PNR 200/PNR200 Exam 4 V3 | Mental
Health Nursing Q&A with Rationale | Fortis
College
1. A client with bipolar disorder is prescribed Lithium carbonate. Which dietary information is
most critical for the nurse to provide?
A. Maintain a consistent intake of dietary sodium.
B. Restrict sodium intake to less than 1500mg daily.
C. Increase caffeine consumption to manage lethargy.
D. Switch to a low-protein diet to prevent renal strain.
Correct Answer: A
Expert Explanation: Lithium is a salt, and its excretion is inversely related to sodium
levels in the body. If sodium levels drop, the kidneys retain lithium, leading to toxic levels.
The client must maintain consistent salt and fluid intake to ensure therapeutic stability.
2. The nurse is caring for a client with Borderline Personality Disorder who is ‘splitting’ the
staff. What is the most appropriate nursing intervention?
A. Allow the client to choose which staff member provides care.
B. Hold a staff meeting to ensure a consistent approach to care.
C. Limit contact with the client to only one specific nurse.
,D. Confront the client about their manipulative behavior immediately.
Correct Answer: B
Expert Explanation: Splitting is a defense mechanism where the client perceives others as
all good or all bad. Consistency among the treatment team is vital to prevent the client from
playing staff against each other. This approach helps maintain clear boundaries and
provides a stable therapeutic environment.
3. A client is admitted for alcohol detoxification. Which assessment finding should the nurse
prioritize as a sign of Delirium Tremens (DTs)?
A. Mild tremors and headache.
B. Increased appetite and hypersomnia.
C. Tachycardia, hypertension, and disorientation.
D. Auditory hallucinations and diaphoresis.
Correct Answer: C
Expert Explanation: Delirium Tremens is a severe form of alcohol withdrawal
characterized by autonomic hyperactivity and altered sensorium. Symptoms like
tachycardia, hypertension, and fever can be life-threatening if not managed. This condition
typically occurs 48 to 72 hours after the last drink.
4. Which side effect of Haloperidol (Haldol) should the nurse report to the provider
immediately?
A. Dry mouth and blurred vision.
, B. High fever, muscle rigidity, and tachycardia.
C. Weight gain of 2 lbs in one week.
D. Mild sedation during daytime hours.
Correct Answer: B
Expert Explanation: These symptoms are characteristic of Neuroleptic Malignant
Syndrome (NMS), which is a medical emergency. NMS is a rare but fatal reaction to
antipsychotic medications like Haloperidol. Immediate cessation of the drug and
supportive care are required to prevent death.
5. A client with Anorexia Nervosa has a BMI of 15. What is the nursing priority for this client?
A. Initiating family therapy sessions.
B. Teaching the client about healthy food choices.
C. Monitoring for cardiac arrhythmias and electrolyte imbalance.
D. Encouraging the client to express feelings about body image.
Correct Answer: C
Expert Explanation: Physiological stability is the primary concern for a client with severe
malnutrition. A BMI of 15 indicates extreme thinness and places the client at high risk for
heart failure and metabolic disturbances. Once the client is medically stable, psychological
issues can be addressed.
Health Nursing Q&A with Rationale | Fortis
College
1. A client with bipolar disorder is prescribed Lithium carbonate. Which dietary information is
most critical for the nurse to provide?
A. Maintain a consistent intake of dietary sodium.
B. Restrict sodium intake to less than 1500mg daily.
C. Increase caffeine consumption to manage lethargy.
D. Switch to a low-protein diet to prevent renal strain.
Correct Answer: A
Expert Explanation: Lithium is a salt, and its excretion is inversely related to sodium
levels in the body. If sodium levels drop, the kidneys retain lithium, leading to toxic levels.
The client must maintain consistent salt and fluid intake to ensure therapeutic stability.
2. The nurse is caring for a client with Borderline Personality Disorder who is ‘splitting’ the
staff. What is the most appropriate nursing intervention?
A. Allow the client to choose which staff member provides care.
B. Hold a staff meeting to ensure a consistent approach to care.
C. Limit contact with the client to only one specific nurse.
,D. Confront the client about their manipulative behavior immediately.
Correct Answer: B
Expert Explanation: Splitting is a defense mechanism where the client perceives others as
all good or all bad. Consistency among the treatment team is vital to prevent the client from
playing staff against each other. This approach helps maintain clear boundaries and
provides a stable therapeutic environment.
3. A client is admitted for alcohol detoxification. Which assessment finding should the nurse
prioritize as a sign of Delirium Tremens (DTs)?
A. Mild tremors and headache.
B. Increased appetite and hypersomnia.
C. Tachycardia, hypertension, and disorientation.
D. Auditory hallucinations and diaphoresis.
Correct Answer: C
Expert Explanation: Delirium Tremens is a severe form of alcohol withdrawal
characterized by autonomic hyperactivity and altered sensorium. Symptoms like
tachycardia, hypertension, and fever can be life-threatening if not managed. This condition
typically occurs 48 to 72 hours after the last drink.
4. Which side effect of Haloperidol (Haldol) should the nurse report to the provider
immediately?
A. Dry mouth and blurred vision.
, B. High fever, muscle rigidity, and tachycardia.
C. Weight gain of 2 lbs in one week.
D. Mild sedation during daytime hours.
Correct Answer: B
Expert Explanation: These symptoms are characteristic of Neuroleptic Malignant
Syndrome (NMS), which is a medical emergency. NMS is a rare but fatal reaction to
antipsychotic medications like Haloperidol. Immediate cessation of the drug and
supportive care are required to prevent death.
5. A client with Anorexia Nervosa has a BMI of 15. What is the nursing priority for this client?
A. Initiating family therapy sessions.
B. Teaching the client about healthy food choices.
C. Monitoring for cardiac arrhythmias and electrolyte imbalance.
D. Encouraging the client to express feelings about body image.
Correct Answer: C
Expert Explanation: Physiological stability is the primary concern for a client with severe
malnutrition. A BMI of 15 indicates extreme thinness and places the client at high risk for
heart failure and metabolic disturbances. Once the client is medically stable, psychological
issues can be addressed.
