NU160 | NU160 Mental Health Concepts Final Exam
v2 | Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is caring for a client with schizophrenia who reports hearing voices telling
them to ‘hurt the others.’ Which action should the nurse take first?
A. Administer an as-needed dose of an antipsychotic medication.
B. Place the client in a quiet room with dimmed lights to reduce stimuli.
C. Ask the client directly what the voices are saying to assess for command
hallucinations.
D. Tell the client that the voices are not real and they are safe in the hospital.
Correct Answer: C
Expert Explanation: Assessing the content of hallucinations is the priority to
determine the risk of harm to others. Command hallucinations can be dangerous
and require immediate safety interventions. This assessment helps the nurse
implement appropriate safety precautions for the milieu.
2. A client is prescribed Lithium Carbonate for the treatment of Bipolar Disorder.
Which of the following lab values should the nurse report to the provider
immediately?
A. Serum Lithium level of 0.8 mEq/L
,B. Sodium level of 140 mEq/L
C. Serum Lithium level of 1.8 mEq/L
D. Creatinine level of 0.9 mg/dL
Correct Answer: C
Expert Explanation: The therapeutic range for lithium is 0.6 to 1.2 mEq/L, and a
level of 1.8 mEq/L indicates toxicity. Lithium toxicity can lead to serious
complications such as seizures, coma, or death if not addressed. The nurse must
monitor for signs like coarse tremors, confusion, and ataxia.
3. A nurse is assessing a client for potential alcohol withdrawal. Which of the following
symptoms is an early sign of withdrawal?
A. Hypotension and bradycardia
B. Visual hallucinations and seizures
C. Hypersomnia and decreased appetite
D. Coarse tremors and diaphoresis
Correct Answer: D
Expert Explanation: Early signs of alcohol withdrawal typically occur 6 to 12 hours
after the last drink and include tremors, anxiety, and tachycardia. Diaphoresis and
,irritability are also common during this initial phase. Monitoring for these signs is
crucial to prevent progression to delirium tremens.
4. Which legal concept refers to the nurse’s obligation to protect a third party from
harm when a client makes a specific threat?
A. Beneficence
B. Justice
C. Duty to Warn
D. Fidelity
Correct Answer: C
Expert Explanation: The Duty to Warn arises from the Tarasoff case and requires
clinicians to breach confidentiality if a client poses a specific threat to an identifiable
person. This is an exception to the rule of patient privacy and emphasizes public
safety. The nurse must report such threats to the treatment team and authorities if
necessary.
5. A client with Borderline Personality Disorder frequently ‘splits’ the staff, praising
one nurse while demeaning another. What is the most appropriate nursing
intervention?
A. Hold a staff meeting to ensure a consistent approach and limit-setting.
, B. Confront the client about their manipulative behavior immediately.
C. Assign the client to only one specific nurse for every shift.
D. Allow the client to choose which nurse they want to work with.
Correct Answer: A
Expert Explanation: Consistency among the staff is essential when managing
splitting behavior to prevent staff conflict and provide a stable environment. Limit-
setting helps the client understand boundaries and reduces the effectiveness of
manipulation. All team members must adhere to the same plan of care to maintain
therapeutic integrity.
6. Which medication is most likely to cause agranulocytosis, requiring regular
monitoring of the White Blood Cell (WBC) count?
A. Risperidone
B. Quetiapine
C. Olanzapine
D. Clozapine
Correct Answer: D
Expert Explanation: Clozapine is an atypical antipsychotic that carries a high risk
for agranulocytosis, a life-threatening drop in white blood cells. Patients on this
v2 | Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is caring for a client with schizophrenia who reports hearing voices telling
them to ‘hurt the others.’ Which action should the nurse take first?
A. Administer an as-needed dose of an antipsychotic medication.
B. Place the client in a quiet room with dimmed lights to reduce stimuli.
C. Ask the client directly what the voices are saying to assess for command
hallucinations.
D. Tell the client that the voices are not real and they are safe in the hospital.
Correct Answer: C
Expert Explanation: Assessing the content of hallucinations is the priority to
determine the risk of harm to others. Command hallucinations can be dangerous
and require immediate safety interventions. This assessment helps the nurse
implement appropriate safety precautions for the milieu.
2. A client is prescribed Lithium Carbonate for the treatment of Bipolar Disorder.
Which of the following lab values should the nurse report to the provider
immediately?
A. Serum Lithium level of 0.8 mEq/L
,B. Sodium level of 140 mEq/L
C. Serum Lithium level of 1.8 mEq/L
D. Creatinine level of 0.9 mg/dL
Correct Answer: C
Expert Explanation: The therapeutic range for lithium is 0.6 to 1.2 mEq/L, and a
level of 1.8 mEq/L indicates toxicity. Lithium toxicity can lead to serious
complications such as seizures, coma, or death if not addressed. The nurse must
monitor for signs like coarse tremors, confusion, and ataxia.
3. A nurse is assessing a client for potential alcohol withdrawal. Which of the following
symptoms is an early sign of withdrawal?
A. Hypotension and bradycardia
B. Visual hallucinations and seizures
C. Hypersomnia and decreased appetite
D. Coarse tremors and diaphoresis
Correct Answer: D
Expert Explanation: Early signs of alcohol withdrawal typically occur 6 to 12 hours
after the last drink and include tremors, anxiety, and tachycardia. Diaphoresis and
,irritability are also common during this initial phase. Monitoring for these signs is
crucial to prevent progression to delirium tremens.
4. Which legal concept refers to the nurse’s obligation to protect a third party from
harm when a client makes a specific threat?
A. Beneficence
B. Justice
C. Duty to Warn
D. Fidelity
Correct Answer: C
Expert Explanation: The Duty to Warn arises from the Tarasoff case and requires
clinicians to breach confidentiality if a client poses a specific threat to an identifiable
person. This is an exception to the rule of patient privacy and emphasizes public
safety. The nurse must report such threats to the treatment team and authorities if
necessary.
5. A client with Borderline Personality Disorder frequently ‘splits’ the staff, praising
one nurse while demeaning another. What is the most appropriate nursing
intervention?
A. Hold a staff meeting to ensure a consistent approach and limit-setting.
, B. Confront the client about their manipulative behavior immediately.
C. Assign the client to only one specific nurse for every shift.
D. Allow the client to choose which nurse they want to work with.
Correct Answer: A
Expert Explanation: Consistency among the staff is essential when managing
splitting behavior to prevent staff conflict and provide a stable environment. Limit-
setting helps the client understand boundaries and reduces the effectiveness of
manipulation. All team members must adhere to the same plan of care to maintain
therapeutic integrity.
6. Which medication is most likely to cause agranulocytosis, requiring regular
monitoring of the White Blood Cell (WBC) count?
A. Risperidone
B. Quetiapine
C. Olanzapine
D. Clozapine
Correct Answer: D
Expert Explanation: Clozapine is an atypical antipsychotic that carries a high risk
for agranulocytosis, a life-threatening drop in white blood cells. Patients on this
