NUR180/NUR 180 Final Exam V2 |
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 experiencing a manic episode. Which of the following
activities is most appropriate for the nurse to suggest?
A. A game of competitive basketball
B. Watching a long action movie in the common room
C. Walking around the unit with the nurse
D. Participating in a book club discussion
Correct Answer: C
Rationale: Clients in a manic state benefit from physical activity that is gross motor-
oriented and non-competitive. Walking helps expend energy without the high stimulation
of competition or group settings. The nurse’s presence also provides a safe, structured
boundary for the client’s behavior.
2. Which assessment finding should the nurse prioritize for a client newly prescribed
clozapine (Clozaril)?
A. Weight gain of 2 pounds in a week
B. Complaints of dry mouth
,C. A temperature of 100.4 F (38 C)
D. Dizziness when standing up
Correct Answer: C
Rationale: Clozapine carries a significant risk for agranulocytosis, which is a dangerous
drop in white blood cell count. A fever can be an early sign of infection related to this blood
disorder and requires immediate notification of the provider. While weight gain and dry
mouth are common side effects, they are not as life-threatening as potential sepsis.
3. A client is admitted for alcohol detoxification. Which medication should the nurse expect
to administer to manage acute withdrawal symptoms?
A. Disulfiram
B. Chlordiazepoxide
C. Methadone
D. Naltrexone
Correct Answer: B
Rationale: Benzodiazepines like chlordiazepoxide are the gold standard for preventing
seizures and delirium tremens during acute alcohol withdrawal. Disulfiram is used for
maintenance of sobriety, not during the acute phase. The nurse must monitor the client
closely for respiratory depression and sedation during administration.
, 4. A nurse observes a client with schizophrenia standing in the corner talking to the wall.
Which response by the nurse is most therapeutic?
A. Who are you talking to right now?
B. I don’t see anyone there, but you seem to be listening to something.
C. Please stop talking to the wall; it makes the other clients uncomfortable.
D. There is no one there, so let’s go to the dining room.
Correct Answer: B
Rationale: This response acknowledges the client’s internal experience without validating
the hallucination. Presenting reality in a non-confrontational way helps build trust while
maintaining the nurse’s integrity. It is important to focus on the feeling associated with the
hallucination rather than the content itself.
5. The nurse is reviewing the laboratory results for a client taking lithium carbonate. Which
level indicates a need for immediate intervention?
A. 0.6 mEq/L
B. 0.8 mEq/L
C. 1.2 mEq/L
D. 1.8 mEq/L
Correct Answer: D
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 experiencing a manic episode. Which of the following
activities is most appropriate for the nurse to suggest?
A. A game of competitive basketball
B. Watching a long action movie in the common room
C. Walking around the unit with the nurse
D. Participating in a book club discussion
Correct Answer: C
Rationale: Clients in a manic state benefit from physical activity that is gross motor-
oriented and non-competitive. Walking helps expend energy without the high stimulation
of competition or group settings. The nurse’s presence also provides a safe, structured
boundary for the client’s behavior.
2. Which assessment finding should the nurse prioritize for a client newly prescribed
clozapine (Clozaril)?
A. Weight gain of 2 pounds in a week
B. Complaints of dry mouth
,C. A temperature of 100.4 F (38 C)
D. Dizziness when standing up
Correct Answer: C
Rationale: Clozapine carries a significant risk for agranulocytosis, which is a dangerous
drop in white blood cell count. A fever can be an early sign of infection related to this blood
disorder and requires immediate notification of the provider. While weight gain and dry
mouth are common side effects, they are not as life-threatening as potential sepsis.
3. A client is admitted for alcohol detoxification. Which medication should the nurse expect
to administer to manage acute withdrawal symptoms?
A. Disulfiram
B. Chlordiazepoxide
C. Methadone
D. Naltrexone
Correct Answer: B
Rationale: Benzodiazepines like chlordiazepoxide are the gold standard for preventing
seizures and delirium tremens during acute alcohol withdrawal. Disulfiram is used for
maintenance of sobriety, not during the acute phase. The nurse must monitor the client
closely for respiratory depression and sedation during administration.
, 4. A nurse observes a client with schizophrenia standing in the corner talking to the wall.
Which response by the nurse is most therapeutic?
A. Who are you talking to right now?
B. I don’t see anyone there, but you seem to be listening to something.
C. Please stop talking to the wall; it makes the other clients uncomfortable.
D. There is no one there, so let’s go to the dining room.
Correct Answer: B
Rationale: This response acknowledges the client’s internal experience without validating
the hallucination. Presenting reality in a non-confrontational way helps build trust while
maintaining the nurse’s integrity. It is important to focus on the feeling associated with the
hallucination rather than the content itself.
5. The nurse is reviewing the laboratory results for a client taking lithium carbonate. Which
level indicates a need for immediate intervention?
A. 0.6 mEq/L
B. 0.8 mEq/L
C. 1.2 mEq/L
D. 1.8 mEq/L
Correct Answer: D
