PNR 200/PNR200 Final Exam V3 | Mental
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a client who has a prescription for lithium carbonate. Which of the
following dietary instructions should the nurse provide?
A. Maintain a consistent intake of dietary sodium.
B. Restrict sodium intake to 1,000 mg per day.
C. Limit fluid intake to 1,500 mL per day.
D. Decrease intake of potassium-rich foods.
Correct Answer: A
Expert Explanation: Lithium is a salt, and its excretion is closely linked to sodium levels in
the body. If sodium intake is restricted, the kidneys retain lithium, leading to potential
toxicity. It is essential for the client to maintain consistent sodium and fluid intake to keep
lithium levels within the therapeutic range.
2. A client is experiencing an acute manic episode. Which of the following activities is most
appropriate for the nurse to suggest?
A. Joining a competitive basketball game.
B. Walking around the facility grounds with a staff member.
C. Participating in a group debate about current events.
,D. Watching a high-action movie in the dayroom.
Correct Answer: B
Expert Explanation: Clients in a manic state require activities that help channel excessive
energy without overstimulation or competition. Walking with a staff member provides a
physical outlet in a structured, low-stimulus environment. High-energy group activities or
competitive games can increase agitation and lead to conflict.
3. The nurse is assessing a client for Neuroleptic Malignant Syndrome (NMS). Which of the
following findings should the nurse report to the provider immediately?
A. Acute dystonia of the neck muscles.
B. Dry mouth and blurred vision.
C. Fine hand tremors and restlessness.
D. Severe muscle rigidity and high fever.
Correct Answer: D
Expert Explanation: Neuroleptic Malignant Syndrome is a life-threatening complication of
antipsychotic medications characterized by hyperpyrexia, muscle rigidity, and autonomic
instability. This condition requires immediate medical intervention and discontinuation of
the offending medication. Other options like dry mouth or tremors are common side effects
but not life-threatening like NMS.
, 4. A client with schizophrenia is experiencing auditory hallucinations. Which response by the
nurse is therapeutic?
A. ‘I don’t hear anything, so you must be imagining it.’
B. ‘I understand that the voices are real to you, but I do not hear them.’
C. ‘What are the voices telling you to do right now?’
D. ‘Try to ignore the voices and focus on our conversation.’
Correct Answer: B
Expert Explanation: The nurse should acknowledge the client’s experience without
validating the hallucination as reality. This technique is known as presenting reality while
maintaining empathy. Telling the client they are imagining it is dismissive and non-
therapeutic for building rapport.
5. A nurse is reviewing the laboratory results for a client taking clozapine. Which of the
following results requires immediate action?
A. Platelet count 150,000/mm3.
B. Total cholesterol 190 mg/dL.
C. Blood glucose 110 mg/dL.
D. White blood cell (WBC) count 2,500/mm3.
Correct Answer: D
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a client who has a prescription for lithium carbonate. Which of the
following dietary instructions should the nurse provide?
A. Maintain a consistent intake of dietary sodium.
B. Restrict sodium intake to 1,000 mg per day.
C. Limit fluid intake to 1,500 mL per day.
D. Decrease intake of potassium-rich foods.
Correct Answer: A
Expert Explanation: Lithium is a salt, and its excretion is closely linked to sodium levels in
the body. If sodium intake is restricted, the kidneys retain lithium, leading to potential
toxicity. It is essential for the client to maintain consistent sodium and fluid intake to keep
lithium levels within the therapeutic range.
2. A client is experiencing an acute manic episode. Which of the following activities is most
appropriate for the nurse to suggest?
A. Joining a competitive basketball game.
B. Walking around the facility grounds with a staff member.
C. Participating in a group debate about current events.
,D. Watching a high-action movie in the dayroom.
Correct Answer: B
Expert Explanation: Clients in a manic state require activities that help channel excessive
energy without overstimulation or competition. Walking with a staff member provides a
physical outlet in a structured, low-stimulus environment. High-energy group activities or
competitive games can increase agitation and lead to conflict.
3. The nurse is assessing a client for Neuroleptic Malignant Syndrome (NMS). Which of the
following findings should the nurse report to the provider immediately?
A. Acute dystonia of the neck muscles.
B. Dry mouth and blurred vision.
C. Fine hand tremors and restlessness.
D. Severe muscle rigidity and high fever.
Correct Answer: D
Expert Explanation: Neuroleptic Malignant Syndrome is a life-threatening complication of
antipsychotic medications characterized by hyperpyrexia, muscle rigidity, and autonomic
instability. This condition requires immediate medical intervention and discontinuation of
the offending medication. Other options like dry mouth or tremors are common side effects
but not life-threatening like NMS.
, 4. A client with schizophrenia is experiencing auditory hallucinations. Which response by the
nurse is therapeutic?
A. ‘I don’t hear anything, so you must be imagining it.’
B. ‘I understand that the voices are real to you, but I do not hear them.’
C. ‘What are the voices telling you to do right now?’
D. ‘Try to ignore the voices and focus on our conversation.’
Correct Answer: B
Expert Explanation: The nurse should acknowledge the client’s experience without
validating the hallucination as reality. This technique is known as presenting reality while
maintaining empathy. Telling the client they are imagining it is dismissive and non-
therapeutic for building rapport.
5. A nurse is reviewing the laboratory results for a client taking clozapine. Which of the
following results requires immediate action?
A. Platelet count 150,000/mm3.
B. Total cholesterol 190 mg/dL.
C. Blood glucose 110 mg/dL.
D. White blood cell (WBC) count 2,500/mm3.
Correct Answer: D
