NU160 | NU160 Mental Health Concepts Final Exam
v1 Questions with Correct Answers and Expert
Explanation for Each Question
1. A nurse is caring for a client with schizophrenia who reports hearing voices telling
them to hurt others. What is the nurse’s priority action?
A. Ask the client directly what the voices are saying.
B. Administer a PRN dose of an antipsychotic medication.
C. Place the client in a seclusion room immediately.
D. Tell the client that the voices are not real and to ignore them.
Correct Answer: A
Expert Explanation: Assessment is the first step of the nursing process. Identifying
the content of command hallucinations is critical to ensure the safety of the client
and others. This allows the nurse to implement appropriate safety protocols based
on the level of risk.
2. A client is prescribed lithium carbonate for bipolar disorder. Which laboratory value
should the nurse monitor most closely to prevent toxicity?
A. Serum potassium
B. Alanine aminotransferase (ALT)
C. Hemoglobin and hematocrit
,D. Serum sodium
Correct Answer: D
Expert Explanation: Lithium is a salt and is handled by the kidneys in a manner
similar to sodium. Low sodium levels can lead to decreased lithium excretion and
subsequent toxicity. Monitoring sodium helps ensure the patient remains within a
therapeutic window and avoids life-threatening complications.
3. Which defense mechanism is a client using when they transfer their anger about a
job loss onto their spouse by yelling at them over a small matter?
A. Projection
B. Displacement
C. Sublimation
D. Rationalization
Correct Answer: B
Expert Explanation: Displacement involves shifting feelings from a threatening
target to a less threatening one. In this scenario, the spouse is a safer target for the
client’s anger than the employer. Understanding defense mechanisms helps the
nurse identify how clients cope with stress and anxiety.
,4. A nurse is assessing a client for major depressive disorder. Which of the following
findings is a common vegetative sign of depression?
A. Insomnia or hypersomnia
B. Pressured speech
C. Increased social activity
D. Grandiose delusions
Correct Answer: A
Expert Explanation: Vegetative signs of depression refer to physiological changes
in the body. These commonly include alterations in sleep patterns, appetite changes,
and decreased energy levels. Monitoring these signs helps the nurse evaluate the
severity of the depressive episode.
5. A client with an eating disorder is admitted to the unit. What is the initial nursing
priority?
A. Teaching the client about healthy meal planning.
B. Encouraging the client to participate in group therapy.
C. Exploring the underlying emotional causes of the disorder.
D. Stabilizing the client’s physical and nutritional status.
Correct Answer: D
, Expert Explanation: In cases of severe eating disorders, physiological stability
must be addressed before psychological work can begin. This includes correcting
electrolyte imbalances and ensuring cardiovascular stability. Safety and physical
health always take precedence in the acute phase of treatment.
6. A client is experiencing a severe panic attack. Which nursing intervention is most
appropriate?
A. Stay with the client and use short, simple sentences.
B. Leave the client alone to allow them space to calm down.
C. Provide detailed education on relaxation techniques.
D. Ask the client to explain what triggered the attack.
Correct Answer: A
Expert Explanation: During a severe panic attack, a client’s ability to process
information is severely limited. Staying with the client provides reassurance and
ensures their safety during the crisis. Short, simple sentences are necessary because
the client cannot focus on complex instructions or explanations.
7. Which of the following is a classic sign of opioid withdrawal?
A. Rhinorrhea, lacrimation, and piloerection
B. Constipation and pinpoint pupils
v1 Questions with Correct Answers and Expert
Explanation for Each Question
1. A nurse is caring for a client with schizophrenia who reports hearing voices telling
them to hurt others. What is the nurse’s priority action?
A. Ask the client directly what the voices are saying.
B. Administer a PRN dose of an antipsychotic medication.
C. Place the client in a seclusion room immediately.
D. Tell the client that the voices are not real and to ignore them.
Correct Answer: A
Expert Explanation: Assessment is the first step of the nursing process. Identifying
the content of command hallucinations is critical to ensure the safety of the client
and others. This allows the nurse to implement appropriate safety protocols based
on the level of risk.
2. A client is prescribed lithium carbonate for bipolar disorder. Which laboratory value
should the nurse monitor most closely to prevent toxicity?
A. Serum potassium
B. Alanine aminotransferase (ALT)
C. Hemoglobin and hematocrit
,D. Serum sodium
Correct Answer: D
Expert Explanation: Lithium is a salt and is handled by the kidneys in a manner
similar to sodium. Low sodium levels can lead to decreased lithium excretion and
subsequent toxicity. Monitoring sodium helps ensure the patient remains within a
therapeutic window and avoids life-threatening complications.
3. Which defense mechanism is a client using when they transfer their anger about a
job loss onto their spouse by yelling at them over a small matter?
A. Projection
B. Displacement
C. Sublimation
D. Rationalization
Correct Answer: B
Expert Explanation: Displacement involves shifting feelings from a threatening
target to a less threatening one. In this scenario, the spouse is a safer target for the
client’s anger than the employer. Understanding defense mechanisms helps the
nurse identify how clients cope with stress and anxiety.
,4. A nurse is assessing a client for major depressive disorder. Which of the following
findings is a common vegetative sign of depression?
A. Insomnia or hypersomnia
B. Pressured speech
C. Increased social activity
D. Grandiose delusions
Correct Answer: A
Expert Explanation: Vegetative signs of depression refer to physiological changes
in the body. These commonly include alterations in sleep patterns, appetite changes,
and decreased energy levels. Monitoring these signs helps the nurse evaluate the
severity of the depressive episode.
5. A client with an eating disorder is admitted to the unit. What is the initial nursing
priority?
A. Teaching the client about healthy meal planning.
B. Encouraging the client to participate in group therapy.
C. Exploring the underlying emotional causes of the disorder.
D. Stabilizing the client’s physical and nutritional status.
Correct Answer: D
, Expert Explanation: In cases of severe eating disorders, physiological stability
must be addressed before psychological work can begin. This includes correcting
electrolyte imbalances and ensuring cardiovascular stability. Safety and physical
health always take precedence in the acute phase of treatment.
6. A client is experiencing a severe panic attack. Which nursing intervention is most
appropriate?
A. Stay with the client and use short, simple sentences.
B. Leave the client alone to allow them space to calm down.
C. Provide detailed education on relaxation techniques.
D. Ask the client to explain what triggered the attack.
Correct Answer: A
Expert Explanation: During a severe panic attack, a client’s ability to process
information is severely limited. Staying with the client provides reassurance and
ensures their safety during the crisis. Short, simple sentences are necessary because
the client cannot focus on complex instructions or explanations.
7. Which of the following is a classic sign of opioid withdrawal?
A. Rhinorrhea, lacrimation, and piloerection
B. Constipation and pinpoint pupils
