toxicity?
A. Serum glucose levels
B. Serum sodium levels
C. Liver function tests
D. Hemoglobin and hematocrit
Correct Answer: B
Expert Explanation: Lithium is a salt and is handled by the kidneys in a manner
similar to sodium. When sodium levels are low, the kidneys retain lithium, which
can lead to toxic levels in the blood. Therefore, maintaining consistent sodium
intake and monitoring serum sodium levels is critical for patient safety.
2. A client is admitted to the psychiatric unit with a diagnosis of major depressive
disorder. Which of the following is the priority assessment for the nurse to perform?
A. The client’s ability to perform ADLs
B. The client’s risk for self-harm or suicide
,C. The client’s sleep patterns over the last month
D. The client’s nutritional intake and weight loss
Correct Answer: B
Expert Explanation: Patient safety is always the highest priority in mental health
nursing. Clients with major depressive disorder are at a significantly higher risk for
suicidal ideation and attempts. Assessing for a specific plan and the means to carry
it out is the first step in ensuring a safe environment.
3. A client experiencing a manic episode is running around the unit, interrupting
others, and not eating. Which of the following nursing interventions is most
appropriate?
A. Ask the client to sit down for a full meal in the dining room.
B. Place the client in physical restraints to prevent exhaustion.
C. Provide the client with high-calorie finger foods.
D. Request a sedative medication to stop the behavior immediately.
Correct Answer: C
Expert Explanation: Clients in a manic state often have difficulty sitting still long
enough to eat a traditional meal. Providing high-calorie finger foods allows the
client to maintain nutrition while on the move. This intervention addresses
,physiological needs without escalating the client’s agitation or imposing
unnecessary restrictions.
4. A nurse is teaching a client who has a new prescription for phenelzine (an MAOI).
Which of the following foods should the nurse instruct the client to avoid?
A. Fresh green leafy vegetables
B. Citrus fruits and juices
C. Whole grain breads and cereals
D. Aged cheeses and cured meats
Correct Answer: D
Expert Explanation: Phenelzine is an MAOI which interacts with tyramine-rich
foods to cause a hypertensive crisis. Aged cheeses, cured meats, and fermented
products are all high in tyramine and must be avoided. The nurse must provide a
comprehensive list of restricted foods to ensure the client understands the risks of
dietary non-compliance.
5. A client with Obsessive-Compulsive Disorder (OCD) spends several hours a day
washing their hands. What is the primary purpose of this ritualistic behavior?
A. To gain attention from the nursing staff
B. To improve personal hygiene and cleanliness
, C. To reduce the anxiety caused by obsessive thoughts
D. To manipulate the unit environment to their liking
Correct Answer: C
Expert Explanation: In OCD, compulsions are repetitive behaviors performed in
response to an obsession or according to rules that must be applied rigidly. These
behaviors are intended to prevent or reduce anxiety or distress, not to provide
pleasure or gratification. Understanding that the ritual is a coping mechanism for
internal anxiety helps the nurse develop a therapeutic plan of care.
6. A client is experiencing severe anxiety and is hyperventilating. Which of the
following actions should the nurse take first?
A. Administer an as-needed dose of lorazepam.
B. Stay with the client and speak in a calm, low voice.
C. Instruct the client to use a paper bag for breathing.
D. Ask the client to explain the reason for their anxiety.
Correct Answer: B
Expert Explanation: The nurse’s presence provides a sense of security and safety
for a client in a state of severe anxiety. Using a calm and low voice helps to de-
escalate the situation and models a relaxed state for the client. Attempting to discuss
| Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is caring for a client who is taking lithium carbonate for bipolar disorder.
The nurse should monitor which of the following laboratory values most closely to
prevent toxicity?
A. Serum glucose levels
B. Serum sodium levels
C. Liver function tests
D. Hemoglobin and hematocrit
Correct Answer: B
Expert Explanation: Lithium is a salt and is handled by the kidneys in a manner
similar to sodium. When sodium levels are low, the kidneys retain lithium, which
can lead to toxic levels in the blood. Therefore, maintaining consistent sodium
intake and monitoring serum sodium levels is critical for patient safety.
2. A client is admitted to the psychiatric unit with a diagnosis of major depressive
disorder. Which of the following is the priority assessment for the nurse to perform?
A. The client’s ability to perform ADLs
B. The client’s risk for self-harm or suicide
,C. The client’s sleep patterns over the last month
D. The client’s nutritional intake and weight loss
Correct Answer: B
Expert Explanation: Patient safety is always the highest priority in mental health
nursing. Clients with major depressive disorder are at a significantly higher risk for
suicidal ideation and attempts. Assessing for a specific plan and the means to carry
it out is the first step in ensuring a safe environment.
3. A client experiencing a manic episode is running around the unit, interrupting
others, and not eating. Which of the following nursing interventions is most
appropriate?
A. Ask the client to sit down for a full meal in the dining room.
B. Place the client in physical restraints to prevent exhaustion.
C. Provide the client with high-calorie finger foods.
D. Request a sedative medication to stop the behavior immediately.
Correct Answer: C
Expert Explanation: Clients in a manic state often have difficulty sitting still long
enough to eat a traditional meal. Providing high-calorie finger foods allows the
client to maintain nutrition while on the move. This intervention addresses
,physiological needs without escalating the client’s agitation or imposing
unnecessary restrictions.
4. A nurse is teaching a client who has a new prescription for phenelzine (an MAOI).
Which of the following foods should the nurse instruct the client to avoid?
A. Fresh green leafy vegetables
B. Citrus fruits and juices
C. Whole grain breads and cereals
D. Aged cheeses and cured meats
Correct Answer: D
Expert Explanation: Phenelzine is an MAOI which interacts with tyramine-rich
foods to cause a hypertensive crisis. Aged cheeses, cured meats, and fermented
products are all high in tyramine and must be avoided. The nurse must provide a
comprehensive list of restricted foods to ensure the client understands the risks of
dietary non-compliance.
5. A client with Obsessive-Compulsive Disorder (OCD) spends several hours a day
washing their hands. What is the primary purpose of this ritualistic behavior?
A. To gain attention from the nursing staff
B. To improve personal hygiene and cleanliness
, C. To reduce the anxiety caused by obsessive thoughts
D. To manipulate the unit environment to their liking
Correct Answer: C
Expert Explanation: In OCD, compulsions are repetitive behaviors performed in
response to an obsession or according to rules that must be applied rigidly. These
behaviors are intended to prevent or reduce anxiety or distress, not to provide
pleasure or gratification. Understanding that the ritual is a coping mechanism for
internal anxiety helps the nurse develop a therapeutic plan of care.
6. A client is experiencing severe anxiety and is hyperventilating. Which of the
following actions should the nurse take first?
A. Administer an as-needed dose of lorazepam.
B. Stay with the client and speak in a calm, low voice.
C. Instruct the client to use a paper bag for breathing.
D. Ask the client to explain the reason for their anxiety.
Correct Answer: B
Expert Explanation: The nurse’s presence provides a sense of security and safety
for a client in a state of severe anxiety. Using a calm and low voice helps to de-
escalate the situation and models a relaxed state for the client. Attempting to discuss
