NURS 222 | NURS222 Exam 2: Mental Health - WCU
Updated and Latest Questions and Correct
Answers with Rationale
1. A client is experiencing a panic attack in the emergency department. Which nursing
intervention is the priority?
A. Encourage the client to discuss the source of their anxiety.
B. Administer a high dose of an oral antidepressant immediately.
C. Stay with the client and maintain a calm, quiet environment.
D. Teach the client new coping mechanisms for future episodes.
Correct Answer: C
Rationale: During a panic attack, the nurse must ensure the client’s safety and provide a
non-threatening presence. Staying with the client helps reduce the fear of being alone
during a perceived life-threatening event. A calm environment reduces external stimuli
that could exacerbate the physiological symptoms of panic. The client is unable to process
complex information or learn new skills during the acute phase. Brief, simple
communication is most effective when the client is in a state of severe anxiety or panic.
2. A client with Bipolar I Disorder is in the manic phase and is moving rapidly around the unit.
What is the most appropriate snack to provide?
A. An apple and a protein granola bar.
B. A steak dinner with a baked potato.
C. A bowl of hot chicken noodle soup.
D. A large salad with vinaigrette dressing.
Correct Answer: A
Rationale: Clients in a manic state often have difficulty sitting still long enough to consume
a full meal. Finger foods that are high in calories and protein allow the client to eat while on
the move. Providing nutrient-dense portable options helps prevent exhaustion and
significant weight loss during hyperactive periods. Soup and steak are inappropriate
because they require utensils and the client to remain seated. Constant monitoring of
nutritional intake is vital for maintaining physical health in manic patients.
3. Which clinical manifestation is most characteristic of Borderline Personality Disorder?
A. A pattern of intense and unstable relationships with a fear of abandonment.
B. Arrogance and a constant need for admiration from others.
C. Lack of remorse for violating the rights of others.
,D. Social isolation and a complete lack of interest in social relationships.
Correct Answer: A
Rationale: Borderline Personality Disorder is marked by significant emotional
dysregulation and instability in self-image. Clients often experience ‘splitting,’ where they
view people as either all good or all bad. The fear of real or imagined abandonment leads to
desperate efforts to maintain connections. These individuals may engage in self-harming
behaviors as a way to cope with intense psychic pain. Nursing interventions should focus
on maintaining consistent boundaries and monitoring for safety.
4. A client taking Lithium Carbonate for Bipolar Disorder reports blurred vision, tremors, and
a stumbling gait. What should the nurse do first?
A. Withhold the medication and notify the healthcare provider.
B. Administer the next scheduled dose as prescribed.
C. Advise the client to drink more water to flush the medication.
D. Check the client’s blood pressure while standing.
Correct Answer: A
Rationale: The symptoms of blurred vision, ataxia, and tremors are classic signs of Lithium
toxicity. Because Lithium has a narrow therapeutic index, any sign of toxicity must be
addressed immediately to prevent permanent damage or death. The nurse should hold the
dose and anticipate an order for a serum lithium level. Normal therapeutic levels range
from 0.6 to 1.2 mEq/L, and levels above 1.5 are considered toxic. Fluid and electrolyte
balance must be assessed as dehydration can increase lithium levels.
5. A client with Obsessive-Compulsive Disorder (OCD) spends two hours washing their hands
every morning. What is the best initial nursing action?
A. Allow the client enough time in the schedule for the ritual.
B. Lock the bathroom door to prevent the client from washing.
C. Explain to the client that their hands are already clean.
D. Tell the client they will lose privileges if they continue the behavior.
Correct Answer: A
Rationale: Initially, the nurse should allow the client to perform the ritual to avoid causing
extreme anxiety. Forcing an immediate stop to the compulsion can lead to a panic state for
the individual. The ritual serves as a mechanism to lower the anxiety caused by obsessive
thoughts. As the treatment progresses, the nurse can work with the client to gradually limit
the time spent on the ritual. Cognitive-behavioral therapy and SSRIs are common long-term
treatments for reducing these behaviors.
, 6. A nurse is assessing a client with Antisocial Personality Disorder. Which behavior is most
likely to be observed?
A. Extreme shyness and sensitivity to rejection.
B. Excessive emotionality and attention-seeking.
C. Rigidity and preoccupation with rules and order.
D. Exploitation of others for personal gain without guilt.
Correct Answer: D
Rationale: Antisocial Personality Disorder is characterized by a pervasive pattern of
disregard for the rights of others. Clients often display manipulative behavior and a lack of
empathy or remorse for their actions. They may be charming on the surface but are often
deceitful for personal profit or pleasure. Nursing management focuses on setting firm, clear
limits and avoiding manipulation by the client. It is essential for the staff to maintain a
united front to prevent the client from playing team members against each other.
7. A client is prescribed Buspirone for Generalized Anxiety Disorder. Which statement by the
client indicates an understanding of the teaching?
A. I can take this medicine only when I feel a panic attack coming on.
B. This medication will help me feel better within 30 minutes of taking it.
C. I should stop taking this medication if I feel sleepy.
D. It may take 2 to 4 weeks for this medication to be fully effective.
Correct Answer: D
Rationale: Unlike benzodiazepines, Buspirone is not an ‘as-needed’ (PRN) medication and
does not have an immediate effect. It requires consistent daily dosing to reach therapeutic
levels in the bloodstream. Patients should be educated that they will not feel an immediate
relief of anxiety. This drug is preferred for long-term management because it lacks the
addictive potential of benzodiazepines. Side effects like dizziness or nausea may occur but
often subside as the body adjusts to the medication.
8. Which intervention is most appropriate for a client with Major Depressive Disorder who
has stopped eating and grooming?
A. Wait for the client to ask for help before intervening.
B. Assist the client with ADLs while encouraging participation.
C. Give the client a list of tasks to complete by the end of the day.
D. Inform the client they will be force-fed if they do not eat.
Correct Answer: B
Updated and Latest Questions and Correct
Answers with Rationale
1. A client is experiencing a panic attack in the emergency department. Which nursing
intervention is the priority?
A. Encourage the client to discuss the source of their anxiety.
B. Administer a high dose of an oral antidepressant immediately.
C. Stay with the client and maintain a calm, quiet environment.
D. Teach the client new coping mechanisms for future episodes.
Correct Answer: C
Rationale: During a panic attack, the nurse must ensure the client’s safety and provide a
non-threatening presence. Staying with the client helps reduce the fear of being alone
during a perceived life-threatening event. A calm environment reduces external stimuli
that could exacerbate the physiological symptoms of panic. The client is unable to process
complex information or learn new skills during the acute phase. Brief, simple
communication is most effective when the client is in a state of severe anxiety or panic.
2. A client with Bipolar I Disorder is in the manic phase and is moving rapidly around the unit.
What is the most appropriate snack to provide?
A. An apple and a protein granola bar.
B. A steak dinner with a baked potato.
C. A bowl of hot chicken noodle soup.
D. A large salad with vinaigrette dressing.
Correct Answer: A
Rationale: Clients in a manic state often have difficulty sitting still long enough to consume
a full meal. Finger foods that are high in calories and protein allow the client to eat while on
the move. Providing nutrient-dense portable options helps prevent exhaustion and
significant weight loss during hyperactive periods. Soup and steak are inappropriate
because they require utensils and the client to remain seated. Constant monitoring of
nutritional intake is vital for maintaining physical health in manic patients.
3. Which clinical manifestation is most characteristic of Borderline Personality Disorder?
A. A pattern of intense and unstable relationships with a fear of abandonment.
B. Arrogance and a constant need for admiration from others.
C. Lack of remorse for violating the rights of others.
,D. Social isolation and a complete lack of interest in social relationships.
Correct Answer: A
Rationale: Borderline Personality Disorder is marked by significant emotional
dysregulation and instability in self-image. Clients often experience ‘splitting,’ where they
view people as either all good or all bad. The fear of real or imagined abandonment leads to
desperate efforts to maintain connections. These individuals may engage in self-harming
behaviors as a way to cope with intense psychic pain. Nursing interventions should focus
on maintaining consistent boundaries and monitoring for safety.
4. A client taking Lithium Carbonate for Bipolar Disorder reports blurred vision, tremors, and
a stumbling gait. What should the nurse do first?
A. Withhold the medication and notify the healthcare provider.
B. Administer the next scheduled dose as prescribed.
C. Advise the client to drink more water to flush the medication.
D. Check the client’s blood pressure while standing.
Correct Answer: A
Rationale: The symptoms of blurred vision, ataxia, and tremors are classic signs of Lithium
toxicity. Because Lithium has a narrow therapeutic index, any sign of toxicity must be
addressed immediately to prevent permanent damage or death. The nurse should hold the
dose and anticipate an order for a serum lithium level. Normal therapeutic levels range
from 0.6 to 1.2 mEq/L, and levels above 1.5 are considered toxic. Fluid and electrolyte
balance must be assessed as dehydration can increase lithium levels.
5. A client with Obsessive-Compulsive Disorder (OCD) spends two hours washing their hands
every morning. What is the best initial nursing action?
A. Allow the client enough time in the schedule for the ritual.
B. Lock the bathroom door to prevent the client from washing.
C. Explain to the client that their hands are already clean.
D. Tell the client they will lose privileges if they continue the behavior.
Correct Answer: A
Rationale: Initially, the nurse should allow the client to perform the ritual to avoid causing
extreme anxiety. Forcing an immediate stop to the compulsion can lead to a panic state for
the individual. The ritual serves as a mechanism to lower the anxiety caused by obsessive
thoughts. As the treatment progresses, the nurse can work with the client to gradually limit
the time spent on the ritual. Cognitive-behavioral therapy and SSRIs are common long-term
treatments for reducing these behaviors.
, 6. A nurse is assessing a client with Antisocial Personality Disorder. Which behavior is most
likely to be observed?
A. Extreme shyness and sensitivity to rejection.
B. Excessive emotionality and attention-seeking.
C. Rigidity and preoccupation with rules and order.
D. Exploitation of others for personal gain without guilt.
Correct Answer: D
Rationale: Antisocial Personality Disorder is characterized by a pervasive pattern of
disregard for the rights of others. Clients often display manipulative behavior and a lack of
empathy or remorse for their actions. They may be charming on the surface but are often
deceitful for personal profit or pleasure. Nursing management focuses on setting firm, clear
limits and avoiding manipulation by the client. It is essential for the staff to maintain a
united front to prevent the client from playing team members against each other.
7. A client is prescribed Buspirone for Generalized Anxiety Disorder. Which statement by the
client indicates an understanding of the teaching?
A. I can take this medicine only when I feel a panic attack coming on.
B. This medication will help me feel better within 30 minutes of taking it.
C. I should stop taking this medication if I feel sleepy.
D. It may take 2 to 4 weeks for this medication to be fully effective.
Correct Answer: D
Rationale: Unlike benzodiazepines, Buspirone is not an ‘as-needed’ (PRN) medication and
does not have an immediate effect. It requires consistent daily dosing to reach therapeutic
levels in the bloodstream. Patients should be educated that they will not feel an immediate
relief of anxiety. This drug is preferred for long-term management because it lacks the
addictive potential of benzodiazepines. Side effects like dizziness or nausea may occur but
often subside as the body adjusts to the medication.
8. Which intervention is most appropriate for a client with Major Depressive Disorder who
has stopped eating and grooming?
A. Wait for the client to ask for help before intervening.
B. Assist the client with ADLs while encouraging participation.
C. Give the client a list of tasks to complete by the end of the day.
D. Inform the client they will be force-fed if they do not eat.
Correct Answer: B
