NUR 208/NUR208 Exam 1 V2 | Mental
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a client who is voluntarily admitted to an inpatient psychiatric unit.
The client asks to leave the facility against medical advice. Which action should the nurse
take first?
A. Inform the client that they cannot leave because they are a danger to themselves.
B. Initiate a physical restraint protocol to prevent the client from exiting.
C. Administer a PRN sedative to reduce the client’s agitation regarding discharge.
D. Notify the provider and prepare for a legal clinical review of the client’s status.
Correct Answer: D
Expert Explanation: Voluntary clients generally have the right to request discharge, but
the nurse must first follow institutional policy which involves provider notification. If the
client is deemed a danger to self or others during the evaluation, the status may be
converted to involuntary. This process ensures patient safety while respecting legal rights
and clinical protocols.
2. Which neurotransmitter is primarily targeted by Selective Serotonin Reuptake Inhibitors
(SSRIs) to treat Major Depressive Disorder?
A. Dopamine
,B. Serotonin
C. GABA
D. Acetylcholine
Correct Answer: B
Expert Explanation: SSRIs work by inhibiting the reuptake of serotonin at the synaptic
cleft, thereby increasing its availability. This increase in serotonin levels is associated with
improved mood and emotional regulation in patients with depression. Understanding
neurochemical pathways is a fundamental requirement for psychiatric nursing
pharmacology.
3. A nurse is conducting a mental status examination (MSE). The client states, ‘The silver stars
are singing in the sapphire sky.’ The nurse should document this as which of the following?
A. Neologism
B. Clang association
C. Alliteration and potentially poetic thought process
D. Flight of ideas
Correct Answer: B
Expert Explanation: Clang association is a thought form where the client chooses words
based on their sound rather than their meaning, often involving rhyming or alliteration.
, This is frequently seen in clients experiencing a manic episode or schizophrenia. Accurate
documentation of speech patterns is critical for diagnosing thought disorders.
4. A client is prescribed Lithium Carbonate for Bipolar Disorder. Which of the following
instructions should the nurse include in the teaching plan?
A. Limit fluid intake to less than 1 liter per day.
B. Maintain a consistent intake of dietary sodium.
C. Stop the medication if a fine hand tremor occurs.
D. Use NSAIDs like Ibuprofen for minor headaches.
Correct Answer: B
Expert Explanation: Lithium is a salt, and its excretion is closely tied to sodium levels in
the body. If sodium intake drops significantly, the kidneys retain lithium, leading to toxicity.
Maintaining a stable sodium and fluid intake is the most important teaching point to
prevent life-threatening complications.
5. During a nurse-client interaction, the client becomes angry and shouts, ‘You are just like
my mother, always telling me what to do!’ This is an example of:
A. Countertransference
B. Transference
C. Resistance
D. Projection
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a client who is voluntarily admitted to an inpatient psychiatric unit.
The client asks to leave the facility against medical advice. Which action should the nurse
take first?
A. Inform the client that they cannot leave because they are a danger to themselves.
B. Initiate a physical restraint protocol to prevent the client from exiting.
C. Administer a PRN sedative to reduce the client’s agitation regarding discharge.
D. Notify the provider and prepare for a legal clinical review of the client’s status.
Correct Answer: D
Expert Explanation: Voluntary clients generally have the right to request discharge, but
the nurse must first follow institutional policy which involves provider notification. If the
client is deemed a danger to self or others during the evaluation, the status may be
converted to involuntary. This process ensures patient safety while respecting legal rights
and clinical protocols.
2. Which neurotransmitter is primarily targeted by Selective Serotonin Reuptake Inhibitors
(SSRIs) to treat Major Depressive Disorder?
A. Dopamine
,B. Serotonin
C. GABA
D. Acetylcholine
Correct Answer: B
Expert Explanation: SSRIs work by inhibiting the reuptake of serotonin at the synaptic
cleft, thereby increasing its availability. This increase in serotonin levels is associated with
improved mood and emotional regulation in patients with depression. Understanding
neurochemical pathways is a fundamental requirement for psychiatric nursing
pharmacology.
3. A nurse is conducting a mental status examination (MSE). The client states, ‘The silver stars
are singing in the sapphire sky.’ The nurse should document this as which of the following?
A. Neologism
B. Clang association
C. Alliteration and potentially poetic thought process
D. Flight of ideas
Correct Answer: B
Expert Explanation: Clang association is a thought form where the client chooses words
based on their sound rather than their meaning, often involving rhyming or alliteration.
, This is frequently seen in clients experiencing a manic episode or schizophrenia. Accurate
documentation of speech patterns is critical for diagnosing thought disorders.
4. A client is prescribed Lithium Carbonate for Bipolar Disorder. Which of the following
instructions should the nurse include in the teaching plan?
A. Limit fluid intake to less than 1 liter per day.
B. Maintain a consistent intake of dietary sodium.
C. Stop the medication if a fine hand tremor occurs.
D. Use NSAIDs like Ibuprofen for minor headaches.
Correct Answer: B
Expert Explanation: Lithium is a salt, and its excretion is closely tied to sodium levels in
the body. If sodium intake drops significantly, the kidneys retain lithium, leading to toxicity.
Maintaining a stable sodium and fluid intake is the most important teaching point to
prevent life-threatening complications.
5. During a nurse-client interaction, the client becomes angry and shouts, ‘You are just like
my mother, always telling me what to do!’ This is an example of:
A. Countertransference
B. Transference
C. Resistance
D. Projection
