NUR 208/NUR208 Exam 3 V3 | Mental
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing a client with Bipolar I Disorder who is in a manic phase. Which
nutritional intervention is most appropriate for this client?
A. Offer high-protein, high-calorie finger foods that can be eaten while walking.
B. Provide the client with large, calorie-dense meals in the dining room.
C. Allow the client to choose their own meals from the hospital cafeteria menu.
D. Restrict fluid intake to prevent electrolyte imbalances during hyperactivity.
Correct Answer: A
Expert Explanation: Clients in a manic phase are often too hyperactive to sit down for a
full meal. Providing high-protein and high-calorie finger foods allows them to maintain
nutritional intake while on the move. This intervention addresses the physical exhaustion
and weight loss commonly associated with acute mania.
2. A client is prescribed Lithium Carbonate for the treatment of Bipolar Disorder. The nurse
should instruct the client to maintain a consistent intake of which substance?
A. Sodium
B. Potassium
C. Vitamin K
,D. Calcium
Correct Answer: A
Expert Explanation: Lithium is a salt, and its excretion is closely linked to sodium levels in
the body. If sodium intake decreases or is lost through sweating, the kidneys retain lithium,
leading to toxicity. Therefore, a consistent intake of sodium and adequate fluid is essential
for safe therapy.
3. A nurse is caring for a client with Borderline Personality Disorder who is using ‘splitting’
behavior. How should the nursing staff respond?
A. Hold frequent staff meetings to ensure a consistent approach to care.
B. Allow the client to choose which nurse they prefer to work with.
C. Assign a different nurse each shift to provide variety in care.
D. Ignore the behavior as it is a typical symptom of the disorder.
Correct Answer: A
Expert Explanation: Splitting involves the client seeing staff as either ‘all good’ or ‘all bad,’
which can cause conflict among the care team. Frequent staff meetings ensure that all team
members are following the same plan of care and set consistent limits. This prevents the
client from playing staff members against each other and promotes a stable milieu.
4. A client with Anorexia Nervosa is admitted to an inpatient unit. Which physical finding
should the nurse expect to observe?
A. Lanugo and bradycardia
, B. Tachycardia and hypertension
C. Hyperthermia and oily skin
D. Evidence of Russell’s sign on the knuckles
Correct Answer: A
Expert Explanation: Lanugo, which is fine, downy hair, grows as a physiological response
to insulate the body when body fat is lost. Bradycardia and hypotension are also common
as the body’s metabolism slows down to conserve energy. These findings reflect the severe
physiological stress caused by malnutrition.
5. The nurse is evaluating a client for Lithium toxicity. Which serum lithium level should the
nurse report to the provider as toxic?
A. 0.6 mEq/L
B. 1.0 mEq/L
C. 1.8 mEq/L
D. 1.2 mEq/L
Correct Answer: C
Expert Explanation: The therapeutic range for lithium is narrow, typically between 0.6
and 1.2 mEq/L for maintenance. A level of 1.8 mEq/L is significantly above the therapeutic
threshold and indicates moderate to severe toxicity. At this level, the nurse should
anticipate symptoms like blurred vision, seizures, and severe hypotension.
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing a client with Bipolar I Disorder who is in a manic phase. Which
nutritional intervention is most appropriate for this client?
A. Offer high-protein, high-calorie finger foods that can be eaten while walking.
B. Provide the client with large, calorie-dense meals in the dining room.
C. Allow the client to choose their own meals from the hospital cafeteria menu.
D. Restrict fluid intake to prevent electrolyte imbalances during hyperactivity.
Correct Answer: A
Expert Explanation: Clients in a manic phase are often too hyperactive to sit down for a
full meal. Providing high-protein and high-calorie finger foods allows them to maintain
nutritional intake while on the move. This intervention addresses the physical exhaustion
and weight loss commonly associated with acute mania.
2. A client is prescribed Lithium Carbonate for the treatment of Bipolar Disorder. The nurse
should instruct the client to maintain a consistent intake of which substance?
A. Sodium
B. Potassium
C. Vitamin K
,D. Calcium
Correct Answer: A
Expert Explanation: Lithium is a salt, and its excretion is closely linked to sodium levels in
the body. If sodium intake decreases or is lost through sweating, the kidneys retain lithium,
leading to toxicity. Therefore, a consistent intake of sodium and adequate fluid is essential
for safe therapy.
3. A nurse is caring for a client with Borderline Personality Disorder who is using ‘splitting’
behavior. How should the nursing staff respond?
A. Hold frequent staff meetings to ensure a consistent approach to care.
B. Allow the client to choose which nurse they prefer to work with.
C. Assign a different nurse each shift to provide variety in care.
D. Ignore the behavior as it is a typical symptom of the disorder.
Correct Answer: A
Expert Explanation: Splitting involves the client seeing staff as either ‘all good’ or ‘all bad,’
which can cause conflict among the care team. Frequent staff meetings ensure that all team
members are following the same plan of care and set consistent limits. This prevents the
client from playing staff members against each other and promotes a stable milieu.
4. A client with Anorexia Nervosa is admitted to an inpatient unit. Which physical finding
should the nurse expect to observe?
A. Lanugo and bradycardia
, B. Tachycardia and hypertension
C. Hyperthermia and oily skin
D. Evidence of Russell’s sign on the knuckles
Correct Answer: A
Expert Explanation: Lanugo, which is fine, downy hair, grows as a physiological response
to insulate the body when body fat is lost. Bradycardia and hypotension are also common
as the body’s metabolism slows down to conserve energy. These findings reflect the severe
physiological stress caused by malnutrition.
5. The nurse is evaluating a client for Lithium toxicity. Which serum lithium level should the
nurse report to the provider as toxic?
A. 0.6 mEq/L
B. 1.0 mEq/L
C. 1.8 mEq/L
D. 1.2 mEq/L
Correct Answer: C
Expert Explanation: The therapeutic range for lithium is narrow, typically between 0.6
and 1.2 mEq/L for maintenance. A level of 1.8 mEq/L is significantly above the therapeutic
threshold and indicates moderate to severe toxicity. At this level, the nurse should
anticipate symptoms like blurred vision, seizures, and severe hypotension.
