PRN 1562/PRN1562 Exam 2 V1 | Principles
of Mental Health Nursing Q&A with
Rationale | Rasmussen University
1. A nurse is caring for a client who is exhibiting severe anxiety and is pacing the hallway.
Which of the following actions should the nurse take first?
A. Ask the client to describe how they are feeling.
B. Administer an as-needed sedative medication.
C. Stay with the client and remain calm.
D. Instruct the client to go to their room.
Correct Answer: C
Expert Explanation: Staying with the client provides a sense of security and safety during
a high-anxiety state. Remaining calm helps prevent the escalation of the client’s anxiety
through emotional contagion. This intervention is the priority to ensure the client’s
immediate well-being before further assessment.
2. A client is hospitalized for major depressive disorder and refuses to participate in group
activities. Which response by the nurse is therapeutic?
A. ‘Why do you think you don’t want to go to group today?’
B. ‘I will sit here with you for a while.’
C. ‘You really should go; it will make you feel better.’
,D. ‘The doctor ordered group therapy for your recovery.’
Correct Answer: B
Expert Explanation: Offering self is a therapeutic technique that shows the nurse’s
interest in the client without placing demands on them. This approach conveys acceptance
and helps build trust in a non-threatening way. It is particularly effective for clients who
are withdrawn or severely depressed.
3. A nurse is assessing a client for lithium toxicity. Which of the following findings should the
nurse identify as an early sign of toxicity?
A. Coarse hand tremors
B. Fine hand tremors
C. Severe hypotension
D. Slurred speech
Correct Answer: B
Expert Explanation: Fine hand tremors are considered an early sign of lithium toxicity or
a common side effect that needs monitoring. As toxicity progresses, these may become
coarse tremors, which are much more serious. The nurse must differentiate between these
to determine the urgency of intervention.
4. A client with schizophrenia tells the nurse, ‘The FBI is monitoring my every move through
the television.’ Which of the following is the most appropriate nursing response?
A. ‘The FBI does not have the technology to do that.’
, B. ‘That sounds very frightening for you.’
C. ‘Why would the FBI want to watch you?’
D. ‘I think you should turn off the television.’
Correct Answer: B
Expert Explanation: Acknowledging the client’s feelings focuses on the emotion rather
than the delusional content. This validates the client’s internal experience without
confirming the delusion as reality. It maintains a therapeutic relationship while avoiding
direct confrontation.
5. Which defense mechanism is a client using when they yell at their spouse because they are
angry with their boss?
A. Rationalization
B. Sublimation
C. Projection
D. Displacement
Correct Answer: D
Expert Explanation: Displacement involves transferring emotions from a person or object
that is perceived as threatening to a less threatening target. In this scenario, the spouse is a
safer target for anger than the boss. This mechanism helps the individual reduce anxiety
caused by the original conflict.
of Mental Health Nursing Q&A with
Rationale | Rasmussen University
1. A nurse is caring for a client who is exhibiting severe anxiety and is pacing the hallway.
Which of the following actions should the nurse take first?
A. Ask the client to describe how they are feeling.
B. Administer an as-needed sedative medication.
C. Stay with the client and remain calm.
D. Instruct the client to go to their room.
Correct Answer: C
Expert Explanation: Staying with the client provides a sense of security and safety during
a high-anxiety state. Remaining calm helps prevent the escalation of the client’s anxiety
through emotional contagion. This intervention is the priority to ensure the client’s
immediate well-being before further assessment.
2. A client is hospitalized for major depressive disorder and refuses to participate in group
activities. Which response by the nurse is therapeutic?
A. ‘Why do you think you don’t want to go to group today?’
B. ‘I will sit here with you for a while.’
C. ‘You really should go; it will make you feel better.’
,D. ‘The doctor ordered group therapy for your recovery.’
Correct Answer: B
Expert Explanation: Offering self is a therapeutic technique that shows the nurse’s
interest in the client without placing demands on them. This approach conveys acceptance
and helps build trust in a non-threatening way. It is particularly effective for clients who
are withdrawn or severely depressed.
3. A nurse is assessing a client for lithium toxicity. Which of the following findings should the
nurse identify as an early sign of toxicity?
A. Coarse hand tremors
B. Fine hand tremors
C. Severe hypotension
D. Slurred speech
Correct Answer: B
Expert Explanation: Fine hand tremors are considered an early sign of lithium toxicity or
a common side effect that needs monitoring. As toxicity progresses, these may become
coarse tremors, which are much more serious. The nurse must differentiate between these
to determine the urgency of intervention.
4. A client with schizophrenia tells the nurse, ‘The FBI is monitoring my every move through
the television.’ Which of the following is the most appropriate nursing response?
A. ‘The FBI does not have the technology to do that.’
, B. ‘That sounds very frightening for you.’
C. ‘Why would the FBI want to watch you?’
D. ‘I think you should turn off the television.’
Correct Answer: B
Expert Explanation: Acknowledging the client’s feelings focuses on the emotion rather
than the delusional content. This validates the client’s internal experience without
confirming the delusion as reality. It maintains a therapeutic relationship while avoiding
direct confrontation.
5. Which defense mechanism is a client using when they yell at their spouse because they are
angry with their boss?
A. Rationalization
B. Sublimation
C. Projection
D. Displacement
Correct Answer: D
Expert Explanation: Displacement involves transferring emotions from a person or object
that is perceived as threatening to a less threatening target. In this scenario, the spouse is a
safer target for anger than the boss. This mechanism helps the individual reduce anxiety
caused by the original conflict.
