NUR 208/NUR208 Exam 3 V1 | Mental
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing a client with bipolar disorder who is experiencing a manic episode. The
client has not eaten or slept for two days. Which intervention is the priority?
A. Encouraging the client to join a group therapy session.
B. Providing high-calorie, portable finger foods and drinks.
C. Assessing the client’s lithium levels immediately.
D. Teaching the client about the importance of sleep hygiene.
Correct Answer: B
Expert Explanation: Clients in a manic state are often too hyperactive to sit down for
regular meals, placing them at risk for exhaustion and malnutrition. Providing finger foods
allows the client to maintain nutritional intake while remaining mobile. This intervention
addresses physiological safety, which is a priority in the acute phase of mania.
2. A client is prescribed Lithium carbonate for the treatment of bipolar I disorder. Which
laboratory value should the nurse monitor most closely to prevent toxicity?
A. Serum potassium
B. Blood urea nitrogen (BUN)
C. White blood cell count
,D. Serum sodium
Correct Answer: D
Expert Explanation: Lithium is a salt, and its excretion is directly affected by sodium levels
in the body. When sodium levels are low, the kidneys retain lithium, which can lead to toxic
accumulations. The nurse must educate the client on maintaining a consistent sodium and
fluid intake to avoid this life-threatening complication.
3. The nurse is caring for a client with Borderline Personality Disorder who is using ‘splitting’
behavior. How should the nurse best respond?
A. Confront the client about their manipulative behavior.
B. Maintain consistent boundaries and communicate frequently with the staff.
C. Avoid the client to prevent further conflict.
D. Agree with the client to build a therapeutic rapport.
Correct Answer: B
Expert Explanation: Splitting is a defense mechanism where the client views people as all
good or all bad, often causing staff discord. Maintaining a united front among the
healthcare team prevents the client from successfully manipulating staff members.
Consistency in care and boundaries is essential for the stability and safety of the
therapeutic environment.
, 4. A client is admitted for alcohol detoxification. Which of the following medications should
the nurse expect to administer to manage acute withdrawal symptoms?
A. Chlordiazepoxide
B. Methadone
C. Disulfiram
D. Naltrexone
Correct Answer: A
Expert Explanation: Benzodiazepines like chlordiazepoxide are the gold standard for
managing acute alcohol withdrawal symptoms and preventing delirium tremens. These
medications help stabilize vital signs and reduce the risk of withdrawal-induced seizures.
Unlike disulfiram, which is used for maintenance, benzodiazepines treat the immediate
physiological crisis.
5. A client with Schizophrenia is experiencing command hallucinations telling them to ‘hurt
the nurse.’ What is the nurse’s priority action?
A. Ask the client if they intend to follow the command.
B. Administer a PRN antipsychotic medication immediately.
C. Tell the client that the voices are not real.
D. Place the client in a quiet room with no stimulation.
Correct Answer: A
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing a client with bipolar disorder who is experiencing a manic episode. The
client has not eaten or slept for two days. Which intervention is the priority?
A. Encouraging the client to join a group therapy session.
B. Providing high-calorie, portable finger foods and drinks.
C. Assessing the client’s lithium levels immediately.
D. Teaching the client about the importance of sleep hygiene.
Correct Answer: B
Expert Explanation: Clients in a manic state are often too hyperactive to sit down for
regular meals, placing them at risk for exhaustion and malnutrition. Providing finger foods
allows the client to maintain nutritional intake while remaining mobile. This intervention
addresses physiological safety, which is a priority in the acute phase of mania.
2. A client is prescribed Lithium carbonate for the treatment of bipolar I disorder. Which
laboratory value should the nurse monitor most closely to prevent toxicity?
A. Serum potassium
B. Blood urea nitrogen (BUN)
C. White blood cell count
,D. Serum sodium
Correct Answer: D
Expert Explanation: Lithium is a salt, and its excretion is directly affected by sodium levels
in the body. When sodium levels are low, the kidneys retain lithium, which can lead to toxic
accumulations. The nurse must educate the client on maintaining a consistent sodium and
fluid intake to avoid this life-threatening complication.
3. The nurse is caring for a client with Borderline Personality Disorder who is using ‘splitting’
behavior. How should the nurse best respond?
A. Confront the client about their manipulative behavior.
B. Maintain consistent boundaries and communicate frequently with the staff.
C. Avoid the client to prevent further conflict.
D. Agree with the client to build a therapeutic rapport.
Correct Answer: B
Expert Explanation: Splitting is a defense mechanism where the client views people as all
good or all bad, often causing staff discord. Maintaining a united front among the
healthcare team prevents the client from successfully manipulating staff members.
Consistency in care and boundaries is essential for the stability and safety of the
therapeutic environment.
, 4. A client is admitted for alcohol detoxification. Which of the following medications should
the nurse expect to administer to manage acute withdrawal symptoms?
A. Chlordiazepoxide
B. Methadone
C. Disulfiram
D. Naltrexone
Correct Answer: A
Expert Explanation: Benzodiazepines like chlordiazepoxide are the gold standard for
managing acute alcohol withdrawal symptoms and preventing delirium tremens. These
medications help stabilize vital signs and reduce the risk of withdrawal-induced seizures.
Unlike disulfiram, which is used for maintenance, benzodiazepines treat the immediate
physiological crisis.
5. A client with Schizophrenia is experiencing command hallucinations telling them to ‘hurt
the nurse.’ What is the nurse’s priority action?
A. Ask the client if they intend to follow the command.
B. Administer a PRN antipsychotic medication immediately.
C. Tell the client that the voices are not real.
D. Place the client in a quiet room with no stimulation.
Correct Answer: A
