NUR180/NUR 180 Exam 3 V1 | Concepts
of Mental Health Nursing for the Practical
Nurse Q&A with Rationale | Hondros
College of Nursing
1. A client diagnosed with bipolar disorder is experiencing an acute manic episode. What is
the priority nursing intervention for this client regarding nutrition?
A. Provide high-calorie, high-protein finger foods that can be eaten on the go.
B. Encourage the client to sit in the dining hall for three full meals.
C. Allow the client to skip meals if they are feeling too energetic.
D. Request a strictly liquid diet to prevent choking during hyperactivity.
Correct Answer: A
Rationale: Clients in a manic state often have excessive psychomotor activity and cannot
remain seated long enough to consume a traditional meal. High-calorie finger foods allow
the client to maintain nutritional intake while remaining active. This nursing intervention
directly addresses the risk of imbalanced nutrition during the manic phase.
2. A nurse is monitoring a client taking Lithium Carbonate for bipolar disorder. Which serum
lithium level should the nurse report to the provider as toxic?
A. 0.6 mEq/L
B. 1.8 mEq/L
,C. 1.2 mEq/L
D. 1.0 mEq/L
Correct Answer: B
Rationale: The therapeutic range for lithium is narrow, typically between 0.6 and 1.2
mEq/L for maintenance. A level of 1.8 mEq/L indicates lithium toxicity, which can lead to
serious neurological and cardiac complications. The nurse must immediately notify the
healthcare provider and prepare to hold the next dose.
3. Which assessment finding is considered a ‘negative symptom’ of schizophrenia?
A. Auditory hallucinations
B. Delusions of grandeur
C. Disorganized speech patterns
D. Flat affect and social withdrawal
Correct Answer: D
Rationale: Negative symptoms refer to the absence or diminution of normal functions,
such as flat affect, alogia, and avolition. Positive symptoms, conversely, involve the addition
of abnormal behaviors like hallucinations or delusions. Understanding this distinction is
vital for determining the efficacy of antipsychotic medications.
, 4. A client is prescribed Clozapine (Clozaril) for treatment-resistant schizophrenia. Which
laboratory value must be monitored weekly due to the risk of agranulocytosis?
A. Blood Urea Nitrogen (BUN)
B. White Blood Cell (WBC) count
C. Serum Potassium
D. Liver Function Tests (LFTs)
Correct Answer: B
Rationale: Clozapine carries a high risk for agranulocytosis, a life-threatening decrease in
white blood cells. National protocols require strict monitoring of the Absolute Neutrophil
Count (ANC) and WBC count to continue the medication. If the WBC count drops below a
specific threshold, the medication must be discontinued immediately to prevent infection.
5. A client is admitted to the detox unit with a history of heavy alcohol use. Which symptom
indicates the onset of Delirium Tremens (DTs)?
A. Mild hand tremors and headache
B. Increased appetite and hypersomnia
C. Visual hallucinations and autonomic hyperactivity
D. Bradycardia and hypotension
Correct Answer: C
of Mental Health Nursing for the Practical
Nurse Q&A with Rationale | Hondros
College of Nursing
1. A client diagnosed with bipolar disorder is experiencing an acute manic episode. What is
the priority nursing intervention for this client regarding nutrition?
A. Provide high-calorie, high-protein finger foods that can be eaten on the go.
B. Encourage the client to sit in the dining hall for three full meals.
C. Allow the client to skip meals if they are feeling too energetic.
D. Request a strictly liquid diet to prevent choking during hyperactivity.
Correct Answer: A
Rationale: Clients in a manic state often have excessive psychomotor activity and cannot
remain seated long enough to consume a traditional meal. High-calorie finger foods allow
the client to maintain nutritional intake while remaining active. This nursing intervention
directly addresses the risk of imbalanced nutrition during the manic phase.
2. A nurse is monitoring a client taking Lithium Carbonate for bipolar disorder. Which serum
lithium level should the nurse report to the provider as toxic?
A. 0.6 mEq/L
B. 1.8 mEq/L
,C. 1.2 mEq/L
D. 1.0 mEq/L
Correct Answer: B
Rationale: The therapeutic range for lithium is narrow, typically between 0.6 and 1.2
mEq/L for maintenance. A level of 1.8 mEq/L indicates lithium toxicity, which can lead to
serious neurological and cardiac complications. The nurse must immediately notify the
healthcare provider and prepare to hold the next dose.
3. Which assessment finding is considered a ‘negative symptom’ of schizophrenia?
A. Auditory hallucinations
B. Delusions of grandeur
C. Disorganized speech patterns
D. Flat affect and social withdrawal
Correct Answer: D
Rationale: Negative symptoms refer to the absence or diminution of normal functions,
such as flat affect, alogia, and avolition. Positive symptoms, conversely, involve the addition
of abnormal behaviors like hallucinations or delusions. Understanding this distinction is
vital for determining the efficacy of antipsychotic medications.
, 4. A client is prescribed Clozapine (Clozaril) for treatment-resistant schizophrenia. Which
laboratory value must be monitored weekly due to the risk of agranulocytosis?
A. Blood Urea Nitrogen (BUN)
B. White Blood Cell (WBC) count
C. Serum Potassium
D. Liver Function Tests (LFTs)
Correct Answer: B
Rationale: Clozapine carries a high risk for agranulocytosis, a life-threatening decrease in
white blood cells. National protocols require strict monitoring of the Absolute Neutrophil
Count (ANC) and WBC count to continue the medication. If the WBC count drops below a
specific threshold, the medication must be discontinued immediately to prevent infection.
5. A client is admitted to the detox unit with a history of heavy alcohol use. Which symptom
indicates the onset of Delirium Tremens (DTs)?
A. Mild hand tremors and headache
B. Increased appetite and hypersomnia
C. Visual hallucinations and autonomic hyperactivity
D. Bradycardia and hypotension
Correct Answer: C
