NUR180/NUR 180 Exam 4 V1 | Concepts of
Mental Health Nursing for the Practical
Nurse Q&A with Rationale | Hondros
College of Nursing
1. A nurse is assessing a client with major depressive disorder. Which of the following
statements by the client most accurately indicates a high risk for suicide?
A. “I have been feeling very tired and I cannot sleep at night.”
B. “I do not enjoy the hobbies that I used to find fun anymore.”
C. “My family would be much better off if I were just gone for a while.”
D. “I finally have a plan to end my pain and I have the means to do it.”
Correct Answer: D
Rationale: The statement regarding a specific plan and access to lethal means represents a
high-risk situation for immediate self-harm. In psychiatric nursing, the nurse must
prioritize safety by assessing the lethality of a client’s plan. This requires immediate
intervention, including constant observation or one-to-one monitoring to ensure the
client’s safety.
2. A client is prescribed Lithium Carbonate for bipolar disorder. Which serum lithium level
should the nurse recognize as being within the therapeutic range?
A. 1.8 mEq/L
,B. 2.2 mEq/L
C. 0.8 mEq/L
D. 0.3 mEq/L
Correct Answer: C
Rationale: The standard therapeutic range for serum lithium is generally accepted as 0.6
to 1.2 mEq/L for maintenance therapy. A level of 0.8 mEq/L falls within this safe and
effective window for treating mood instability. Levels above 1.5 mEq/L are considered
toxic and require immediate medical attention to prevent severe complications like
seizures or coma.
3. A nurse is caring for a client experiencing a manic episode. Which of the following
interventions is the priority?
A. Encouraging the client to participate in a high-energy group exercise.
B. Allowing the client to lead the community meeting to boost self-esteem.
C. Engaging the client in a long, detailed discussion about their behavior.
D. Providing high-calorie finger foods that can be eaten while walking.
Correct Answer: D
Rationale: Clients in a manic state often have high energy levels and cannot sit down long
enough to eat a full meal, putting them at risk for nutritional deficits. High-calorie finger
, foods allow the client to maintain intake while remaining active. Maintaining physical
health and safety is a primary nursing goal during the acute phase of mania.
4. A client with schizophrenia is experiencing auditory hallucinations and says, “The voices
are telling me I am a bad person.” Which response by the nurse is therapeutic?
A. “Why do you think the voices are saying those things to you?”
B. “You are a good person, so the voices must be lying to you.”
C. “I do not hear the voices, but I understand that they are real to you.”
D. “Try to ignore them and focus on the television show we are watching.”
Correct Answer: C
Rationale: The nurse should acknowledge the client’s experience without validating the
hallucination as reality, a technique known as presenting reality. Using the phrase “I do not
hear them” clarifies the nurse’s perception while showing empathy for the client’s distress.
Avoiding arguments about the hallucination helps maintain the therapeutic relationship
and reduces client anxiety.
5. Which of the following is considered a positive symptom of schizophrenia?
A. Flat affect
B. Delusions
C. Anhedonia
D. Avolition
Mental Health Nursing for the Practical
Nurse Q&A with Rationale | Hondros
College of Nursing
1. A nurse is assessing a client with major depressive disorder. Which of the following
statements by the client most accurately indicates a high risk for suicide?
A. “I have been feeling very tired and I cannot sleep at night.”
B. “I do not enjoy the hobbies that I used to find fun anymore.”
C. “My family would be much better off if I were just gone for a while.”
D. “I finally have a plan to end my pain and I have the means to do it.”
Correct Answer: D
Rationale: The statement regarding a specific plan and access to lethal means represents a
high-risk situation for immediate self-harm. In psychiatric nursing, the nurse must
prioritize safety by assessing the lethality of a client’s plan. This requires immediate
intervention, including constant observation or one-to-one monitoring to ensure the
client’s safety.
2. A client is prescribed Lithium Carbonate for bipolar disorder. Which serum lithium level
should the nurse recognize as being within the therapeutic range?
A. 1.8 mEq/L
,B. 2.2 mEq/L
C. 0.8 mEq/L
D. 0.3 mEq/L
Correct Answer: C
Rationale: The standard therapeutic range for serum lithium is generally accepted as 0.6
to 1.2 mEq/L for maintenance therapy. A level of 0.8 mEq/L falls within this safe and
effective window for treating mood instability. Levels above 1.5 mEq/L are considered
toxic and require immediate medical attention to prevent severe complications like
seizures or coma.
3. A nurse is caring for a client experiencing a manic episode. Which of the following
interventions is the priority?
A. Encouraging the client to participate in a high-energy group exercise.
B. Allowing the client to lead the community meeting to boost self-esteem.
C. Engaging the client in a long, detailed discussion about their behavior.
D. Providing high-calorie finger foods that can be eaten while walking.
Correct Answer: D
Rationale: Clients in a manic state often have high energy levels and cannot sit down long
enough to eat a full meal, putting them at risk for nutritional deficits. High-calorie finger
, foods allow the client to maintain intake while remaining active. Maintaining physical
health and safety is a primary nursing goal during the acute phase of mania.
4. A client with schizophrenia is experiencing auditory hallucinations and says, “The voices
are telling me I am a bad person.” Which response by the nurse is therapeutic?
A. “Why do you think the voices are saying those things to you?”
B. “You are a good person, so the voices must be lying to you.”
C. “I do not hear the voices, but I understand that they are real to you.”
D. “Try to ignore them and focus on the television show we are watching.”
Correct Answer: C
Rationale: The nurse should acknowledge the client’s experience without validating the
hallucination as reality, a technique known as presenting reality. Using the phrase “I do not
hear them” clarifies the nurse’s perception while showing empathy for the client’s distress.
Avoiding arguments about the hallucination helps maintain the therapeutic relationship
and reduces client anxiety.
5. Which of the following is considered a positive symptom of schizophrenia?
A. Flat affect
B. Delusions
C. Anhedonia
D. Avolition
