PRN 1562/PRN1562 Final Exam V2 |
Principles of Mental Health Nursing Q&A
with Rationale | Rasmussen University
1. A nurse is caring for a client who is experiencing a manic episode. Which of the following
actions should the nurse take first?
A. Provide the client with high-calorie finger foods.
B. Encourage the client to join a group therapy session.
C. Ask the client to explain their feelings in detail.
D. Administer a sedative as needed for agitation.
Correct Answer: A
Expert Explanation: During a manic episode, clients are often too hyperactive to sit down
for a full meal. Providing high-calorie finger foods allows the client to maintain nutritional
intake while on the move. This intervention addresses the basic physiological need for
nutrition, which is a priority in the care plan.
2. A client is prescribed lithium carbonate for bipolar disorder. Which of the following
findings should the nurse report to the provider as a sign of lithium toxicity?
A. Occasional fine hand tremors
B. Polyuria and mild thirst
C. Blurred vision and ataxia
,D. Weight gain of 2 pounds
Correct Answer: C
Expert Explanation: Blurred vision and ataxia are considered advanced signs of lithium
toxicity. Fine hand tremors and mild thirst are common side effects that usually do not
indicate toxicity. The nurse must monitor serum lithium levels closely because the
therapeutic range is very narrow.
3. A nurse is discussing the ethical principle of autonomy with a group of nursing students.
Which of the following examples should the nurse include?
A. A nurse providing the same care to all clients regardless of status.
B. A nurse keeping a promise to return to a client’s room.
C. A client choosing to refuse a scheduled medication.
D. A nurse reporting a medication error to the supervisor.
Correct Answer: C
Expert Explanation: Autonomy refers to the right of the client to make their own decisions
about their healthcare. In this scenario, the client exercising the right to refuse medication
is a direct example of autonomy. It is the nurse’s responsibility to respect this choice while
providing education on the consequences.
4. Which of the following defense mechanisms is a client using when they claim they failed a
test only because the teacher is unfair?
A. Rationalization
, B. Sublimation
C. Reaction Formation
D. Displacement
Correct Answer: A
Expert Explanation: Rationalization involves justifying illogical or unreasonable ideas or
feelings by developing acceptable explanations. By blaming the teacher, the client is
avoiding the reality of their own failure. This is a common defense mechanism used to
protect one’s self-esteem.
5. A nurse is assessing a client for risk of suicide. Which of the following factors should the
nurse identify as the highest risk?
A. The client is married with three children.
B. The client has a history of a previous suicide attempt.
C. The client is employed in a high-stress job.
D. The client expresses a fear of dying.
Correct Answer: B
Expert Explanation: A history of previous suicide attempts is one of the strongest
predictors of future suicide completion. The nurse should perform a detailed assessment of
the client’s current plan and access to means. Protective factors, such as family support or
employment, do not outweigh the risk posed by past behavior.
Principles of Mental Health Nursing Q&A
with Rationale | Rasmussen University
1. A nurse is caring for a client who is experiencing a manic episode. Which of the following
actions should the nurse take first?
A. Provide the client with high-calorie finger foods.
B. Encourage the client to join a group therapy session.
C. Ask the client to explain their feelings in detail.
D. Administer a sedative as needed for agitation.
Correct Answer: A
Expert Explanation: During a manic episode, clients are often too hyperactive to sit down
for a full meal. Providing high-calorie finger foods allows the client to maintain nutritional
intake while on the move. This intervention addresses the basic physiological need for
nutrition, which is a priority in the care plan.
2. A client is prescribed lithium carbonate for bipolar disorder. Which of the following
findings should the nurse report to the provider as a sign of lithium toxicity?
A. Occasional fine hand tremors
B. Polyuria and mild thirst
C. Blurred vision and ataxia
,D. Weight gain of 2 pounds
Correct Answer: C
Expert Explanation: Blurred vision and ataxia are considered advanced signs of lithium
toxicity. Fine hand tremors and mild thirst are common side effects that usually do not
indicate toxicity. The nurse must monitor serum lithium levels closely because the
therapeutic range is very narrow.
3. A nurse is discussing the ethical principle of autonomy with a group of nursing students.
Which of the following examples should the nurse include?
A. A nurse providing the same care to all clients regardless of status.
B. A nurse keeping a promise to return to a client’s room.
C. A client choosing to refuse a scheduled medication.
D. A nurse reporting a medication error to the supervisor.
Correct Answer: C
Expert Explanation: Autonomy refers to the right of the client to make their own decisions
about their healthcare. In this scenario, the client exercising the right to refuse medication
is a direct example of autonomy. It is the nurse’s responsibility to respect this choice while
providing education on the consequences.
4. Which of the following defense mechanisms is a client using when they claim they failed a
test only because the teacher is unfair?
A. Rationalization
, B. Sublimation
C. Reaction Formation
D. Displacement
Correct Answer: A
Expert Explanation: Rationalization involves justifying illogical or unreasonable ideas or
feelings by developing acceptable explanations. By blaming the teacher, the client is
avoiding the reality of their own failure. This is a common defense mechanism used to
protect one’s self-esteem.
5. A nurse is assessing a client for risk of suicide. Which of the following factors should the
nurse identify as the highest risk?
A. The client is married with three children.
B. The client has a history of a previous suicide attempt.
C. The client is employed in a high-stress job.
D. The client expresses a fear of dying.
Correct Answer: B
Expert Explanation: A history of previous suicide attempts is one of the strongest
predictors of future suicide completion. The nurse should perform a detailed assessment of
the client’s current plan and access to means. Protective factors, such as family support or
employment, do not outweigh the risk posed by past behavior.
