PNR 200/PNR200 Exam 4 V2 | Mental
Health Nursing Q&A with Rationale | Fortis
College
1. A client is admitted to the psychiatric unit with a diagnosis of delirium. Which clinical
manifestation should the nurse expect to observe?
A. Gradual decline in cognitive function over several years
B. Sudden onset of confusion and fluctuating levels of consciousness
C. Stable level of consciousness throughout the day
D. Intact short-term memory with loss of long-term memory
Correct Answer: B
Expert Explanation: Delirium is characterized by an acute and sudden onset of confusion
that often fluctuates during a 24-hour period. This condition is usually reversible if the
underlying physiological cause is identified and treated promptly. In contrast, dementia
involves a slow, progressive decline in cognition that is generally irreversible.
2. A nurse is caring for a client experiencing alcohol withdrawal. Which medication is
considered the gold standard for preventing seizures and managing symptoms?
A. Disulfiram
B. Haloperidol
C. Lorazepam
,D. Methadone
Correct Answer: C
Expert Explanation: Benzodiazepines like lorazepam are the first-line treatment for
managing alcohol withdrawal symptoms and preventing seizures. These medications
cross-taper with alcohol to stabilize the central nervous system during the detox process.
The nurse should monitor the client’s vital signs and use the CIWA-Ar scale to titrate the
dosage effectively.
3. A client with schizophrenia is prescribed Clozapine. Which laboratory value must the nurse
monitor most closely to ensure client safety?
A. Serum potassium levels
B. Blood urea nitrogen (BUN)
C. White blood cell (WBC) count
D. Platelet count
Correct Answer: C
Expert Explanation: Clozapine carries a significant risk of agranulocytosis, which is a life-
threatening decrease in the white blood cell count. Nurses must ensure the client receives
weekly or bi-weekly blood draws to monitor the Absolute Neutrophil Count (ANC) as
mandated by the Clozapine REMS program. If the WBC or ANC falls below a specific
threshold, the medication must be discontinued immediately to prevent severe infection.
,4. A nurse is assessing a client with Anorexia Nervosa. Which physical finding is most
indicative of the body’s attempt to conserve heat?
A. Lanugo
B. Hypertension
C. Tachycardia
D. Hyperglycemia
Correct Answer: A
Expert Explanation: Lanugo is the growth of fine, downy hair on the face and back, which
is a common compensatory mechanism in clients with severe malnutrition. This occurs as
the body attempts to provide insulation and maintain core temperature in the absence of
subcutaneous fat. Other signs often include bradycardia and hypotension due to the
metabolic slowdown associated with starvation.
5. A client taking Lithium Carbonate for Bipolar Disorder reports blurred vision and a severe
hand tremor. What is the nurse’s priority action?
A. Hold the medication and notify the provider
B. Administer the next dose as scheduled
C. Encourage the client to increase fluid intake
D. Advise the client that these are common side effects
Correct Answer: A
, Expert Explanation: Blurred vision and coarse hand tremors are signs of moderate to
severe lithium toxicity, which can be life-threatening. The nurse must hold the medication
and request a serum lithium level immediately to assess the severity of the toxicity. Safe
therapeutic levels range from 0.6 to 1.2 mEq/L, and values exceeding 1.5 mEq/L require
urgent intervention.
6. A client is diagnosed with Antisocial Personality Disorder. Which behavior should the nurse
anticipate?
A. Extreme sensitivity to rejection
B. Lack of remorse or guilt for hurting others
C. Social withdrawal and avoidance of others
D. Excessive need to be taken care of
Correct Answer: B
Expert Explanation: Antisocial Personality Disorder is characterized by a pervasive
pattern of disregard for the rights of others and a lack of empathy. These individuals often
engage in deceitful or manipulative behaviors for personal gain without feeling guilt.
Nursing care should focus on setting firm, consistent limits and holding the client
accountable for their actions.
7. Which electrolyte imbalance is a primary concern during the ‘refeeding syndrome’ phase of
treating Anorexia Nervosa?
A. Hypernatremia
Health Nursing Q&A with Rationale | Fortis
College
1. A client is admitted to the psychiatric unit with a diagnosis of delirium. Which clinical
manifestation should the nurse expect to observe?
A. Gradual decline in cognitive function over several years
B. Sudden onset of confusion and fluctuating levels of consciousness
C. Stable level of consciousness throughout the day
D. Intact short-term memory with loss of long-term memory
Correct Answer: B
Expert Explanation: Delirium is characterized by an acute and sudden onset of confusion
that often fluctuates during a 24-hour period. This condition is usually reversible if the
underlying physiological cause is identified and treated promptly. In contrast, dementia
involves a slow, progressive decline in cognition that is generally irreversible.
2. A nurse is caring for a client experiencing alcohol withdrawal. Which medication is
considered the gold standard for preventing seizures and managing symptoms?
A. Disulfiram
B. Haloperidol
C. Lorazepam
,D. Methadone
Correct Answer: C
Expert Explanation: Benzodiazepines like lorazepam are the first-line treatment for
managing alcohol withdrawal symptoms and preventing seizures. These medications
cross-taper with alcohol to stabilize the central nervous system during the detox process.
The nurse should monitor the client’s vital signs and use the CIWA-Ar scale to titrate the
dosage effectively.
3. A client with schizophrenia is prescribed Clozapine. Which laboratory value must the nurse
monitor most closely to ensure client safety?
A. Serum potassium levels
B. Blood urea nitrogen (BUN)
C. White blood cell (WBC) count
D. Platelet count
Correct Answer: C
Expert Explanation: Clozapine carries a significant risk of agranulocytosis, which is a life-
threatening decrease in the white blood cell count. Nurses must ensure the client receives
weekly or bi-weekly blood draws to monitor the Absolute Neutrophil Count (ANC) as
mandated by the Clozapine REMS program. If the WBC or ANC falls below a specific
threshold, the medication must be discontinued immediately to prevent severe infection.
,4. A nurse is assessing a client with Anorexia Nervosa. Which physical finding is most
indicative of the body’s attempt to conserve heat?
A. Lanugo
B. Hypertension
C. Tachycardia
D. Hyperglycemia
Correct Answer: A
Expert Explanation: Lanugo is the growth of fine, downy hair on the face and back, which
is a common compensatory mechanism in clients with severe malnutrition. This occurs as
the body attempts to provide insulation and maintain core temperature in the absence of
subcutaneous fat. Other signs often include bradycardia and hypotension due to the
metabolic slowdown associated with starvation.
5. A client taking Lithium Carbonate for Bipolar Disorder reports blurred vision and a severe
hand tremor. What is the nurse’s priority action?
A. Hold the medication and notify the provider
B. Administer the next dose as scheduled
C. Encourage the client to increase fluid intake
D. Advise the client that these are common side effects
Correct Answer: A
, Expert Explanation: Blurred vision and coarse hand tremors are signs of moderate to
severe lithium toxicity, which can be life-threatening. The nurse must hold the medication
and request a serum lithium level immediately to assess the severity of the toxicity. Safe
therapeutic levels range from 0.6 to 1.2 mEq/L, and values exceeding 1.5 mEq/L require
urgent intervention.
6. A client is diagnosed with Antisocial Personality Disorder. Which behavior should the nurse
anticipate?
A. Extreme sensitivity to rejection
B. Lack of remorse or guilt for hurting others
C. Social withdrawal and avoidance of others
D. Excessive need to be taken care of
Correct Answer: B
Expert Explanation: Antisocial Personality Disorder is characterized by a pervasive
pattern of disregard for the rights of others and a lack of empathy. These individuals often
engage in deceitful or manipulative behaviors for personal gain without feeling guilt.
Nursing care should focus on setting firm, consistent limits and holding the client
accountable for their actions.
7. Which electrolyte imbalance is a primary concern during the ‘refeeding syndrome’ phase of
treating Anorexia Nervosa?
A. Hypernatremia
