NUR 208/NUR208 Exam 2 V2 | Mental
Health Nursing Q&A with Rationale | Fortis
College
1. A patient with bipolar I disorder is in the middle of a manic episode. Which meal choice
should the nurse provide to ensure adequate nutrition?
A. Spaghetti and meatballs with a side salad
B. Beef stew and a bowl of pudding
C. Tomato soup with crackers
D. A cheeseburger and an apple
Correct Answer: D
Expert Explanation: Patients in a manic state are often hyperactive and unable to sit still
for long periods. Finger foods like a cheeseburger and an apple allow the patient to
maintain caloric intake while remaining mobile. This intervention prioritizes physical
health and nutrition during periods of psychomotor agitation.
2. A client is prescribed Lithium Carbonate for mood stabilization. Which laboratory value
should the nurse report to the provider immediately?
A. Serum Sodium level of 128 mEq/L
B. Serum Lithium level of 1.1 mEq/L
C. White blood cell count of 8,000/mm3
,D. Serum Potassium level of 4.2 mEq/L
Correct Answer: A
Expert Explanation: Sodium and lithium have an inverse relationship in the kidneys; low
sodium levels can lead to decreased lithium excretion and toxicity. A sodium level of 128
mEq/L is significantly low and places the client at high risk for lithium toxicity. The nurse
must monitor electrolyte levels closely to maintain the therapeutic window of lithium.
3. A patient diagnosed with schizophrenia is hearing voices telling them that the food is
poisoned. Which response by the nurse is therapeutic?
A. I do not see anyone else in the room; you are safe.
B. I know the voices are real to you, but I do not hear them.
C. Why do you think the voices are telling you the food is bad?
D. You should ignore the voices and eat your meal.
Correct Answer: B
Expert Explanation: This response uses the therapeutic technique of presenting reality
without dismissing the patient’s experience. It acknowledges the patient’s perception while
clearly stating the nurse’s own reality. It avoids arguing with the hallucination, which is
essential in schizophrenia care.
4. The nurse is assessing a patient for extrapyramidal side effects (EPS) after starting
haloperidol. Which symptom indicates dystonia?
A. Shuffling gait and drooling
, B. Muscle spasms of the neck and face
C. Fine tremors of the hands
D. Restlessness and an urgent need to move
Correct Answer: B
Expert Explanation: Acute dystonia is characterized by severe muscle spasms, often
involving the tongue, face, neck, or back. It is a common extrapyramidal side effect of first-
generation antipsychotics like haloperidol. Immediate treatment with an anticholinergic
medication like benztropine is usually required.
5. A client is being treated with Clozapine for treatment-resistant schizophrenia. Which
monitoring requirement is most critical for this medication?
A. Frequent blood pressure checks for hypertension
B. Monthly liver function tests
C. Weekly White Blood Cell (WBC) counts
D. Annual eye examinations for cataracts
Correct Answer: C
Expert Explanation: Clozapine carries a high risk for agranulocytosis, a life-threatening
drop in white blood cells. Strict protocol requires baseline and periodic WBC and Absolute
Neutrophil Count (ANC) monitoring to ensure patient safety. If the WBC count drops too
low, the medication must be discontinued immediately.
Health Nursing Q&A with Rationale | Fortis
College
1. A patient with bipolar I disorder is in the middle of a manic episode. Which meal choice
should the nurse provide to ensure adequate nutrition?
A. Spaghetti and meatballs with a side salad
B. Beef stew and a bowl of pudding
C. Tomato soup with crackers
D. A cheeseburger and an apple
Correct Answer: D
Expert Explanation: Patients in a manic state are often hyperactive and unable to sit still
for long periods. Finger foods like a cheeseburger and an apple allow the patient to
maintain caloric intake while remaining mobile. This intervention prioritizes physical
health and nutrition during periods of psychomotor agitation.
2. A client is prescribed Lithium Carbonate for mood stabilization. Which laboratory value
should the nurse report to the provider immediately?
A. Serum Sodium level of 128 mEq/L
B. Serum Lithium level of 1.1 mEq/L
C. White blood cell count of 8,000/mm3
,D. Serum Potassium level of 4.2 mEq/L
Correct Answer: A
Expert Explanation: Sodium and lithium have an inverse relationship in the kidneys; low
sodium levels can lead to decreased lithium excretion and toxicity. A sodium level of 128
mEq/L is significantly low and places the client at high risk for lithium toxicity. The nurse
must monitor electrolyte levels closely to maintain the therapeutic window of lithium.
3. A patient diagnosed with schizophrenia is hearing voices telling them that the food is
poisoned. Which response by the nurse is therapeutic?
A. I do not see anyone else in the room; you are safe.
B. I know the voices are real to you, but I do not hear them.
C. Why do you think the voices are telling you the food is bad?
D. You should ignore the voices and eat your meal.
Correct Answer: B
Expert Explanation: This response uses the therapeutic technique of presenting reality
without dismissing the patient’s experience. It acknowledges the patient’s perception while
clearly stating the nurse’s own reality. It avoids arguing with the hallucination, which is
essential in schizophrenia care.
4. The nurse is assessing a patient for extrapyramidal side effects (EPS) after starting
haloperidol. Which symptom indicates dystonia?
A. Shuffling gait and drooling
, B. Muscle spasms of the neck and face
C. Fine tremors of the hands
D. Restlessness and an urgent need to move
Correct Answer: B
Expert Explanation: Acute dystonia is characterized by severe muscle spasms, often
involving the tongue, face, neck, or back. It is a common extrapyramidal side effect of first-
generation antipsychotics like haloperidol. Immediate treatment with an anticholinergic
medication like benztropine is usually required.
5. A client is being treated with Clozapine for treatment-resistant schizophrenia. Which
monitoring requirement is most critical for this medication?
A. Frequent blood pressure checks for hypertension
B. Monthly liver function tests
C. Weekly White Blood Cell (WBC) counts
D. Annual eye examinations for cataracts
Correct Answer: C
Expert Explanation: Clozapine carries a high risk for agranulocytosis, a life-threatening
drop in white blood cells. Strict protocol requires baseline and periodic WBC and Absolute
Neutrophil Count (ANC) monitoring to ensure patient safety. If the WBC count drops too
low, the medication must be discontinued immediately.
