PNR 200/PNR200 Exam 3 V3 | Mental
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a client who is experiencing a manic episode. Which of the following
nursing interventions is the priority?
A. Encouraging the client to join a group therapy session.
B. Restricting the client’s fluid intake to prevent water intoxication.
C. Providing high-calorie finger foods that can be eaten while walking.
D. Teaching the client relaxation techniques and deep breathing.
Correct Answer: C
Expert Explanation: Clients in a manic phase often experience excessive physical activity
and have difficulty sitting down to eat full meals. Providing high-calorie finger foods helps
maintain nutritional requirements and prevents weight loss during periods of
hyperactivity. This intervention addresses physiological safety, which is a priority
according to Maslow’s hierarchy of needs.
2. A client is prescribed lithium carbonate for the treatment of bipolar disorder. Which
laboratory value should the nurse monitor most closely to prevent toxicity?
A. Serum glucose levels
B. Prothrombin time (PT)
,C. Liver enzymes (AST/ALT)
D. Serum sodium levels
Correct Answer: D
Expert Explanation: Lithium is a salt, and its excretion is closely linked to sodium levels in
the body. When sodium levels are low, the kidneys retain lithium, which can lead to toxic
accumulations. The nurse must educate the patient on maintaining consistent sodium and
fluid intake to ensure the medication remains within the therapeutic range.
3. The nurse is evaluating a client’s understanding of their new prescription for phenelzine
(Nardil). Which statement by the client indicates a need for further teaching?
A. ‘I will avoid eating aged cheeses and smoked meats.’
B. ‘I will stop taking my OTC cold medicine while on this drug.’
C. ‘I can have a glass of red wine with my dinner occasionally.’
D. ‘I need to monitor my blood pressure regularly.’
Correct Answer: C
Expert Explanation: Phenelzine is a Monoamine Oxidase Inhibitor (MAOI) that requires a
strict low-tyramine diet to prevent a hypertensive crisis. Red wine, aged cheeses, and cured
meats are high in tyramine and must be avoided entirely. A hypertensive crisis is a medical
emergency characterized by a rapid rise in blood pressure and potential organ damage.
, 4. A nurse is assessing a client for adverse effects of haloperidol. Which of the following
findings should the nurse report to the provider as a potential sign of Neuroleptic Malignant
Syndrome (NMS)?
A. Hypotension and bradycardia
B. High fever and muscle rigidity
C. Muscle flaccidity and lethargy
D. Frequent urination and increased thirst
Correct Answer: B
Expert Explanation: Neuroleptic Malignant Syndrome is a rare but life-threatening
reaction to antipsychotic medications like haloperidol. Key clinical manifestations include
high fever, severe muscle rigidity, tachycardia, and autonomic instability. Immediate
discontinuation of the medication and supportive care in an intensive care setting are
required for survival.
5. A client with schizophrenia is experiencing auditory hallucinations and tells the nurse, ‘The
voices are telling me I am a bad person.’ Which response by the nurse is therapeutic?
A. ‘I don’t hear any voices; you are just imagining things.’
B. ‘What are the voices saying to you exactly?’
C. ‘Why do you think the voices are saying those mean things?’
D. ‘I understand that the voices are real to you, but I do not hear them.’
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a client who is experiencing a manic episode. Which of the following
nursing interventions is the priority?
A. Encouraging the client to join a group therapy session.
B. Restricting the client’s fluid intake to prevent water intoxication.
C. Providing high-calorie finger foods that can be eaten while walking.
D. Teaching the client relaxation techniques and deep breathing.
Correct Answer: C
Expert Explanation: Clients in a manic phase often experience excessive physical activity
and have difficulty sitting down to eat full meals. Providing high-calorie finger foods helps
maintain nutritional requirements and prevents weight loss during periods of
hyperactivity. This intervention addresses physiological safety, which is a priority
according to Maslow’s hierarchy of needs.
2. A client is prescribed lithium carbonate for the treatment of bipolar disorder. Which
laboratory value should the nurse monitor most closely to prevent toxicity?
A. Serum glucose levels
B. Prothrombin time (PT)
,C. Liver enzymes (AST/ALT)
D. Serum sodium levels
Correct Answer: D
Expert Explanation: Lithium is a salt, and its excretion is closely linked to sodium levels in
the body. When sodium levels are low, the kidneys retain lithium, which can lead to toxic
accumulations. The nurse must educate the patient on maintaining consistent sodium and
fluid intake to ensure the medication remains within the therapeutic range.
3. The nurse is evaluating a client’s understanding of their new prescription for phenelzine
(Nardil). Which statement by the client indicates a need for further teaching?
A. ‘I will avoid eating aged cheeses and smoked meats.’
B. ‘I will stop taking my OTC cold medicine while on this drug.’
C. ‘I can have a glass of red wine with my dinner occasionally.’
D. ‘I need to monitor my blood pressure regularly.’
Correct Answer: C
Expert Explanation: Phenelzine is a Monoamine Oxidase Inhibitor (MAOI) that requires a
strict low-tyramine diet to prevent a hypertensive crisis. Red wine, aged cheeses, and cured
meats are high in tyramine and must be avoided entirely. A hypertensive crisis is a medical
emergency characterized by a rapid rise in blood pressure and potential organ damage.
, 4. A nurse is assessing a client for adverse effects of haloperidol. Which of the following
findings should the nurse report to the provider as a potential sign of Neuroleptic Malignant
Syndrome (NMS)?
A. Hypotension and bradycardia
B. High fever and muscle rigidity
C. Muscle flaccidity and lethargy
D. Frequent urination and increased thirst
Correct Answer: B
Expert Explanation: Neuroleptic Malignant Syndrome is a rare but life-threatening
reaction to antipsychotic medications like haloperidol. Key clinical manifestations include
high fever, severe muscle rigidity, tachycardia, and autonomic instability. Immediate
discontinuation of the medication and supportive care in an intensive care setting are
required for survival.
5. A client with schizophrenia is experiencing auditory hallucinations and tells the nurse, ‘The
voices are telling me I am a bad person.’ Which response by the nurse is therapeutic?
A. ‘I don’t hear any voices; you are just imagining things.’
B. ‘What are the voices saying to you exactly?’
C. ‘Why do you think the voices are saying those mean things?’
D. ‘I understand that the voices are real to you, but I do not hear them.’
