NUR180/NUR 180 Final Exam V1 |
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 with a new prescription for lithium carbonate to treat bipolar
disorder. Which laboratory value should the nurse prioritize monitoring to prevent toxicity?
A. Serum sodium levels
B. Serum glucose levels
C. Liver function tests
D. Hemoglobin and hematocrit
Correct Answer: A
Rationale: Lithium is a salt that is inversely related to sodium levels in the body. When
sodium levels are low, the kidneys retain lithium, which can quickly lead to toxic levels in
the bloodstream. The nurse must educate the patient on maintaining consistent sodium
and fluid intake to ensure therapeutic stability.
2. Which statement by a client exhibiting ‘splitting’ behavior is most characteristic of
Borderline Personality Disorder?
A. ‘I don’t think I need to follow the rules that everyone else does.’
B. ‘The day shift nurse is an angel, but the night shift nurse is evil and hateful.’
,C. ‘I am the only person who can solve the problems of this world.’
D. ‘I prefer to spend my time alone rather than with people who don’t understand me.’
Correct Answer: B
Rationale: Splitting is a primitive defense mechanism where individuals view others as
either all good or all bad. This behavior is a hallmark sign of Borderline Personality
Disorder and is used to manage internal conflict. It often leads to staff conflict and requires
a consistent, team-based nursing approach.
3. A client is experiencing an acute manic episode. Which meal choice is most appropriate for
the nurse to provide?
A. A large bowl of vegetable soup and crackers
B. A grilled steak with mashed potatoes and gravy
C. A turkey wrap and an apple
D. Spaghetti with meatballs and a side salad
Correct Answer: C
Rationale: Clients in a manic state are often too hyperactive to sit down for a full meal.
Providing ‘finger foods’ allows the client to eat while moving, ensuring they receive
necessary calories and nutrition. This intervention addresses the risk for imbalanced
nutrition related to excessive physical activity.
, 4. A nurse is assessing a client for side effects of haloperidol. The client is experiencing muscle
rigidity, a high fever, and tachycardia. Which condition should the nurse suspect?
A. Tardive dyskinesia
B. Dystonia
C. Neuroleptic Malignant Syndrome (NMS)
D. Akathisia
Correct Answer: C
Rationale: Neuroleptic Malignant Syndrome is a rare but life-threatening reaction to
antipsychotic medications. Key symptoms include ‘lead pipe’ muscle rigidity, hyperpyrexia
(high fever), and autonomic instability. The nurse must immediately stop the medication
and notify the provider to begin emergency treatment.
5. What is the primary goal of the ‘Orientation Phase’ of the nurse-client relationship?
A. To facilitate the client’s expression of feelings and problem-solving
B. To evaluate the progress made toward achieving identified goals
C. To establish trust, rapport, and define the parameters of the relationship
D. To promote the client’s independence and use of community resources
Correct Answer: C
Rationale: The orientation phase is the initial meeting where the nurse sets the stage for a
therapeutic alliance. During this phase, boundaries are established, the contract is defined,
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 with a new prescription for lithium carbonate to treat bipolar
disorder. Which laboratory value should the nurse prioritize monitoring to prevent toxicity?
A. Serum sodium levels
B. Serum glucose levels
C. Liver function tests
D. Hemoglobin and hematocrit
Correct Answer: A
Rationale: Lithium is a salt that is inversely related to sodium levels in the body. When
sodium levels are low, the kidneys retain lithium, which can quickly lead to toxic levels in
the bloodstream. The nurse must educate the patient on maintaining consistent sodium
and fluid intake to ensure therapeutic stability.
2. Which statement by a client exhibiting ‘splitting’ behavior is most characteristic of
Borderline Personality Disorder?
A. ‘I don’t think I need to follow the rules that everyone else does.’
B. ‘The day shift nurse is an angel, but the night shift nurse is evil and hateful.’
,C. ‘I am the only person who can solve the problems of this world.’
D. ‘I prefer to spend my time alone rather than with people who don’t understand me.’
Correct Answer: B
Rationale: Splitting is a primitive defense mechanism where individuals view others as
either all good or all bad. This behavior is a hallmark sign of Borderline Personality
Disorder and is used to manage internal conflict. It often leads to staff conflict and requires
a consistent, team-based nursing approach.
3. A client is experiencing an acute manic episode. Which meal choice is most appropriate for
the nurse to provide?
A. A large bowl of vegetable soup and crackers
B. A grilled steak with mashed potatoes and gravy
C. A turkey wrap and an apple
D. Spaghetti with meatballs and a side salad
Correct Answer: C
Rationale: Clients in a manic state are often too hyperactive to sit down for a full meal.
Providing ‘finger foods’ allows the client to eat while moving, ensuring they receive
necessary calories and nutrition. This intervention addresses the risk for imbalanced
nutrition related to excessive physical activity.
, 4. A nurse is assessing a client for side effects of haloperidol. The client is experiencing muscle
rigidity, a high fever, and tachycardia. Which condition should the nurse suspect?
A. Tardive dyskinesia
B. Dystonia
C. Neuroleptic Malignant Syndrome (NMS)
D. Akathisia
Correct Answer: C
Rationale: Neuroleptic Malignant Syndrome is a rare but life-threatening reaction to
antipsychotic medications. Key symptoms include ‘lead pipe’ muscle rigidity, hyperpyrexia
(high fever), and autonomic instability. The nurse must immediately stop the medication
and notify the provider to begin emergency treatment.
5. What is the primary goal of the ‘Orientation Phase’ of the nurse-client relationship?
A. To facilitate the client’s expression of feelings and problem-solving
B. To evaluate the progress made toward achieving identified goals
C. To establish trust, rapport, and define the parameters of the relationship
D. To promote the client’s independence and use of community resources
Correct Answer: C
Rationale: The orientation phase is the initial meeting where the nurse sets the stage for a
therapeutic alliance. During this phase, boundaries are established, the contract is defined,
