PNR 200/PNR200 Exam 3 V1 | Mental
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a client with Bipolar Disorder who is in the manic phase. What is the
priority nursing intervention for this client?
A. Encouraging the client to join a group activity.
B. Assessing the client’s understanding of their illness.
C. Providing high-calorie finger foods.
D. Allowing the client to lead the community meeting.
Correct Answer: C
Expert Explanation: During a manic episode, clients are often hyperactive and cannot sit
long enough for a full meal. Providing high-calorie finger foods allows the client to maintain
nutrition while remaining mobile. Physiological stability and safety are the primary
concerns in this acute phase.
2. A client is prescribed Lithium Carbonate for mood stabilization. Which of the following lab
values should the nurse report to the provider immediately?
A. Lithium level of 1.8 mEq/L
B. Sodium level of 140 mEq/L
C. Potassium level of 4.0 mEq/L
,D. Lithium level of 0.8 mEq/L
Correct Answer: A
Expert Explanation: A lithium level of 1.8 mEq/L indicates lithium toxicity, as the
therapeutic range is typically 0.6 to 1.2 mEq/L. Levels above 1.5 mEq/L require immediate
medical intervention to prevent severe complications. The nurse should also monitor for
clinical signs such as diarrhea, vomiting, and tremors.
3. Which of the following is considered a negative symptom of Schizophrenia?
A. Auditory hallucinations
B. Flat affect
C. Delusions of grandeur
D. Disorganized speech
Correct Answer: B
Expert Explanation: Negative symptoms represent a loss of normal function, such as flat
affect, alogia, and avolition. Positive symptoms, such as hallucinations and delusions,
involve the presence of behaviors that should not be there. Recognizing the difference is
essential for determining the effectiveness of antipsychotic therapy.
4. A client with Obsessive-Compulsive Disorder (OCD) spends several hours a day washing
their hands. What should the nurse’s initial goal be?
A. Stopping the ritualistic behavior immediately.
, B. Gradually reducing the time spent on rituals.
C. Forcing the client to touch dirty objects.
D. Ignoring the behavior entirely.
Correct Answer: B
Expert Explanation: Initial goals for OCD involve allowing enough time for rituals to
prevent overwhelming anxiety while gradually implementing limits. Abruptly stopping
rituals can cause severe panic and crisis for the client. The long-term objective is to develop
healthier coping mechanisms to manage underlying anxiety.
5. A nurse is assessing a client for Serotonin Syndrome. Which symptom is a classic indicator
of this condition?
A. Lead-pipe muscle rigidity
B. Hyporeflexia
C. Hyperreflexia and tremors
D. Profound bradycardia
Correct Answer: C
Expert Explanation: Serotonin syndrome is characterized by mental status changes,
autonomic hyperactivity, and neuromuscular abnormalities like hyperreflexia. This is a
potentially life-threatening reaction to serotonergic medications. Nurses must monitor for
these signs especially when doses are increased or new medications are added.
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a client with Bipolar Disorder who is in the manic phase. What is the
priority nursing intervention for this client?
A. Encouraging the client to join a group activity.
B. Assessing the client’s understanding of their illness.
C. Providing high-calorie finger foods.
D. Allowing the client to lead the community meeting.
Correct Answer: C
Expert Explanation: During a manic episode, clients are often hyperactive and cannot sit
long enough for a full meal. Providing high-calorie finger foods allows the client to maintain
nutrition while remaining mobile. Physiological stability and safety are the primary
concerns in this acute phase.
2. A client is prescribed Lithium Carbonate for mood stabilization. Which of the following lab
values should the nurse report to the provider immediately?
A. Lithium level of 1.8 mEq/L
B. Sodium level of 140 mEq/L
C. Potassium level of 4.0 mEq/L
,D. Lithium level of 0.8 mEq/L
Correct Answer: A
Expert Explanation: A lithium level of 1.8 mEq/L indicates lithium toxicity, as the
therapeutic range is typically 0.6 to 1.2 mEq/L. Levels above 1.5 mEq/L require immediate
medical intervention to prevent severe complications. The nurse should also monitor for
clinical signs such as diarrhea, vomiting, and tremors.
3. Which of the following is considered a negative symptom of Schizophrenia?
A. Auditory hallucinations
B. Flat affect
C. Delusions of grandeur
D. Disorganized speech
Correct Answer: B
Expert Explanation: Negative symptoms represent a loss of normal function, such as flat
affect, alogia, and avolition. Positive symptoms, such as hallucinations and delusions,
involve the presence of behaviors that should not be there. Recognizing the difference is
essential for determining the effectiveness of antipsychotic therapy.
4. A client with Obsessive-Compulsive Disorder (OCD) spends several hours a day washing
their hands. What should the nurse’s initial goal be?
A. Stopping the ritualistic behavior immediately.
, B. Gradually reducing the time spent on rituals.
C. Forcing the client to touch dirty objects.
D. Ignoring the behavior entirely.
Correct Answer: B
Expert Explanation: Initial goals for OCD involve allowing enough time for rituals to
prevent overwhelming anxiety while gradually implementing limits. Abruptly stopping
rituals can cause severe panic and crisis for the client. The long-term objective is to develop
healthier coping mechanisms to manage underlying anxiety.
5. A nurse is assessing a client for Serotonin Syndrome. Which symptom is a classic indicator
of this condition?
A. Lead-pipe muscle rigidity
B. Hyporeflexia
C. Hyperreflexia and tremors
D. Profound bradycardia
Correct Answer: C
Expert Explanation: Serotonin syndrome is characterized by mental status changes,
autonomic hyperactivity, and neuromuscular abnormalities like hyperreflexia. This is a
potentially life-threatening reaction to serotonergic medications. Nurses must monitor for
these signs especially when doses are increased or new medications are added.
