PNR 200/PNR200 Exam 2 V1 | Mental
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a client experiencing a panic attack. Which of the following actions is
the priority for the nurse to take?
A. Instruct the client to practice progressive muscle relaxation.
B. Stay with the client and use short, simple sentences.
C. Leave the client alone to allow them space to calm down.
D. Encourage the client to discuss the underlying cause of the anxiety.
Correct Answer: B
Expert Explanation: During a panic attack, the client’s perceptual field is severely
narrowed, making it difficult for them to process complex information. The nurse should
provide a calm presence and use clear, concise instructions to help the client feel safe and
grounded. Leaving the client alone could increase their fear and sense of isolation during a
crisis.
2. A client with Bipolar Disorder is prescribed Lithium Carbonate. Which of the following lab
values should the nurse report to the provider immediately?
A. Serum lithium level of 0.8 mEq/L
B. Serum lithium level of 0.6 mEq/L
,C. Serum lithium level of 1.1 mEq/L
D. Serum lithium level of 1.8 mEq/L
Correct Answer: D
Expert Explanation: The therapeutic range for lithium is 0.6 to 1.2 mEq/L; therefore, a
level of 1.8 mEq/L indicates toxicity. Toxicity symptoms can include coarse tremors,
persistent gastrointestinal upset, and mental confusion. The nurse must prioritize
reporting this value to prevent severe complications such as seizures or renal failure.
3. A nurse is providing teaching to a client starting Phenelzine (Nardil). Which food choice by
the client indicates an understanding of the dietary restrictions?
A. Pepperoni pizza with extra cheese
B. Grilled chicken breast with steamed broccoli
C. A glass of red wine with aged cheddar
D. Smoked salmon bagel with cream cheese
Correct Answer: B
Expert Explanation: Phenelzine is an MAOI that requires a low-tyramine diet to prevent a
hypertensive crisis. Foods such as aged cheeses, cured meats, and fermented products are
high in tyramine and must be avoided. Freshly prepared meats like grilled chicken and
fresh vegetables are safe options for these clients.
,4. A client is prescribed Haloperidol for the treatment of Schizophrenia. The nurse observes
that the client is experiencing muscle rigidity and a temperature of 103 degrees F. What is the
nurse’s priority action?
A. Administer an extra dose of Haloperidol to calm the client.
B. Apply a cooling blanket and reassess in one hour.
C. Notify the provider and prepare for emergency intervention.
D. Administer Benztropine as prescribed for EPS.
Correct Answer: C
Expert Explanation: High fever and muscle rigidity are hallmark signs of Neuroleptic
Malignant Syndrome (NMS), a life-threatening complication of antipsychotic use. This
condition is a medical emergency that requires the immediate discontinuation of the
medication and supportive care. The nurse must act quickly to notify the physician as NMS
can lead to organ failure and death.
5. Which statement by a client with Obsessive-Compulsive Disorder (OCD) regarding their
hand-washing ritual requires intervention by the nurse?
A. I will stop washing my hands immediately because you told me to.
B. I know that my hands are clean, but I feel I must wash them anyway.
C. I wash my hands because it makes me feel less anxious.
D. The rituals take up several hours of my day.
, Correct Answer: A
Expert Explanation: Forcing a client with OCD to stop their rituals abruptly can lead to
overwhelming anxiety and panic. The goal of therapy is to gradually reduce the time spent
on rituals rather than stopping them suddenly. The nurse should support the client while
implementing a plan to decrease the frequency of the behavior over time.
6. A nurse is assessing a client for suicidal ideation. Which of the following questions is the
most direct and appropriate to ask?
A. Do you feel like you might hurt yourself?
B. Are you thinking about killing yourself?
C. Have things been so bad that you wish you weren’t here?
D. Are you feeling better than you were yesterday?
Correct Answer: B
Expert Explanation: When assessing for suicide risk, the nurse must use direct and clear
language to ensure there is no ambiguity. Asking specifically about killing oneself helps the
nurse gather accurate data to determine the level of risk. Indirect questions may allow the
client to minimize their feelings or avoid providing an honest answer.
7. A nurse is caring for a client with Post-Traumatic Stress Disorder (PTSD) who is
experiencing a flashback. What is the nurse’s first action?
A. Reorient the client to the present environment.
B. Ask the client to describe the trauma in detail.
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a client experiencing a panic attack. Which of the following actions is
the priority for the nurse to take?
A. Instruct the client to practice progressive muscle relaxation.
B. Stay with the client and use short, simple sentences.
C. Leave the client alone to allow them space to calm down.
D. Encourage the client to discuss the underlying cause of the anxiety.
Correct Answer: B
Expert Explanation: During a panic attack, the client’s perceptual field is severely
narrowed, making it difficult for them to process complex information. The nurse should
provide a calm presence and use clear, concise instructions to help the client feel safe and
grounded. Leaving the client alone could increase their fear and sense of isolation during a
crisis.
2. A client with Bipolar Disorder is prescribed Lithium Carbonate. Which of the following lab
values should the nurse report to the provider immediately?
A. Serum lithium level of 0.8 mEq/L
B. Serum lithium level of 0.6 mEq/L
,C. Serum lithium level of 1.1 mEq/L
D. Serum lithium level of 1.8 mEq/L
Correct Answer: D
Expert Explanation: The therapeutic range for lithium is 0.6 to 1.2 mEq/L; therefore, a
level of 1.8 mEq/L indicates toxicity. Toxicity symptoms can include coarse tremors,
persistent gastrointestinal upset, and mental confusion. The nurse must prioritize
reporting this value to prevent severe complications such as seizures or renal failure.
3. A nurse is providing teaching to a client starting Phenelzine (Nardil). Which food choice by
the client indicates an understanding of the dietary restrictions?
A. Pepperoni pizza with extra cheese
B. Grilled chicken breast with steamed broccoli
C. A glass of red wine with aged cheddar
D. Smoked salmon bagel with cream cheese
Correct Answer: B
Expert Explanation: Phenelzine is an MAOI that requires a low-tyramine diet to prevent a
hypertensive crisis. Foods such as aged cheeses, cured meats, and fermented products are
high in tyramine and must be avoided. Freshly prepared meats like grilled chicken and
fresh vegetables are safe options for these clients.
,4. A client is prescribed Haloperidol for the treatment of Schizophrenia. The nurse observes
that the client is experiencing muscle rigidity and a temperature of 103 degrees F. What is the
nurse’s priority action?
A. Administer an extra dose of Haloperidol to calm the client.
B. Apply a cooling blanket and reassess in one hour.
C. Notify the provider and prepare for emergency intervention.
D. Administer Benztropine as prescribed for EPS.
Correct Answer: C
Expert Explanation: High fever and muscle rigidity are hallmark signs of Neuroleptic
Malignant Syndrome (NMS), a life-threatening complication of antipsychotic use. This
condition is a medical emergency that requires the immediate discontinuation of the
medication and supportive care. The nurse must act quickly to notify the physician as NMS
can lead to organ failure and death.
5. Which statement by a client with Obsessive-Compulsive Disorder (OCD) regarding their
hand-washing ritual requires intervention by the nurse?
A. I will stop washing my hands immediately because you told me to.
B. I know that my hands are clean, but I feel I must wash them anyway.
C. I wash my hands because it makes me feel less anxious.
D. The rituals take up several hours of my day.
, Correct Answer: A
Expert Explanation: Forcing a client with OCD to stop their rituals abruptly can lead to
overwhelming anxiety and panic. The goal of therapy is to gradually reduce the time spent
on rituals rather than stopping them suddenly. The nurse should support the client while
implementing a plan to decrease the frequency of the behavior over time.
6. A nurse is assessing a client for suicidal ideation. Which of the following questions is the
most direct and appropriate to ask?
A. Do you feel like you might hurt yourself?
B. Are you thinking about killing yourself?
C. Have things been so bad that you wish you weren’t here?
D. Are you feeling better than you were yesterday?
Correct Answer: B
Expert Explanation: When assessing for suicide risk, the nurse must use direct and clear
language to ensure there is no ambiguity. Asking specifically about killing oneself helps the
nurse gather accurate data to determine the level of risk. Indirect questions may allow the
client to minimize their feelings or avoid providing an honest answer.
7. A nurse is caring for a client with Post-Traumatic Stress Disorder (PTSD) who is
experiencing a flashback. What is the nurse’s first action?
A. Reorient the client to the present environment.
B. Ask the client to describe the trauma in detail.
