PNR 200/PNR200 Final Exam V1 | 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 findings should the nurse identify as an indication of lithium toxicity?
A. Polyuria
B. Confusion and coarse hand tremors
C. Fine hand tremors
D. Weight gain
Correct Answer: B
Expert Explanation: Confusion and coarse hand tremors are advanced signs of lithium
toxicity that require immediate intervention. While fine tremors and polyuria are common
side effects, they do not typically indicate toxicity levels. The nurse must monitor serum
levels to ensure they stay within the narrow therapeutic range of 0.6 to 1.2 mEq/L.
2. A client is admitted to the psychiatric unit with a diagnosis of major depressive disorder.
Which of the following is the priority nursing intervention?
A. Encouraging the client to attend group therapy sessions
B. Assessing the client’s risk for self-harm or suicide
C. Assisting the client with daily hygiene tasks
,D. Teaching the client about antidepressant medications
Correct Answer: B
Expert Explanation: Safety is always the primary concern in mental health nursing,
especially for clients with depression. The nurse must assess for suicidal ideation, plan, and
means to ensure the client’s physical safety. Other interventions like group therapy and
medication teaching are secondary to stabilization and safety monitoring.
3. Which of the following defense mechanisms is a client using when they refuse to
acknowledge the reality of a terminal illness?
A. Denial
B. Projection
C. Rationalization
D. Displacement
Correct Answer: A
Expert Explanation: Denial is a defense mechanism where the individual refuses to accept
or acknowledge an unpleasant reality. It serves as a protective layer against intense anxiety
or trauma. The nurse should support the client while gradually helping them move toward
acceptance as they become emotionally ready.
4. A nurse is caring for a client diagnosed with schizophrenia who is experiencing auditory
hallucinations. What is the most appropriate nursing response?
A. ‘What are the voices telling you to do?’
, B. ‘Why do you think the voices are talking to you right now?’
C. ‘The voices are just part of your imagination, try to ignore them.’
D. ‘I don’t hear the voices, but I understand they are real to you.’
Correct Answer: D
Expert Explanation: Acknowledging the client’s experience without validating the
hallucination as reality is a key therapeutic communication technique. It helps build trust
while maintaining a focus on reality. Asking what the voices are saying (option D) is also
important to assess for safety, but option A best illustrates the therapeutic stance of
presenting reality.
5. A client is prescribed phenelzine, an MAO inhibitor. Which of the following foods should
the nurse instruct the client to avoid?
A. Aged cheeses and cured meats
B. Fresh green leafy vegetables
C. Whole grain breads and cereals
D. Citrus fruits and juices
Correct Answer: A
Expert Explanation: Phenelzine is an MAOI that requires a tyramine-restricted diet to
prevent a hypertensive crisis. Foods like aged cheese, cured meats, and red wine contain
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 findings should the nurse identify as an indication of lithium toxicity?
A. Polyuria
B. Confusion and coarse hand tremors
C. Fine hand tremors
D. Weight gain
Correct Answer: B
Expert Explanation: Confusion and coarse hand tremors are advanced signs of lithium
toxicity that require immediate intervention. While fine tremors and polyuria are common
side effects, they do not typically indicate toxicity levels. The nurse must monitor serum
levels to ensure they stay within the narrow therapeutic range of 0.6 to 1.2 mEq/L.
2. A client is admitted to the psychiatric unit with a diagnosis of major depressive disorder.
Which of the following is the priority nursing intervention?
A. Encouraging the client to attend group therapy sessions
B. Assessing the client’s risk for self-harm or suicide
C. Assisting the client with daily hygiene tasks
,D. Teaching the client about antidepressant medications
Correct Answer: B
Expert Explanation: Safety is always the primary concern in mental health nursing,
especially for clients with depression. The nurse must assess for suicidal ideation, plan, and
means to ensure the client’s physical safety. Other interventions like group therapy and
medication teaching are secondary to stabilization and safety monitoring.
3. Which of the following defense mechanisms is a client using when they refuse to
acknowledge the reality of a terminal illness?
A. Denial
B. Projection
C. Rationalization
D. Displacement
Correct Answer: A
Expert Explanation: Denial is a defense mechanism where the individual refuses to accept
or acknowledge an unpleasant reality. It serves as a protective layer against intense anxiety
or trauma. The nurse should support the client while gradually helping them move toward
acceptance as they become emotionally ready.
4. A nurse is caring for a client diagnosed with schizophrenia who is experiencing auditory
hallucinations. What is the most appropriate nursing response?
A. ‘What are the voices telling you to do?’
, B. ‘Why do you think the voices are talking to you right now?’
C. ‘The voices are just part of your imagination, try to ignore them.’
D. ‘I don’t hear the voices, but I understand they are real to you.’
Correct Answer: D
Expert Explanation: Acknowledging the client’s experience without validating the
hallucination as reality is a key therapeutic communication technique. It helps build trust
while maintaining a focus on reality. Asking what the voices are saying (option D) is also
important to assess for safety, but option A best illustrates the therapeutic stance of
presenting reality.
5. A client is prescribed phenelzine, an MAO inhibitor. Which of the following foods should
the nurse instruct the client to avoid?
A. Aged cheeses and cured meats
B. Fresh green leafy vegetables
C. Whole grain breads and cereals
D. Citrus fruits and juices
Correct Answer: A
Expert Explanation: Phenelzine is an MAOI that requires a tyramine-restricted diet to
prevent a hypertensive crisis. Foods like aged cheese, cured meats, and red wine contain
