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 who states, ‘I don’t think I should leave the hospital. I am still
hearing voices.’ Which response by the nurse is therapeutic?
A. ‘Why do you think the voices are still occurring?’
B. ‘You are saying you feel unready to be discharged because of the voices.’
C. ‘You will be fine once you get back to your routine.’
D. ‘We have adjusted your medications, so the voices should stop soon.’
Correct Answer: B
Rationale: This response uses the therapeutic communication technique of restating or
reflecting. It encourages the client to elaborate on their feelings and concerns without
judgment. By repeating the client’s concern, the nurse validates their experience and
fosters a stronger nurse-client relationship. Avoid using ‘why’ questions as they can make
the client defensive. Giving false reassurance is non-therapeutic because it dismisses the
client’s legitimate fears.
2. A client with bipolar disorder is taking lithium carbonate. The nurse should monitor for
which of the following serum lithium levels to prevent toxicity?
A. 0.2 - 0.5 mEq/L
B. 1.5 - 2.0 mEq/L
C. 0.6 - 1.2 mEq/L
D. 2.5 - 3.0 mEq/L
Correct Answer: C
Rationale: The therapeutic range for lithium is narrow, typically between 0.6 and 1.2
mEq/L. Levels above 1.5 mEq/L are considered toxic and require immediate intervention.
Monitoring serum levels is critical because lithium has a low therapeutic index. Toxicity can
lead to severe neurological symptoms, renal failure, and even death if untreated. Nurses
must educate clients on the importance of regular blood tests and consistent salt intake.
3. A nurse is assessing a client experiencing a manic episode. Which of the following findings
should the nurse expect?
A. Excessive sleeping and lethargy
B. Intense focus on one specific task
C. Catatonic behavior and mutism
,D. Pressured speech and grandiosity
Correct Answer: D
Rationale: Manic episodes are characterized by elevated mood, inflated self-esteem, and
increased energy. Pressured speech is a common symptom where the client speaks rapidly
and is difficult to interrupt. Grandiosity refers to the client’s belief that they possess special
powers or superior abilities. These clients often exhibit flight of ideas and a decreased need
for sleep. Understanding these symptoms helps the nurse prioritize safety and symptom
management in a bipolar crisis.
4. A client is prescribed phenelzine for depression. Which food should the nurse instruct the
client to avoid?
A. Fresh green leafy vegetables
B. Aged cheddar cheese
C. Grilled chicken breast
D. Whole grain bread
Correct Answer: B
Rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI) which requires strict
dietary restrictions. Foods high in tyramine, such as aged cheeses, smoked meats, and red
wine, must be avoided. Consuming tyramine while on an MAOI can cause a hypertensive
crisis. This life-threatening condition manifests as severe headaches, palpitations, and
extremely high blood pressure. The nurse must provide a comprehensive list of safe and
unsafe foods to ensure patient safety.
5. A nurse is caring for a client with schizophrenia who is experiencing auditory
hallucinations. Which action should the nurse take first?
A. Leave the client alone in a quiet room to reduce stimulation.
B. Tell the client that the voices are not real.
C. Administer an as-needed dose of an antipsychotic.
D. Ask the client directly what the voices are saying.
Correct Answer: D
Rationale: The priority action is to assess the content of the hallucinations to determine if
they are command hallucinations. Command hallucinations can instruct the client to hurt
themselves or others, posing an immediate safety risk. Validating that the nurse does not
hear the voices is helpful, but dismissing them entirely is non-therapeutic. Gathering
information allows the nurse to implement appropriate safety precautions. Following
assessment, the nurse can then focus on distraction or medication administration.
, 6. A client with an eating disorder is admitted to the unit. Which of the following is the
highest priority nursing intervention?
A. Encouraging the client to participate in group therapy.
B. Monitoring the client’s electrolyte levels and vital signs.
C. Discussing the client’s body image perceptions.
D. Establishing a strictly timed exercise routine.
Correct Answer: B
Rationale: Physiological stability is the priority in clients with eating disorders like
anorexia or bulimia. Electrolyte imbalances, especially potassium, can lead to fatal cardiac
arrhythmias. Vital signs may reveal bradycardia or hypotension, indicating severe
malnutrition or dehydration. Once the client is medically stable, psychological and
behavioral interventions can be addressed. The nurse must prioritize life-saving
assessments over cognitive or social therapies in the acute phase.
7. A nurse is reviewing the laboratory results of a client taking clozapine. Which of the
following results should the nurse report to the provider immediately?
A. Hemoglobin of 14 g/dL
B. Platelet count of 200,000/mm3
C. Blood glucose of 110 mg/dL
D. WBC count of 2,500/mm3
Correct Answer: D
Rationale: Clozapine is an atypical antipsychotic associated with a high risk of
agranulocytosis. Agranulocytosis is a severe reduction in white blood cells, making the
client susceptible to life-threatening infections. A WBC count of 2,500/mm3 is significantly
below the normal range and requires immediate medical attention. Clients on clozapine
must undergo regular blood monitoring to ensure safety. The nurse should also monitor for
signs of infection like fever or sore throat.
8. A nurse is caring for a client who is experiencing alcohol withdrawal. Which medication
should the nurse expect to administer?
A. Disulfiram
B. Naltrexone
C. Methadone
D. Lorazepam
Correct Answer: D
WCU Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is caring for a client who states, ‘I don’t think I should leave the hospital. I am still
hearing voices.’ Which response by the nurse is therapeutic?
A. ‘Why do you think the voices are still occurring?’
B. ‘You are saying you feel unready to be discharged because of the voices.’
C. ‘You will be fine once you get back to your routine.’
D. ‘We have adjusted your medications, so the voices should stop soon.’
Correct Answer: B
Rationale: This response uses the therapeutic communication technique of restating or
reflecting. It encourages the client to elaborate on their feelings and concerns without
judgment. By repeating the client’s concern, the nurse validates their experience and
fosters a stronger nurse-client relationship. Avoid using ‘why’ questions as they can make
the client defensive. Giving false reassurance is non-therapeutic because it dismisses the
client’s legitimate fears.
2. A client with bipolar disorder is taking lithium carbonate. The nurse should monitor for
which of the following serum lithium levels to prevent toxicity?
A. 0.2 - 0.5 mEq/L
B. 1.5 - 2.0 mEq/L
C. 0.6 - 1.2 mEq/L
D. 2.5 - 3.0 mEq/L
Correct Answer: C
Rationale: The therapeutic range for lithium is narrow, typically between 0.6 and 1.2
mEq/L. Levels above 1.5 mEq/L are considered toxic and require immediate intervention.
Monitoring serum levels is critical because lithium has a low therapeutic index. Toxicity can
lead to severe neurological symptoms, renal failure, and even death if untreated. Nurses
must educate clients on the importance of regular blood tests and consistent salt intake.
3. A nurse is assessing a client experiencing a manic episode. Which of the following findings
should the nurse expect?
A. Excessive sleeping and lethargy
B. Intense focus on one specific task
C. Catatonic behavior and mutism
,D. Pressured speech and grandiosity
Correct Answer: D
Rationale: Manic episodes are characterized by elevated mood, inflated self-esteem, and
increased energy. Pressured speech is a common symptom where the client speaks rapidly
and is difficult to interrupt. Grandiosity refers to the client’s belief that they possess special
powers or superior abilities. These clients often exhibit flight of ideas and a decreased need
for sleep. Understanding these symptoms helps the nurse prioritize safety and symptom
management in a bipolar crisis.
4. A client is prescribed phenelzine for depression. Which food should the nurse instruct the
client to avoid?
A. Fresh green leafy vegetables
B. Aged cheddar cheese
C. Grilled chicken breast
D. Whole grain bread
Correct Answer: B
Rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI) which requires strict
dietary restrictions. Foods high in tyramine, such as aged cheeses, smoked meats, and red
wine, must be avoided. Consuming tyramine while on an MAOI can cause a hypertensive
crisis. This life-threatening condition manifests as severe headaches, palpitations, and
extremely high blood pressure. The nurse must provide a comprehensive list of safe and
unsafe foods to ensure patient safety.
5. A nurse is caring for a client with schizophrenia who is experiencing auditory
hallucinations. Which action should the nurse take first?
A. Leave the client alone in a quiet room to reduce stimulation.
B. Tell the client that the voices are not real.
C. Administer an as-needed dose of an antipsychotic.
D. Ask the client directly what the voices are saying.
Correct Answer: D
Rationale: The priority action is to assess the content of the hallucinations to determine if
they are command hallucinations. Command hallucinations can instruct the client to hurt
themselves or others, posing an immediate safety risk. Validating that the nurse does not
hear the voices is helpful, but dismissing them entirely is non-therapeutic. Gathering
information allows the nurse to implement appropriate safety precautions. Following
assessment, the nurse can then focus on distraction or medication administration.
, 6. A client with an eating disorder is admitted to the unit. Which of the following is the
highest priority nursing intervention?
A. Encouraging the client to participate in group therapy.
B. Monitoring the client’s electrolyte levels and vital signs.
C. Discussing the client’s body image perceptions.
D. Establishing a strictly timed exercise routine.
Correct Answer: B
Rationale: Physiological stability is the priority in clients with eating disorders like
anorexia or bulimia. Electrolyte imbalances, especially potassium, can lead to fatal cardiac
arrhythmias. Vital signs may reveal bradycardia or hypotension, indicating severe
malnutrition or dehydration. Once the client is medically stable, psychological and
behavioral interventions can be addressed. The nurse must prioritize life-saving
assessments over cognitive or social therapies in the acute phase.
7. A nurse is reviewing the laboratory results of a client taking clozapine. Which of the
following results should the nurse report to the provider immediately?
A. Hemoglobin of 14 g/dL
B. Platelet count of 200,000/mm3
C. Blood glucose of 110 mg/dL
D. WBC count of 2,500/mm3
Correct Answer: D
Rationale: Clozapine is an atypical antipsychotic associated with a high risk of
agranulocytosis. Agranulocytosis is a severe reduction in white blood cells, making the
client susceptible to life-threatening infections. A WBC count of 2,500/mm3 is significantly
below the normal range and requires immediate medical attention. Clients on clozapine
must undergo regular blood monitoring to ensure safety. The nurse should also monitor for
signs of infection like fever or sore throat.
8. A nurse is caring for a client who is experiencing alcohol withdrawal. Which medication
should the nurse expect to administer?
A. Disulfiram
B. Naltrexone
C. Methadone
D. Lorazepam
Correct Answer: D
