NURS 222 | NURS222 Exam 3: Mental Health - WCU
Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is caring for a client with schizophrenia who is experiencing auditory
hallucinations. Which of the following responses is most therapeutic?
A. Why do you think the voices are talking to you right now?
B. I don’t hear the voices, but I can see that you are upset.
C. The voices are not real, so you should try to ignore them.
D. I will leave you alone until the voices stop talking.
Correct Answer: B
Rationale: This response acknowledges the client’s feelings while presenting reality
without challenging the client’s perception. Presenting reality helps the client differentiate
between their internal experience and the external environment. It is important to validate
the emotional impact of the hallucination rather than dismissing the experience. Nurses
should avoid ‘why’ questions as they can be perceived as accusatory or defensive.
Consistency and empathy are key components of building a therapeutic relationship with
psychotic patients.
2. A patient is prescribed Clozapine for treatment-resistant schizophrenia. Which laboratory
value is the priority for the nurse to monitor?
A. Serum potassium
B. Platelet count
C. Blood urea nitrogen
D. White blood cell count
Correct Answer: D
Rationale: Clozapine carries a high risk for agranulocytosis, which is a severe and
potentially fatal decrease in white blood cells. Clients must have baseline and weekly or bi-
weekly WBC and Absolute Neutrophil Counts performed. If the WBC drops below a certain
threshold, the medication must be discontinued immediately. This monitoring is mandated
by the Clozapine Risk Evaluation and Mitigation Strategy (REMS) program. The nurse must
educate the patient on reporting signs of infection such as fever or sore throat.
3. Which of the following symptoms is considered a negative symptom of schizophrenia?
A. Delusions of grandeur
B. Echolalia
,C. Disorganized speech
D. Flat affect
Correct Answer: D
Rationale: Negative symptoms represent a loss or deficit of normal functions, such as
emotional expression or motivation. Flat affect refers to a lack of emotional response or
minimal facial expression. Other negative symptoms include alogia, avolition, anhedonia,
and social withdrawal. Positive symptoms, by contrast, are additions to normal behavior
like hallucinations and delusions. Recognizing negative symptoms is crucial as they often
interfere more with daily functioning than positive symptoms.
4. A client is experiencing alcohol withdrawal and exhibits tremors, diaphoresis, and a heart
rate of 110 bpm. Which medication should the nurse anticipate administering?
A. Disulfiram
B. Naltrexone
C. Methadone
D. Lorazepam
Correct Answer: D
Rationale: Benzodiazepines like Lorazepam are the gold standard for managing acute
alcohol withdrawal symptoms and preventing seizures. They work by enhancing the effects
of GABA to stabilize the central nervous system during detoxification. The dosage is often
determined by a standardized scale like the CIWA-Ar. Monitoring vital signs is essential
during this period to prevent progression to delirium tremens. Other medications like
Disulfiram are used for maintenance of sobriety, not acute withdrawal.
5. The nurse observes a client who has been taking Haloperidol for two weeks. The client is
now experiencing neck spasms and their eyes are rolling upward. This is known as:
A. Akathisia
B. Pseudoparkinsonism
C. Tardive dyskinesia
D. Acute dystonia
Correct Answer: D
Rationale: Acute dystonia involves severe spasms of the tongue, face, neck, or back
muscles and is an emergency. It typically occurs within the first few days of starting first-
generation antipsychotics. An oculogyric crisis, where eyes roll upward, is a specific form of
dystonic reaction. The treatment usually involves the administration of an anticholinergic
medication like Benztropine or Diphenhydramine. Nurses must act quickly to relieve the
client’s distress and maintain their airway.
, 6. Which assessment tool is most commonly used to screen for alcohol use disorder in a
primary care setting?
A. AIMS
B. PHQ-9
C. MMSE
D. CAGE questionnaire
Correct Answer: D
Rationale: The CAGE questionnaire is a four-question tool used to screen for alcohol
dependency. It asks about Cutting down, Annoyance by criticism, Guilt, and Eye-openers. A
score of two or more ‘yes’ responses is considered clinically significant. This tool is efficient
for busy clinical settings and helps identify patients needing further intervention. Early
detection of substance use disorders leads to better long-term health outcomes for the
patient.
7. A nurse is teaching a client about Disulfiram therapy. Which statement by the client
indicates understanding of the teaching?
A. I need to avoid using mouthwash that contains alcohol.
B. I can drink alcohol as long as I only have one beer.
C. The medication will stop my cravings for alcohol.
D. If I get a headache, I should stop taking the medication immediately.
Correct Answer: A
Rationale: Disulfiram causes a severe physical reaction when even small amounts of
alcohol are consumed. Clients must be taught to avoid hidden sources of alcohol, such as
mouthwash, vanilla extract, and cough syrups. The reaction includes symptoms like
flushing, nausea, vomiting, and tachycardia. It is a form of aversion therapy designed to
discourage drinking through negative reinforcement. Clients should also be warned that
the sensitivity to alcohol lasts for up to two weeks after the last dose.
8. A client with schizophrenia is exhibiting ‘word salad.’ This is characterized by:
A. Repeating words spoken by the nurse.
B. Moving rapidly from one thought to another.
C. Making up new words that have no meaning.
D. A jumble of words that is meaningless to the listener.
Correct Answer: D
Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is caring for a client with schizophrenia who is experiencing auditory
hallucinations. Which of the following responses is most therapeutic?
A. Why do you think the voices are talking to you right now?
B. I don’t hear the voices, but I can see that you are upset.
C. The voices are not real, so you should try to ignore them.
D. I will leave you alone until the voices stop talking.
Correct Answer: B
Rationale: This response acknowledges the client’s feelings while presenting reality
without challenging the client’s perception. Presenting reality helps the client differentiate
between their internal experience and the external environment. It is important to validate
the emotional impact of the hallucination rather than dismissing the experience. Nurses
should avoid ‘why’ questions as they can be perceived as accusatory or defensive.
Consistency and empathy are key components of building a therapeutic relationship with
psychotic patients.
2. A patient is prescribed Clozapine for treatment-resistant schizophrenia. Which laboratory
value is the priority for the nurse to monitor?
A. Serum potassium
B. Platelet count
C. Blood urea nitrogen
D. White blood cell count
Correct Answer: D
Rationale: Clozapine carries a high risk for agranulocytosis, which is a severe and
potentially fatal decrease in white blood cells. Clients must have baseline and weekly or bi-
weekly WBC and Absolute Neutrophil Counts performed. If the WBC drops below a certain
threshold, the medication must be discontinued immediately. This monitoring is mandated
by the Clozapine Risk Evaluation and Mitigation Strategy (REMS) program. The nurse must
educate the patient on reporting signs of infection such as fever or sore throat.
3. Which of the following symptoms is considered a negative symptom of schizophrenia?
A. Delusions of grandeur
B. Echolalia
,C. Disorganized speech
D. Flat affect
Correct Answer: D
Rationale: Negative symptoms represent a loss or deficit of normal functions, such as
emotional expression or motivation. Flat affect refers to a lack of emotional response or
minimal facial expression. Other negative symptoms include alogia, avolition, anhedonia,
and social withdrawal. Positive symptoms, by contrast, are additions to normal behavior
like hallucinations and delusions. Recognizing negative symptoms is crucial as they often
interfere more with daily functioning than positive symptoms.
4. A client is experiencing alcohol withdrawal and exhibits tremors, diaphoresis, and a heart
rate of 110 bpm. Which medication should the nurse anticipate administering?
A. Disulfiram
B. Naltrexone
C. Methadone
D. Lorazepam
Correct Answer: D
Rationale: Benzodiazepines like Lorazepam are the gold standard for managing acute
alcohol withdrawal symptoms and preventing seizures. They work by enhancing the effects
of GABA to stabilize the central nervous system during detoxification. The dosage is often
determined by a standardized scale like the CIWA-Ar. Monitoring vital signs is essential
during this period to prevent progression to delirium tremens. Other medications like
Disulfiram are used for maintenance of sobriety, not acute withdrawal.
5. The nurse observes a client who has been taking Haloperidol for two weeks. The client is
now experiencing neck spasms and their eyes are rolling upward. This is known as:
A. Akathisia
B. Pseudoparkinsonism
C. Tardive dyskinesia
D. Acute dystonia
Correct Answer: D
Rationale: Acute dystonia involves severe spasms of the tongue, face, neck, or back
muscles and is an emergency. It typically occurs within the first few days of starting first-
generation antipsychotics. An oculogyric crisis, where eyes roll upward, is a specific form of
dystonic reaction. The treatment usually involves the administration of an anticholinergic
medication like Benztropine or Diphenhydramine. Nurses must act quickly to relieve the
client’s distress and maintain their airway.
, 6. Which assessment tool is most commonly used to screen for alcohol use disorder in a
primary care setting?
A. AIMS
B. PHQ-9
C. MMSE
D. CAGE questionnaire
Correct Answer: D
Rationale: The CAGE questionnaire is a four-question tool used to screen for alcohol
dependency. It asks about Cutting down, Annoyance by criticism, Guilt, and Eye-openers. A
score of two or more ‘yes’ responses is considered clinically significant. This tool is efficient
for busy clinical settings and helps identify patients needing further intervention. Early
detection of substance use disorders leads to better long-term health outcomes for the
patient.
7. A nurse is teaching a client about Disulfiram therapy. Which statement by the client
indicates understanding of the teaching?
A. I need to avoid using mouthwash that contains alcohol.
B. I can drink alcohol as long as I only have one beer.
C. The medication will stop my cravings for alcohol.
D. If I get a headache, I should stop taking the medication immediately.
Correct Answer: A
Rationale: Disulfiram causes a severe physical reaction when even small amounts of
alcohol are consumed. Clients must be taught to avoid hidden sources of alcohol, such as
mouthwash, vanilla extract, and cough syrups. The reaction includes symptoms like
flushing, nausea, vomiting, and tachycardia. It is a form of aversion therapy designed to
discourage drinking through negative reinforcement. Clients should also be warned that
the sensitivity to alcohol lasts for up to two weeks after the last dose.
8. A client with schizophrenia is exhibiting ‘word salad.’ This is characterized by:
A. Repeating words spoken by the nurse.
B. Moving rapidly from one thought to another.
C. Making up new words that have no meaning.
D. A jumble of words that is meaningless to the listener.
Correct Answer: D
