NURS 222 | NURS222 Exam 3: Mental Health - WCU
Updated and Latest Questions and Correct
Answers with Rationale
1. A client diagnosed with schizophrenia is prescribed clozapine. Which laboratory result
should the nurse prioritize monitoring during the first six months of treatment?
A. Blood glucose levels
B. Liver enzymes
C. Serum creatinine
D. White blood cell (WBC) count
Correct Answer: D
Rationale: Clozapine is known to cause agranulocytosis, which is a life-threatening drop in
white blood cells. The nurse must monitor the absolute neutrophil count and WBC count
weekly during the initial phase. This monitoring is mandatory to prevent severe infection
or sepsis in the client. If the WBC count falls below a specific threshold, the medication
must be discontinued immediately. Safety protocols require reporting any signs of
infection, such as fever or sore throat, to the provider.
2. A client is experiencing severe alcohol withdrawal and is exhibiting tremors, tachycardia,
and hypertension. Which medication should the nurse expect the provider to order?
A. Haloperidol
B. Lorazepam
C. Naloxone
D. Disulfiram
Correct Answer: B
Rationale: Benzodiazepines like lorazepam are the gold standard for managing acute
alcohol withdrawal symptoms. These medications help stabilize vital signs and reduce the
risk of seizures during the detoxification process. They work by enhancing the effects of
GABA in the central nervous system to provide a calming effect. The nurse should use the
Clinical Institute Withdrawal Assessment (CIWA) scale to determine the appropriate
dosage. Monitoring for respiratory depression is a critical nursing responsibility when
administering these sedatives.
3. Which symptom is considered a ‘negative’ symptom of schizophrenia?
A. Auditory hallucinations
B. Flat affect
,C. Delusions of grandeur
D. Disorganized speech
Correct Answer: B
Rationale: Negative symptoms of schizophrenia refer to the absence or reduction of
normal functions and behaviors. Flat affect is characterized by a lack of emotional
expression in the face and voice. Unlike positive symptoms, negative symptoms often
interfere more significantly with a client’s ability to maintain social relationships. Other
examples of negative symptoms include avolition, alogia, and anhedonia. Treatment for
these symptoms often requires second-generation antipsychotics and long-term
psychosocial support.
4. A client is admitted with suspected Neuroleptic Malignant Syndrome (NMS) after starting a
new antipsychotic. Which clinical finding should the nurse anticipate?
A. Muscle flaccidity
B. Severe muscle rigidity and high fever
C. Hypothermia and bradycardia
D. Excessive salivation and diarrhea
Correct Answer: B
Rationale: Neuroleptic Malignant Syndrome is a rare but life-threatening reaction to
antipsychotic medications. It is characterized by severe muscle rigidity, high fever, and
autonomic instability like tachycardia. The nurse must immediately stop the offending
medication and notify the healthcare provider. Treatment usually involves supportive care,
hydration, and medications like dantrolene or bromocriptine. Monitoring the client’s
creatine kinase levels is also essential to assess for potential muscle breakdown.
5. A nurse is caring for a client who is experiencing command hallucinations. Which nursing
action is the priority?
A. Place the client in a quiet room with the door closed.
B. Tell the client that the voices are not real.
C. Encourage the client to listen to music to drown out the voices.
D. Ask the client what the voices are telling them to do.
Correct Answer: D
Rationale: Safety is the absolute priority when a client is experiencing command
hallucinations. The nurse must determine if the voices are instructing the client to harm
themselves or others. Identifying the content of the hallucination allows the nurse to
implement appropriate safety precautions immediately. It is important to maintain a calm,
, non-threatening approach while gathering this information. Providing a safe environment
helps prevent the client from acting on dangerous commands.
6. A client with a history of alcohol use disorder presents with ataxia, confusion, and
nystagmus. Which nutritional deficiency does the nurse suspect?
A. Thiamine (Vitamin B1)
B. Vitamin C
C. Vitamin B12
D. Folic acid
Correct Answer: A
Rationale: Wernicke-Korsakoff syndrome is a neurological disorder caused by a severe
deficiency of thiamine. This condition is frequently seen in chronic alcoholics due to poor
nutrition and impaired absorption. The triad of symptoms includes ataxia, confusion, and
various visual disturbances like nystagmus. Prompt administration of intravenous thiamine
is necessary to prevent permanent brain damage. The nurse should advocate for early
nutritional intervention to support neurological recovery.
7. Which assessment tool is most appropriate for a nurse to use when screening a client for
potential alcohol use disorder?
A. AIMS scale
B. PHQ-9
C. CAGE questionnaire
D. MMSE
Correct Answer: C
Rationale: The CAGE questionnaire is a widely used screening tool for identifying potential
alcohol abuse or dependence. It consists of four simple questions regarding the need to Cut
down, Annoyance at criticism, Guilt, and the need for an Eye-opener. Scoring two or more
positive responses suggests a high likelihood of a substance use problem. This tool is
effective because it is quick and non-confrontational for the client. The nurse should follow
up any positive screen with a more comprehensive diagnostic assessment.
8. A client is prescribed disulfiram for alcohol abstinence. Which statement by the client
indicates a need for further teaching?
A. ‘I can use alcohol-based mouthwash as long as I don’t swallow it.’
B. ‘I should wait at least 12 hours after my last drink to start the med.’
C. ‘I will avoid drinking beer and wine.’
D. ‘I need to read labels on cough syrups and vanilla extracts.’
Updated and Latest Questions and Correct
Answers with Rationale
1. A client diagnosed with schizophrenia is prescribed clozapine. Which laboratory result
should the nurse prioritize monitoring during the first six months of treatment?
A. Blood glucose levels
B. Liver enzymes
C. Serum creatinine
D. White blood cell (WBC) count
Correct Answer: D
Rationale: Clozapine is known to cause agranulocytosis, which is a life-threatening drop in
white blood cells. The nurse must monitor the absolute neutrophil count and WBC count
weekly during the initial phase. This monitoring is mandatory to prevent severe infection
or sepsis in the client. If the WBC count falls below a specific threshold, the medication
must be discontinued immediately. Safety protocols require reporting any signs of
infection, such as fever or sore throat, to the provider.
2. A client is experiencing severe alcohol withdrawal and is exhibiting tremors, tachycardia,
and hypertension. Which medication should the nurse expect the provider to order?
A. Haloperidol
B. Lorazepam
C. Naloxone
D. Disulfiram
Correct Answer: B
Rationale: Benzodiazepines like lorazepam are the gold standard for managing acute
alcohol withdrawal symptoms. These medications help stabilize vital signs and reduce the
risk of seizures during the detoxification process. They work by enhancing the effects of
GABA in the central nervous system to provide a calming effect. The nurse should use the
Clinical Institute Withdrawal Assessment (CIWA) scale to determine the appropriate
dosage. Monitoring for respiratory depression is a critical nursing responsibility when
administering these sedatives.
3. Which symptom is considered a ‘negative’ symptom of schizophrenia?
A. Auditory hallucinations
B. Flat affect
,C. Delusions of grandeur
D. Disorganized speech
Correct Answer: B
Rationale: Negative symptoms of schizophrenia refer to the absence or reduction of
normal functions and behaviors. Flat affect is characterized by a lack of emotional
expression in the face and voice. Unlike positive symptoms, negative symptoms often
interfere more significantly with a client’s ability to maintain social relationships. Other
examples of negative symptoms include avolition, alogia, and anhedonia. Treatment for
these symptoms often requires second-generation antipsychotics and long-term
psychosocial support.
4. A client is admitted with suspected Neuroleptic Malignant Syndrome (NMS) after starting a
new antipsychotic. Which clinical finding should the nurse anticipate?
A. Muscle flaccidity
B. Severe muscle rigidity and high fever
C. Hypothermia and bradycardia
D. Excessive salivation and diarrhea
Correct Answer: B
Rationale: Neuroleptic Malignant Syndrome is a rare but life-threatening reaction to
antipsychotic medications. It is characterized by severe muscle rigidity, high fever, and
autonomic instability like tachycardia. The nurse must immediately stop the offending
medication and notify the healthcare provider. Treatment usually involves supportive care,
hydration, and medications like dantrolene or bromocriptine. Monitoring the client’s
creatine kinase levels is also essential to assess for potential muscle breakdown.
5. A nurse is caring for a client who is experiencing command hallucinations. Which nursing
action is the priority?
A. Place the client in a quiet room with the door closed.
B. Tell the client that the voices are not real.
C. Encourage the client to listen to music to drown out the voices.
D. Ask the client what the voices are telling them to do.
Correct Answer: D
Rationale: Safety is the absolute priority when a client is experiencing command
hallucinations. The nurse must determine if the voices are instructing the client to harm
themselves or others. Identifying the content of the hallucination allows the nurse to
implement appropriate safety precautions immediately. It is important to maintain a calm,
, non-threatening approach while gathering this information. Providing a safe environment
helps prevent the client from acting on dangerous commands.
6. A client with a history of alcohol use disorder presents with ataxia, confusion, and
nystagmus. Which nutritional deficiency does the nurse suspect?
A. Thiamine (Vitamin B1)
B. Vitamin C
C. Vitamin B12
D. Folic acid
Correct Answer: A
Rationale: Wernicke-Korsakoff syndrome is a neurological disorder caused by a severe
deficiency of thiamine. This condition is frequently seen in chronic alcoholics due to poor
nutrition and impaired absorption. The triad of symptoms includes ataxia, confusion, and
various visual disturbances like nystagmus. Prompt administration of intravenous thiamine
is necessary to prevent permanent brain damage. The nurse should advocate for early
nutritional intervention to support neurological recovery.
7. Which assessment tool is most appropriate for a nurse to use when screening a client for
potential alcohol use disorder?
A. AIMS scale
B. PHQ-9
C. CAGE questionnaire
D. MMSE
Correct Answer: C
Rationale: The CAGE questionnaire is a widely used screening tool for identifying potential
alcohol abuse or dependence. It consists of four simple questions regarding the need to Cut
down, Annoyance at criticism, Guilt, and the need for an Eye-opener. Scoring two or more
positive responses suggests a high likelihood of a substance use problem. This tool is
effective because it is quick and non-confrontational for the client. The nurse should follow
up any positive screen with a more comprehensive diagnostic assessment.
8. A client is prescribed disulfiram for alcohol abstinence. Which statement by the client
indicates a need for further teaching?
A. ‘I can use alcohol-based mouthwash as long as I don’t swallow it.’
B. ‘I should wait at least 12 hours after my last drink to start the med.’
C. ‘I will avoid drinking beer and wine.’
D. ‘I need to read labels on cough syrups and vanilla extracts.’
