NURS 222 | NURS222 Final Exam: Mental Health -
WCU Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is caring for a client with major depressive disorder who states, “I just don’t see
the point in anything anymore.” Which of the following responses is therapeutic?
A. “You shouldn’t feel that way because you have so much to live for.”
B. “Why do you feel that everything is so hopeless right now?”
C. “I felt the same way once, but things eventually got better.”
D. “It sounds like you are feeling very discouraged today.”
Correct Answer: D
Rationale: This response uses the therapeutic technique of reflection to acknowledge the
client’s feelings. Reflection helps the client feel heard and encourages them to elaborate on
their emotional state. The nurse should avoid asking ‘why’ questions as they can make the
client feel defensive. Providing false reassurance or sharing personal stories shifts the focus
away from the client’s immediate needs. This approach builds a trusting relationship and
supports the assessment of suicide risk.
2. A client with bipolar disorder is prescribed lithium carbonate. Which of the following
dietary instructions should the nurse include in the teaching?
A. Restrict fluid intake to less than one liter per day.
B. Maintain a consistent intake of dietary sodium.
C. Avoid all green leafy vegetables containing vitamin K.
D. Switch to a low-protein diet to prevent kidney strain.
Correct Answer: B
Rationale: Lithium is a salt, and its excretion is closely linked to sodium levels in the body.
If sodium intake is restricted, the kidneys reabsorb lithium, which can lead to toxicity. The
nurse must instruct the client to maintain normal levels of salt and fluid to ensure safety.
Dehydration or excessive sweating can also lead to dangerously high levels of lithium in the
bloodstream. Regular blood monitoring is required to keep the medication within the
narrow therapeutic range.
3. A nurse is assessing a client for serotonin syndrome after they started taking an SSRI.
Which of the following findings should the nurse expect?
A. Hypothermia and bradycardia
B. Weight gain and increased appetite
,C. Urinary retention and constipation
D. Muscle rigidity and hyperreflexia
Correct Answer: D
Rationale: Serotonin syndrome is a potentially life-threatening condition caused by
excessive serotonergic activity. Key clinical manifestations include mental status changes,
autonomic hyperactivity, and neuromuscular abnormalities like hyperreflexia. The nurse
should look for signs such as tremors, shivering, and muscle rigidity in the patient.
Immediate discontinuation of the causative agent is necessary to prevent further
complications. This condition often occurs when SSRIs are combined with other
medications like MAOIs or St. John’s wort.
4. A client is experiencing alcohol withdrawal delirium. Which of the following medications
should the nurse expect the provider to prescribe?
A. Lorazepam
B. Disulfiram
C. Methadone
D. Naltrexone
Correct Answer: A
Rationale: Benzodiazepines like lorazepam are the gold standard for managing acute
alcohol withdrawal symptoms. These medications help stabilize vital signs and prevent the
progression to seizures or delirium tremens. The nurse must monitor the patient’s sedation
levels and respiratory rate while administering this drug. Unlike disulfiram, which is used
for long-term sobriety, benzodiazepines treat the immediate physiological crisis. Proper
dosing is usually based on a standardized withdrawal assessment scale like the CIWA-Ar.
5. A nurse is caring for a client in an inpatient unit who is becoming increasingly aggressive.
Which of the following actions should the nurse take first?
A. Place the client in physical restraints.
B. Administer a PRN dose of haloperidol.
C. Call for a ‘code green’ or security assistance.
D. Attempt to de-escalate the situation verbally.
Correct Answer: D
Rationale: The nurse should always use the least restrictive intervention possible when
managing aggressive behavior. Verbal de-escalation helps the client regain control and may
prevent the need for physical or chemical restraints. The nurse should maintain a calm
voice and provide the client with personal space. Restraints and seclusion are only used as
, a last resort when the client poses an immediate threat to self or others. Documenting the
specific behaviors and the failed less-restrictive measures is a legal requirement.
6. A client is prescribed clozapine for treatment-resistant schizophrenia. Which laboratory
test must be performed weekly for the first six months?
A. Liver function tests
B. Complete blood count with differential
C. Serum creatinine and BUN
D. Fasting blood glucose
Correct Answer: B
Rationale: Clozapine carries a high risk for agranulocytosis, which is a severe and
dangerous decrease in white blood cells. A complete blood count is necessary to monitor
the absolute neutrophil count (ANC) before and during treatment. If the ANC falls below a
certain threshold, the medication must be discontinued immediately to prevent fatal
infections. This monitoring is mandated by a national registry to ensure patient safety. The
nurse should educate the client to report any signs of infection, such as fever or sore throat.
7. A nurse is assessing a client with schizophrenia. Which of the following should the nurse
document as a negative symptom?
A. Auditory hallucinations
B. Delusions of grandeur
C. Disorganized speech patterns
D. Avolition or lack of motivation
Correct Answer: D
Rationale: Negative symptoms of schizophrenia represent a loss or diminution of normal
functions. Avolition, which is a lack of motivation to engage in goal-directed activities, is a
classic negative symptom. Other negative symptoms include alogia, affective flattening, and
anhedonia. Positive symptoms, such as hallucinations and delusions, involve the addition of
abnormal behaviors. Understanding the difference is crucial for selecting appropriate
nursing interventions and evaluating medication efficacy.
8. A client in the manic phase of bipolar disorder is pacing the halls and refusing to sit for
meals. Which of the following is an appropriate nursing intervention?
A. Provide the client with high-calorie finger foods.
B. Require the client to stay in their room until they can sit still.
C. Explain the nutritional importance of a balanced meal.
D. Place the client in a quiet room with a television on.
WCU Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is caring for a client with major depressive disorder who states, “I just don’t see
the point in anything anymore.” Which of the following responses is therapeutic?
A. “You shouldn’t feel that way because you have so much to live for.”
B. “Why do you feel that everything is so hopeless right now?”
C. “I felt the same way once, but things eventually got better.”
D. “It sounds like you are feeling very discouraged today.”
Correct Answer: D
Rationale: This response uses the therapeutic technique of reflection to acknowledge the
client’s feelings. Reflection helps the client feel heard and encourages them to elaborate on
their emotional state. The nurse should avoid asking ‘why’ questions as they can make the
client feel defensive. Providing false reassurance or sharing personal stories shifts the focus
away from the client’s immediate needs. This approach builds a trusting relationship and
supports the assessment of suicide risk.
2. A client with bipolar disorder is prescribed lithium carbonate. Which of the following
dietary instructions should the nurse include in the teaching?
A. Restrict fluid intake to less than one liter per day.
B. Maintain a consistent intake of dietary sodium.
C. Avoid all green leafy vegetables containing vitamin K.
D. Switch to a low-protein diet to prevent kidney strain.
Correct Answer: B
Rationale: Lithium is a salt, and its excretion is closely linked to sodium levels in the body.
If sodium intake is restricted, the kidneys reabsorb lithium, which can lead to toxicity. The
nurse must instruct the client to maintain normal levels of salt and fluid to ensure safety.
Dehydration or excessive sweating can also lead to dangerously high levels of lithium in the
bloodstream. Regular blood monitoring is required to keep the medication within the
narrow therapeutic range.
3. A nurse is assessing a client for serotonin syndrome after they started taking an SSRI.
Which of the following findings should the nurse expect?
A. Hypothermia and bradycardia
B. Weight gain and increased appetite
,C. Urinary retention and constipation
D. Muscle rigidity and hyperreflexia
Correct Answer: D
Rationale: Serotonin syndrome is a potentially life-threatening condition caused by
excessive serotonergic activity. Key clinical manifestations include mental status changes,
autonomic hyperactivity, and neuromuscular abnormalities like hyperreflexia. The nurse
should look for signs such as tremors, shivering, and muscle rigidity in the patient.
Immediate discontinuation of the causative agent is necessary to prevent further
complications. This condition often occurs when SSRIs are combined with other
medications like MAOIs or St. John’s wort.
4. A client is experiencing alcohol withdrawal delirium. Which of the following medications
should the nurse expect the provider to prescribe?
A. Lorazepam
B. Disulfiram
C. Methadone
D. Naltrexone
Correct Answer: A
Rationale: Benzodiazepines like lorazepam are the gold standard for managing acute
alcohol withdrawal symptoms. These medications help stabilize vital signs and prevent the
progression to seizures or delirium tremens. The nurse must monitor the patient’s sedation
levels and respiratory rate while administering this drug. Unlike disulfiram, which is used
for long-term sobriety, benzodiazepines treat the immediate physiological crisis. Proper
dosing is usually based on a standardized withdrawal assessment scale like the CIWA-Ar.
5. A nurse is caring for a client in an inpatient unit who is becoming increasingly aggressive.
Which of the following actions should the nurse take first?
A. Place the client in physical restraints.
B. Administer a PRN dose of haloperidol.
C. Call for a ‘code green’ or security assistance.
D. Attempt to de-escalate the situation verbally.
Correct Answer: D
Rationale: The nurse should always use the least restrictive intervention possible when
managing aggressive behavior. Verbal de-escalation helps the client regain control and may
prevent the need for physical or chemical restraints. The nurse should maintain a calm
voice and provide the client with personal space. Restraints and seclusion are only used as
, a last resort when the client poses an immediate threat to self or others. Documenting the
specific behaviors and the failed less-restrictive measures is a legal requirement.
6. A client is prescribed clozapine for treatment-resistant schizophrenia. Which laboratory
test must be performed weekly for the first six months?
A. Liver function tests
B. Complete blood count with differential
C. Serum creatinine and BUN
D. Fasting blood glucose
Correct Answer: B
Rationale: Clozapine carries a high risk for agranulocytosis, which is a severe and
dangerous decrease in white blood cells. A complete blood count is necessary to monitor
the absolute neutrophil count (ANC) before and during treatment. If the ANC falls below a
certain threshold, the medication must be discontinued immediately to prevent fatal
infections. This monitoring is mandated by a national registry to ensure patient safety. The
nurse should educate the client to report any signs of infection, such as fever or sore throat.
7. A nurse is assessing a client with schizophrenia. Which of the following should the nurse
document as a negative symptom?
A. Auditory hallucinations
B. Delusions of grandeur
C. Disorganized speech patterns
D. Avolition or lack of motivation
Correct Answer: D
Rationale: Negative symptoms of schizophrenia represent a loss or diminution of normal
functions. Avolition, which is a lack of motivation to engage in goal-directed activities, is a
classic negative symptom. Other negative symptoms include alogia, affective flattening, and
anhedonia. Positive symptoms, such as hallucinations and delusions, involve the addition of
abnormal behaviors. Understanding the difference is crucial for selecting appropriate
nursing interventions and evaluating medication efficacy.
8. A client in the manic phase of bipolar disorder is pacing the halls and refusing to sit for
meals. Which of the following is an appropriate nursing intervention?
A. Provide the client with high-calorie finger foods.
B. Require the client to stay in their room until they can sit still.
C. Explain the nutritional importance of a balanced meal.
D. Place the client in a quiet room with a television on.
