Question

A nurse working in a mental health facility is admitting a client.

Answer 1

Correct Answers

Blank 1 Correct Option: cardiac status
Blank 2 Correct Option: purging episodes

Rationale :

🟧 Cardiac status is the priority due to electrolyte imbalance and tachycardia from purging

🟧 The potassium level of 2.9 mEq/L puts the client at high risk for cardiac arrhythmias

🟧 Addressing cardiac concerns first follows Maslow’s hierarchy and ABCs (Airway-Breathing-Circulation)

🟧 Purging behavior is a critical mental health concern that must be targeted next

🟧 Identifying patterns of purging supports both medical stabilization and behavioral therapy

Distractor Analysis :

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Answer 2

Correct Answers:

Walking with the nurse in the courtyard

Rationale :

🟩 Low-stimulation individual activities are best during the manic phase

🟩 Walking provides physical outlet without overstimulation or competitive behavior

🟩 Supervised activity maintains staff-client interaction and safety monitoring

🟩 This setting allows for calm redirection without aggravating manic symptoms

🟩 Group activities and debates can escalate agitation or impulsivity

Distractor Analysis :

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Answer 3

Correct Answers:

Dysrhythmias

Rationale :

🔵 Haloperidol can cause QT prolongation, increasing the risk of cardiac dysrhythmias

🔵 Clients on antipsychotics should be monitored for cardiotoxic effects and ECG changes

🔵 Risk of torsades de pointes or sudden cardiac death increases with electrolyte imbalance

🔵 Monitoring vitals and baseline ECGs is crucial in patients receiving high-potency antipsychotics

🔵 Prompt recognition prevents severe cardiac complications

Distractor Analysis :

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Answer 4

Correct Answers:

Plan the client's schedule to allow time for rituals.

Rationale :

🟨 Allowing structured time for compulsive rituals builds trust and reduces anxiety

🟨 Abruptly stopping rituals may increase obsession-related distress and lead to aggression

🟨 Gradual reduction helps transition into cognitive-behavioral interventions

🟨 Respecting rituals while initiating treatment supports therapeutic alliance

🟨 It provides a sense of control and increases cooperation

Distractor Analysis :

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Answer 5

Correct Answers:

"You must be very upset about something."

Rationale :

🟦 This response uses therapeutic communication and acknowledges the client's feelings

🟦 It helps de-escalate manic or aggressive behavior through emotional validation

🟦 Avoiding confrontation prevents triggering paranoia or further agitation

🟦 Open-ended reflection encourages expression of the underlying need

🟦 It maintains professional boundaries while showing empathy

Distractor Analysis :

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Answer 6

Correct Answers:

Decrease anxiety.

Rationale :

🟨 The repetitive cleaning is a compulsion to reduce anxiety caused by intrusive thoughts

🟨 OCD clients perform rituals to gain temporary relief from distress

🟨 Interruption without support can cause severe panic or distress

🟨 Understanding the purpose of behavior is key to planning behavioral therapy

🟨 Compulsions are maladaptive coping strategies for internal conflict

Distractor Analysis :

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Answer 7

Correct Answers:

Glucose level
Blood pressure
Capillary refill
Sodium level
Magnesium level

Rationale :

🟣 Glucose of 57 mg/dL indicates hypoglycemia, requiring immediate attention

🟣 BP 90/48 mm Hg shows hypotension, which can compromise perfusion

🟣 Capillary refill >2 seconds suggests impaired circulation or hypovolemia

🟣 Magnesium of 1.1 mg/dL risks cardiac arrhythmias and neuromuscular dysfunction

🟣 Sodium of 158 mEq/L is severe hypernatremia, risking seizures or confusion

Distractor Analysis :

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Answer 8

Correct Answers:

Temporary memory loss is the most common adverse effect of ECT.

Rationale :

🟠 Short-term memory loss is the most frequently reported side effect of ECT

🟠 Most clients regain memory within weeks to months post-treatment

🟠 ECT is considered safe and effective for major depression, especially with suicidal ideation

🟠 Pre-procedure medications include muscle relaxants, not seizure suppressants

🟠 ECT is not indicated for substance use disorders, unless comorbid depression is present

Distractor Analysis :

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Answer 9

Correct Answers:

Liver function tests must be monitored.

Rationale :

🧪 Valproate is hepatotoxic, and regular liver enzyme monitoring is essential

🧪 Elevated ALT or AST levels may indicate liver injury and require dose adjustment or discontinuation

🧪 Clients must report signs of hepatotoxicity like jaundice, fatigue, or dark urine

🧪 Baseline and periodic monitoring reduce risk of unnoticed liver damage

🧪 Serum valproate levels also need checking to avoid toxicity

Distractor Analysis :

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Answer 10

Correct Answers:

Providing for adequate hydration and rest

Rationale :

💧 Hydration and rest are critical during alcohol detoxification to stabilize vital functions

💧 Physiological needs come first per Maslow’s hierarchy and aid in safe withdrawal

💧 Preventing dehydration, seizures, and delirium tremens is the top priority

💧 Education and psychotherapy follow only after medical stability is ensured

💧 Fluid balance helps flush toxins and supports hepatic and renal function

Distractor Analysis :

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NUR 2522 Mental Health~Summer 2025

No.

1 :
A nurse working in a mental health facility is admitting a client.

Correct Answers

2 :
A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client?

3 :
A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects?

4 :
A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?

5 :
A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?

6 :
A home-health nurse is assessing a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse knows that this behavior is an attempt to accomplish which of the following?

7 :
A nurse in the emergency department is caring for a 14-year-old who has anorexia nervosa.

Answer Options

8 :
A nurse is teaching a client who has depression about electroconvulsive therapy (ECT). Which of the following information should the nurse
include in the teaching?

9 :
A nurse is caring for a client who has bipolar disorder and a new prescription for valproate. Which of the following instructions should the nurse give the client about the use of this medication?

10 :
A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder. Which of the following interventions should the nurse identify as the priority?

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NUR 2522 Mental Health~Summer 2025

No.

1 : A nurse working in a mental health facility is admitting a client.

Correct Answers

2 : A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client?

3 : A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects?

4 : A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?

5 : A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?

6 : A home-health nurse is assessing a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse knows that this behavior is an attempt to accomplish which of the following?

7 : A nurse in the emergency department is caring for a 14-year-old who has anorexia nervosa.

Answer Options

8 : A nurse is teaching a client who has depression about electroconvulsive therapy (ECT). Which of the following information should the nurseinclude in the teaching?

9 : A nurse is caring for a client who has bipolar disorder and a new prescription for valproate. Which of the following instructions should the nurse give the client about the use of this medication?

10 : A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder. Which of the following interventions should the nurse identify as the priority?

1 :
A nurse working in a mental health facility is admitting a client.

2 :
A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client?

3 :
A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects?

4 :
A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?

5 :
A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?

6 :
A home-health nurse is assessing a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse knows that this behavior is an attempt to accomplish which of the following?

7 :
A nurse in the emergency department is caring for a 14-year-old who has anorexia nervosa.

8 :
A nurse is teaching a client who has depression about electroconvulsive therapy (ECT). Which of the following information should the nurse
include in the teaching?

9 :
A nurse is caring for a client who has bipolar disorder and a new prescription for valproate. Which of the following instructions should the nurse give the client about the use of this medication?

10 :
A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder. Which of the following interventions should the nurse identify as the priority?