PNR 200/PNR200 Exam 2 V3 | Mental
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing a client with moderate anxiety. Which of the following findings should
the nurse expect?
A. The client has a narrowed perceptual field.
B. The client is in a state of total withdrawal.
C. The client reports feeling like they are having a heart attack.
D. The client’s perceptual field is increased.
Correct Answer: A
Expert Explanation: Moderate anxiety causes a narrowed perceptual field where the
individual focuses on immediate concerns. The client can still follow directions but may
experience selective inattention. This level of anxiety differs from severe or panic levels
where the person may lose touch with reality.
2. A client is being treated for a substance use disorder and says, ‘I only drink because my
boss is so hard on me.’ The nurse recognizes this as which defense mechanism?
A. Sublimation
B. Rationalization
C. Reaction Formation
,D. Displacement
Correct Answer: B
Expert Explanation: Rationalization involves justifying illogical or unreasonable ideas or
feelings by developing acceptable explanations. The client is creating a logical-sounding
excuse to justify their alcohol consumption. This defense mechanism helps the individual
avoid taking personal responsibility for their actions.
3. A nurse is caring for a client who has been prescribed Lithium Carbonate for Bipolar
Disorder. Which laboratory value is the priority for the nurse to monitor?
A. Serum Glucose
B. Serum Potassium
C. Serum Sodium
D. Serum Hemoglobin
Correct Answer: C
Expert Explanation: Lithium is a salt, and its excretion is closely tied to sodium levels in
the body. If sodium levels are low, the kidneys retain lithium, which can lead to toxicity.
The nurse must ensure the client maintains adequate sodium and fluid intake to prevent
adverse reactions.
4. A client with Schizophrenia is observed maintaining a rigid posture and refusing to move.
This behavior is documented as:
A. Echolalia
, B. Waxy Flexibility
C. Akathisia
D. Tardive Dyskinesia
Correct Answer: B
Expert Explanation: Waxy flexibility is a condition where a client remains in a specific
position for an extended period after being moved. It is a psychomotor symptom often
associated with catatonic schizophrenia. The nurse should focus on physical safety and skin
integrity when this symptom occurs.
5. Which of the following is an example of a ‘positive’ symptom of Schizophrenia?
A. Auditory hallucinations
B. Anhedonia
C. Flat affect
D. Avolition
Correct Answer: A
Expert Explanation: Positive symptoms are behaviors or sensory experiences that are
added to a person’s normal functions, such as hallucinations or delusions. Negative
symptoms involve a loss of normal function, like flat affect or lack of motivation. Identifying
these symptoms helps the nurse determine the effectiveness of antipsychotic medications.
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing a client with moderate anxiety. Which of the following findings should
the nurse expect?
A. The client has a narrowed perceptual field.
B. The client is in a state of total withdrawal.
C. The client reports feeling like they are having a heart attack.
D. The client’s perceptual field is increased.
Correct Answer: A
Expert Explanation: Moderate anxiety causes a narrowed perceptual field where the
individual focuses on immediate concerns. The client can still follow directions but may
experience selective inattention. This level of anxiety differs from severe or panic levels
where the person may lose touch with reality.
2. A client is being treated for a substance use disorder and says, ‘I only drink because my
boss is so hard on me.’ The nurse recognizes this as which defense mechanism?
A. Sublimation
B. Rationalization
C. Reaction Formation
,D. Displacement
Correct Answer: B
Expert Explanation: Rationalization involves justifying illogical or unreasonable ideas or
feelings by developing acceptable explanations. The client is creating a logical-sounding
excuse to justify their alcohol consumption. This defense mechanism helps the individual
avoid taking personal responsibility for their actions.
3. A nurse is caring for a client who has been prescribed Lithium Carbonate for Bipolar
Disorder. Which laboratory value is the priority for the nurse to monitor?
A. Serum Glucose
B. Serum Potassium
C. Serum Sodium
D. Serum Hemoglobin
Correct Answer: C
Expert Explanation: Lithium is a salt, and its excretion is closely tied to sodium levels in
the body. If sodium levels are low, the kidneys retain lithium, which can lead to toxicity.
The nurse must ensure the client maintains adequate sodium and fluid intake to prevent
adverse reactions.
4. A client with Schizophrenia is observed maintaining a rigid posture and refusing to move.
This behavior is documented as:
A. Echolalia
, B. Waxy Flexibility
C. Akathisia
D. Tardive Dyskinesia
Correct Answer: B
Expert Explanation: Waxy flexibility is a condition where a client remains in a specific
position for an extended period after being moved. It is a psychomotor symptom often
associated with catatonic schizophrenia. The nurse should focus on physical safety and skin
integrity when this symptom occurs.
5. Which of the following is an example of a ‘positive’ symptom of Schizophrenia?
A. Auditory hallucinations
B. Anhedonia
C. Flat affect
D. Avolition
Correct Answer: A
Expert Explanation: Positive symptoms are behaviors or sensory experiences that are
added to a person’s normal functions, such as hallucinations or delusions. Negative
symptoms involve a loss of normal function, like flat affect or lack of motivation. Identifying
these symptoms helps the nurse determine the effectiveness of antipsychotic medications.
