PNR 200/PNR200 Exam 2 V2 | Mental
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a client with Generalized Anxiety Disorder who is experiencing a panic
attack. Which of the following nursing actions is the priority?
A. Teach the client relaxation techniques for future use.
B. Stay with the client and offer reassurance of safety.
C. Encourage the client to explore the cause of the panic.
D. Administer a PRN dose of an oral antidepressant.
Correct Answer: B
Expert Explanation: The immediate priority during a panic attack is to ensure the client’s
safety and reduce their anxiety level by providing a calm presence. Attempting to teach
new skills or explore causes is ineffective while the client is in a state of panic as their
cognitive ability is severely limited. Staying with the client helps build trust and ensures
that the client does not harm themselves during the episode.
2. A client diagnosed with Bipolar Disorder is in a manic phase and is moving rapidly around
the unit. Which of the following snack options is most appropriate?
A. A cup of vegetable soup and crackers.
B. A turkey and cheese wrap.
,C. A bowl of cereal with milk.
D. A piece of chocolate cake.
Correct Answer: B
Expert Explanation: Clients in a manic phase often experience psychomotor agitation and
cannot sit still long enough to eat a full meal. Providing ‘finger foods’ that are high in
protein and calories allows the client to maintain nutrition while remaining mobile. A
turkey and cheese wrap is portable and nutritious, whereas soup or cereal requires the
client to sit and use utensils, which they are unlikely to do.
3. The nurse is assessing a client for Tardive Dyskinesia (TD) following long-term use of
Haloperidol. Which finding should the nurse report to the provider?
A. Muscle rigidity in the neck and shoulders.
B. Involuntary tongue protrusion and lip smacking.
C. Shuffling gait and pill-rolling tremors.
D. A sudden high fever and diaphoresis.
Correct Answer: B
Expert Explanation: Tardive Dyskinesia is characterized by involuntary movements of the
tongue, face, and extremities, often resulting from long-term use of first-generation
antipsychotics. Lip smacking and tongue protrusion are classic early signs that may become
irreversible if not addressed promptly. Other options describe different side effects such as
Parkinsonism, dystonia, or Neuroleptic Malignant Syndrome.
,4. A client is prescribed Lithium Carbonate for the treatment of Bipolar Disorder. Which of the
following instructions should the nurse include in the teaching?
A. Restrict sodium intake to less than 1,500 mg per day.
B. Limit fluid intake to 1 liter per day.
C. Maintain a consistent intake of dietary sodium.
D. Take the medication only when feeling manic.
Correct Answer: C
Expert Explanation: Lithium is a salt, and its excretion is closely linked to sodium levels in
the body. If sodium levels drop, the kidneys retain lithium, which can lead to toxicity;
conversely, excess sodium can cause lithium levels to fall too low. Therefore, the client
must maintain a steady intake of salt and fluids to keep the blood levels of the medication
within the therapeutic range.
5. A nurse is assessing a client who has Major Depressive Disorder and is being considered for
Electroconvulsive Therapy (ECT). Which of the following is a common side effect of ECT?
A. Long-term permanent amnesia.
B. Persistent hypertension.
C. Temporary short-term memory loss.
D. Chronic urinary retention.
Correct Answer: C
, Expert Explanation: Short-term memory loss and confusion are the most common side
effects reported immediately following an ECT procedure. These effects are typically
transient and resolve within a few weeks after the treatment course is completed. It is
important for the nurse to orient the client frequently and reassure them that memory
functions usually return to baseline.
6. A client with Schizophrenia is experiencing auditory hallucinations and says, ‘The voices are
telling me I am a bad person.’ Which response by the nurse is therapeutic?
A. ‘I understand the voices are real to you, but I do not hear them.’
B. ‘What exactly are the voices saying to you?’
C. ‘I don’t hear any voices; you are imagining things.’
D. ‘Why do you think the voices are saying those things?’
Correct Answer: A
Expert Explanation: This response acknowledges the client’s internal experience without
validating the hallucination as reality, a technique known as presenting reality. It is crucial
for the nurse to demonstrate empathy while maintaining a firm grasp on the objective
environment. This approach helps build a therapeutic alliance without reinforcing the
delusional or hallucinatory process.
7. The nurse is caring for a client who is exhibiting signs of Serotonin Syndrome. Which of the
following clinical manifestations should the nurse expect?
A. Bradycardia and hypotension.
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a client with Generalized Anxiety Disorder who is experiencing a panic
attack. Which of the following nursing actions is the priority?
A. Teach the client relaxation techniques for future use.
B. Stay with the client and offer reassurance of safety.
C. Encourage the client to explore the cause of the panic.
D. Administer a PRN dose of an oral antidepressant.
Correct Answer: B
Expert Explanation: The immediate priority during a panic attack is to ensure the client’s
safety and reduce their anxiety level by providing a calm presence. Attempting to teach
new skills or explore causes is ineffective while the client is in a state of panic as their
cognitive ability is severely limited. Staying with the client helps build trust and ensures
that the client does not harm themselves during the episode.
2. A client diagnosed with Bipolar Disorder is in a manic phase and is moving rapidly around
the unit. Which of the following snack options is most appropriate?
A. A cup of vegetable soup and crackers.
B. A turkey and cheese wrap.
,C. A bowl of cereal with milk.
D. A piece of chocolate cake.
Correct Answer: B
Expert Explanation: Clients in a manic phase often experience psychomotor agitation and
cannot sit still long enough to eat a full meal. Providing ‘finger foods’ that are high in
protein and calories allows the client to maintain nutrition while remaining mobile. A
turkey and cheese wrap is portable and nutritious, whereas soup or cereal requires the
client to sit and use utensils, which they are unlikely to do.
3. The nurse is assessing a client for Tardive Dyskinesia (TD) following long-term use of
Haloperidol. Which finding should the nurse report to the provider?
A. Muscle rigidity in the neck and shoulders.
B. Involuntary tongue protrusion and lip smacking.
C. Shuffling gait and pill-rolling tremors.
D. A sudden high fever and diaphoresis.
Correct Answer: B
Expert Explanation: Tardive Dyskinesia is characterized by involuntary movements of the
tongue, face, and extremities, often resulting from long-term use of first-generation
antipsychotics. Lip smacking and tongue protrusion are classic early signs that may become
irreversible if not addressed promptly. Other options describe different side effects such as
Parkinsonism, dystonia, or Neuroleptic Malignant Syndrome.
,4. A client is prescribed Lithium Carbonate for the treatment of Bipolar Disorder. Which of the
following instructions should the nurse include in the teaching?
A. Restrict sodium intake to less than 1,500 mg per day.
B. Limit fluid intake to 1 liter per day.
C. Maintain a consistent intake of dietary sodium.
D. Take the medication only when feeling manic.
Correct Answer: C
Expert Explanation: Lithium is a salt, and its excretion is closely linked to sodium levels in
the body. If sodium levels drop, the kidneys retain lithium, which can lead to toxicity;
conversely, excess sodium can cause lithium levels to fall too low. Therefore, the client
must maintain a steady intake of salt and fluids to keep the blood levels of the medication
within the therapeutic range.
5. A nurse is assessing a client who has Major Depressive Disorder and is being considered for
Electroconvulsive Therapy (ECT). Which of the following is a common side effect of ECT?
A. Long-term permanent amnesia.
B. Persistent hypertension.
C. Temporary short-term memory loss.
D. Chronic urinary retention.
Correct Answer: C
, Expert Explanation: Short-term memory loss and confusion are the most common side
effects reported immediately following an ECT procedure. These effects are typically
transient and resolve within a few weeks after the treatment course is completed. It is
important for the nurse to orient the client frequently and reassure them that memory
functions usually return to baseline.
6. A client with Schizophrenia is experiencing auditory hallucinations and says, ‘The voices are
telling me I am a bad person.’ Which response by the nurse is therapeutic?
A. ‘I understand the voices are real to you, but I do not hear them.’
B. ‘What exactly are the voices saying to you?’
C. ‘I don’t hear any voices; you are imagining things.’
D. ‘Why do you think the voices are saying those things?’
Correct Answer: A
Expert Explanation: This response acknowledges the client’s internal experience without
validating the hallucination as reality, a technique known as presenting reality. It is crucial
for the nurse to demonstrate empathy while maintaining a firm grasp on the objective
environment. This approach helps build a therapeutic alliance without reinforcing the
delusional or hallucinatory process.
7. The nurse is caring for a client who is exhibiting signs of Serotonin Syndrome. Which of the
following clinical manifestations should the nurse expect?
A. Bradycardia and hypotension.
