NUR180/NUR 180 Final Exam V3 |
Concepts of Mental Health Nursing for the
Practical Nurse Q&A with Rationale |
Hondros College of Nursing
1. A nurse is caring for a client who is voluntarily admitted and asks to leave the facility.
Which action should the nurse take if the client is deemed a danger to themselves?
A. Allow the client to sign out against medical advice immediately.
B. Initiate the process for involuntary commitment.
C. Lock the client in a seclusion room for safety.
D. Administer a sedative without the client’s consent.
Correct Answer: B
Rationale: The nurse must ensure the safety of the client and others when a voluntary
patient expresses a desire to leave while still a danger. Involuntary commitment provides a
legal framework to hold the patient for evaluation and treatment. This action prioritizes
safety while adhering to legal standards for mental health care.
2. A client is prescribed Lithium Carbonate for bipolar disorder. Which lab value should the
nurse monitor most closely to prevent toxicity?
A. Blood Urea Nitrogen (BUN)
B. Serum Sodium
,C. Serum Glucose
D. Platelet Count
Correct Answer: B
Rationale: Lithium is a salt and its excretion is inversely related to sodium levels in the
body. If sodium levels drop, the kidneys retain lithium, leading to potentially fatal toxicity.
Maintaining a consistent salt and fluid intake is a critical teaching point for these clients.
3. The nurse is assessing a client for Serotonin Syndrome. Which of the following findings is a
hallmark sign of this condition?
A. Muscle rigidity and hyperreflexia
B. Hypotension and bradycardia
C. Urinary retention and constipation
D. Severe muscle flaccidity
Correct Answer: A
Rationale: Serotonin syndrome is a life-threatening crisis caused by excessive serotonin
levels, often from SSRI use or drug interactions. Key symptoms include hyperreflexia,
muscle spasms, fever, and mental status changes. Immediate discontinuation of the
offending agent and supportive care are the priority interventions.
4. A client is experiencing a panic-level of anxiety. Which nursing intervention is the priority?
A. Teach the client new coping skills for future use.
, B. Leave the client alone to reduce environmental stimuli.
C. Stay with the client and use short, simple sentences.
D. Provide a detailed explanation of the physiological cause of anxiety.
Correct Answer: C
Rationale: During a panic attack, the client’s ability to process information is severely
limited and they may feel a loss of control. Staying with the client provides reassurance and
ensures safety while using simple language ensures the client can understand directions.
New teaching should only occur once the client has returned to a mild or moderate level of
anxiety.
5. A nurse is caring for a client with schizophrenia who is experiencing auditory
hallucinations. Which response by the nurse is therapeutic?
A. ‘Why do you think you are hearing those voices right now?’
B. ‘I do not hear the voices, but I understand that they are real to you.’
C. ‘The voices are just a part of your imagination; please stop listening.’
D. ‘What are the voices telling you to do?’
Correct Answer: B
Rationale: This response validates the client’s experience without agreeing that the
hallucinations are real, which is known as presenting reality. It helps build trust and
Concepts of Mental Health Nursing for the
Practical Nurse Q&A with Rationale |
Hondros College of Nursing
1. A nurse is caring for a client who is voluntarily admitted and asks to leave the facility.
Which action should the nurse take if the client is deemed a danger to themselves?
A. Allow the client to sign out against medical advice immediately.
B. Initiate the process for involuntary commitment.
C. Lock the client in a seclusion room for safety.
D. Administer a sedative without the client’s consent.
Correct Answer: B
Rationale: The nurse must ensure the safety of the client and others when a voluntary
patient expresses a desire to leave while still a danger. Involuntary commitment provides a
legal framework to hold the patient for evaluation and treatment. This action prioritizes
safety while adhering to legal standards for mental health care.
2. A client is prescribed Lithium Carbonate for bipolar disorder. Which lab value should the
nurse monitor most closely to prevent toxicity?
A. Blood Urea Nitrogen (BUN)
B. Serum Sodium
,C. Serum Glucose
D. Platelet Count
Correct Answer: B
Rationale: Lithium is a salt and its excretion is inversely related to sodium levels in the
body. If sodium levels drop, the kidneys retain lithium, leading to potentially fatal toxicity.
Maintaining a consistent salt and fluid intake is a critical teaching point for these clients.
3. The nurse is assessing a client for Serotonin Syndrome. Which of the following findings is a
hallmark sign of this condition?
A. Muscle rigidity and hyperreflexia
B. Hypotension and bradycardia
C. Urinary retention and constipation
D. Severe muscle flaccidity
Correct Answer: A
Rationale: Serotonin syndrome is a life-threatening crisis caused by excessive serotonin
levels, often from SSRI use or drug interactions. Key symptoms include hyperreflexia,
muscle spasms, fever, and mental status changes. Immediate discontinuation of the
offending agent and supportive care are the priority interventions.
4. A client is experiencing a panic-level of anxiety. Which nursing intervention is the priority?
A. Teach the client new coping skills for future use.
, B. Leave the client alone to reduce environmental stimuli.
C. Stay with the client and use short, simple sentences.
D. Provide a detailed explanation of the physiological cause of anxiety.
Correct Answer: C
Rationale: During a panic attack, the client’s ability to process information is severely
limited and they may feel a loss of control. Staying with the client provides reassurance and
ensures safety while using simple language ensures the client can understand directions.
New teaching should only occur once the client has returned to a mild or moderate level of
anxiety.
5. A nurse is caring for a client with schizophrenia who is experiencing auditory
hallucinations. Which response by the nurse is therapeutic?
A. ‘Why do you think you are hearing those voices right now?’
B. ‘I do not hear the voices, but I understand that they are real to you.’
C. ‘The voices are just a part of your imagination; please stop listening.’
D. ‘What are the voices telling you to do?’
Correct Answer: B
Rationale: This response validates the client’s experience without agreeing that the
hallucinations are real, which is known as presenting reality. It helps build trust and
