NUR180/NUR 180 Exam 3 V2 | Concepts of
Mental Health Nursing for the Practical
Nurse Q&A with Rationale | Hondros
College of Nursing
1. A client is prescribed lithium carbonate for the treatment of bipolar disorder. Which serum
lithium level should the nurse recognize as being within the therapeutic range for
maintenance?
A. 0.2 to 0.5 mEq/L
B. 1.5 to 2.0 mEq/L
C. 0.6 to 1.2 mEq/L
D. 2.5 to 3.0 mEq/L
Correct Answer: C
Rationale: The therapeutic maintenance range for serum lithium is generally considered
to be 0.6 to 1.2 mEq/L. Levels below this range are often ineffective for mood stabilization,
while levels above 1.5 mEq/L can lead to toxicity. The nurse must monitor these levels
closely to ensure patient safety and medication efficacy.
2. The nurse is caring for a client who is experiencing a panic attack. Which intervention
should the nurse implement first?
A. Stay with the client and remain calm
,B. Administer an ordered PRN antidepressant
C. Teach the client deep breathing exercises
D. Ask the client to explain what triggered the attack
Correct Answer: A
Rationale: During a panic attack, the priority nursing intervention is to ensure the client’s
safety by staying with them. Remaining calm helps prevent the transmission of anxiety
from the nurse to the client. Explanations and teaching are only effective once the client’s
anxiety level has decreased to a moderate or mild level.
3. A nurse is assessing a client for potential extrapyramidal symptoms (EPS) while taking
haloperidol. Which finding should the nurse document as akathisia?
A. Muscle rigidity and high fever
B. Restlessness and an urgent need to movement
C. Involuntary tongue protrusion and smacking lips
D. Fixed upward gaze of the eyes
Correct Answer: B
Rationale: Akathisia is characterized by internal restlessness and an inability to sit still,
often manifesting as pacing or foot tapping. It is a common extrapyramidal side effect
associated with typical antipsychotics like haloperidol. The nurse should report this to the
provider as it can cause significant distress to the client.
,4. A client diagnosed with schizophrenia states, ‘The FBI is monitoring my every move
through the television.’ Which type of thought content is the client demonstrating?
A. Grandiosity
B. Persecutory delusion
C. Hallucination
D. Ideas of reference
Correct Answer: B
Rationale: A persecutory delusion involves the false belief that one is being targeted,
followed, or conspired against by others or organizations. In this scenario, the belief about
FBI monitoring is a classic example of paranoia and persecution. The nurse should
acknowledge the client’s feelings without reinforcing the false belief.
5. A client is being treated for depression with phenelzine, an MAOI. Which food choice
indicates the client understands the dietary restrictions?
A. Pepperoni pizza and a beer
B. Grilled chicken breast with steamed broccoli
C. Aged cheddar cheese with crackers
D. Smoked salmon and cream cheese bagel
Correct Answer: B
, Rationale: Clients taking Monoamine Oxidase Inhibitors (MAOIs) must follow a low-
tyramine diet to prevent a hypertensive crisis. Foods like aged cheese, cured meats,
fermented products, and alcohol are high in tyramine and must be avoided. Grilled chicken
and fresh vegetables are safe choices because they contain negligible amounts of tyramine.
6. Which physical finding should the nurse expect to observe in a client diagnosed with
anorexia nervosa?
A. Hypertension
B. Tachycardia
C. Hyperthermia
D. Lanugo
Correct Answer: D
Rationale: Lanugo is the growth of fine, downy hair on the body, which is a physiological
response to extreme weight loss and malnutrition in anorexia nervosa. Other common
findings include bradycardia, hypotension, and hypothermia as the body slows down to
conserve energy. These clinical markers help the nurse evaluate the severity of the client’s
nutritional deficit.
7. The nurse is assessing a client for alcohol withdrawal. Which symptom is considered a late,
life-threatening sign of withdrawal?
A. Fine tremors of the hands
B. Anxiety and irritability
Mental Health Nursing for the Practical
Nurse Q&A with Rationale | Hondros
College of Nursing
1. A client is prescribed lithium carbonate for the treatment of bipolar disorder. Which serum
lithium level should the nurse recognize as being within the therapeutic range for
maintenance?
A. 0.2 to 0.5 mEq/L
B. 1.5 to 2.0 mEq/L
C. 0.6 to 1.2 mEq/L
D. 2.5 to 3.0 mEq/L
Correct Answer: C
Rationale: The therapeutic maintenance range for serum lithium is generally considered
to be 0.6 to 1.2 mEq/L. Levels below this range are often ineffective for mood stabilization,
while levels above 1.5 mEq/L can lead to toxicity. The nurse must monitor these levels
closely to ensure patient safety and medication efficacy.
2. The nurse is caring for a client who is experiencing a panic attack. Which intervention
should the nurse implement first?
A. Stay with the client and remain calm
,B. Administer an ordered PRN antidepressant
C. Teach the client deep breathing exercises
D. Ask the client to explain what triggered the attack
Correct Answer: A
Rationale: During a panic attack, the priority nursing intervention is to ensure the client’s
safety by staying with them. Remaining calm helps prevent the transmission of anxiety
from the nurse to the client. Explanations and teaching are only effective once the client’s
anxiety level has decreased to a moderate or mild level.
3. A nurse is assessing a client for potential extrapyramidal symptoms (EPS) while taking
haloperidol. Which finding should the nurse document as akathisia?
A. Muscle rigidity and high fever
B. Restlessness and an urgent need to movement
C. Involuntary tongue protrusion and smacking lips
D. Fixed upward gaze of the eyes
Correct Answer: B
Rationale: Akathisia is characterized by internal restlessness and an inability to sit still,
often manifesting as pacing or foot tapping. It is a common extrapyramidal side effect
associated with typical antipsychotics like haloperidol. The nurse should report this to the
provider as it can cause significant distress to the client.
,4. A client diagnosed with schizophrenia states, ‘The FBI is monitoring my every move
through the television.’ Which type of thought content is the client demonstrating?
A. Grandiosity
B. Persecutory delusion
C. Hallucination
D. Ideas of reference
Correct Answer: B
Rationale: A persecutory delusion involves the false belief that one is being targeted,
followed, or conspired against by others or organizations. In this scenario, the belief about
FBI monitoring is a classic example of paranoia and persecution. The nurse should
acknowledge the client’s feelings without reinforcing the false belief.
5. A client is being treated for depression with phenelzine, an MAOI. Which food choice
indicates the client understands the dietary restrictions?
A. Pepperoni pizza and a beer
B. Grilled chicken breast with steamed broccoli
C. Aged cheddar cheese with crackers
D. Smoked salmon and cream cheese bagel
Correct Answer: B
, Rationale: Clients taking Monoamine Oxidase Inhibitors (MAOIs) must follow a low-
tyramine diet to prevent a hypertensive crisis. Foods like aged cheese, cured meats,
fermented products, and alcohol are high in tyramine and must be avoided. Grilled chicken
and fresh vegetables are safe choices because they contain negligible amounts of tyramine.
6. Which physical finding should the nurse expect to observe in a client diagnosed with
anorexia nervosa?
A. Hypertension
B. Tachycardia
C. Hyperthermia
D. Lanugo
Correct Answer: D
Rationale: Lanugo is the growth of fine, downy hair on the body, which is a physiological
response to extreme weight loss and malnutrition in anorexia nervosa. Other common
findings include bradycardia, hypotension, and hypothermia as the body slows down to
conserve energy. These clinical markers help the nurse evaluate the severity of the client’s
nutritional deficit.
7. The nurse is assessing a client for alcohol withdrawal. Which symptom is considered a late,
life-threatening sign of withdrawal?
A. Fine tremors of the hands
B. Anxiety and irritability
