NUR 253 Exam 3 V2 | Mental
Health Nursing Q&A with Rationale
| Galen College of Nursing
1. A nurse is caring for a client with schizophrenia who reports hearing voices telling them
that the food is poisoned. Which response by the nurse is most therapeutic?
A. Whose voice do you hear and what exactly are they saying about the food?
B. You know that the hospital food is safe and no one is trying to hurt you.
C. I don’t hear any voices, but I can see that you are feeling very anxious right now.
D. If the voices were real, wouldn’t the other patients be worried about the food too?
Correct Answer: C
Expert Explanation: This response acknowledges the client’s feelings while presenting
reality without arguing with the hallucination. By focusing on the client’s anxiety, the nurse
validates the emotional experience without validating the false perception. Arguing or
using logic (options B and D) is usually ineffective for patients experiencing psychosis.
2. A client is prescribed Lithium Carbonate for the treatment of Bipolar I Disorder. Which
laboratory value should the nurse monitor most closely to prevent toxicity?
A. Serum Sodium
B. Serum Potassium
,C. Serum Calcium
D. Serum Magnesium
Correct Answer: A
Expert Explanation: Lithium is a salt, and its excretion is closely linked to sodium levels in
the body. If sodium levels are low, the kidneys retain lithium, which can quickly lead to
toxic levels. Patients must maintain a consistent intake of salt and fluids to ensure safe
lithium levels.
3. Which clinical manifestation is considered a ‘negative’ symptom of schizophrenia?
A. Auditory hallucinations
B. Avolition (lack of motivation)
C. Delusions of grandeur
D. Disorganized speech
Correct Answer: B
Expert Explanation: Negative symptoms represent a loss or deficit of normal functions,
such as avolition, flat affect, or alogia. Positive symptoms, like hallucinations and delusions,
are additions to normal experiences. Recognizing the difference helps nurses tailor
interventions to either manage agitation or encourage social engagement.
, 4. A client with Borderline Personality Disorder (BPD) is praised by one nurse but later tells
another nurse that the first nurse is ‘the worst person alive.’ This behavior is known as:
A. Projection
B. Splitting
C. Reaction Formation
D. Sublimation
Correct Answer: B
Expert Explanation: Splitting is a primitive defense mechanism common in BPD where
individuals view others as either all good or all bad. This behavior often leads to conflict
within the healthcare team as the patient plays staff against one another. Consistent team
communication and boundaries are essential to manage this specific behavior.
5. A patient is admitted to the emergency department with a suspected opioid overdose.
Which medication should the nurse anticipate administering immediately?
A. Naloxone
B. Flumazenil
C. Methadone
D. Disulfiram
Correct Answer: A
Health Nursing Q&A with Rationale
| Galen College of Nursing
1. A nurse is caring for a client with schizophrenia who reports hearing voices telling them
that the food is poisoned. Which response by the nurse is most therapeutic?
A. Whose voice do you hear and what exactly are they saying about the food?
B. You know that the hospital food is safe and no one is trying to hurt you.
C. I don’t hear any voices, but I can see that you are feeling very anxious right now.
D. If the voices were real, wouldn’t the other patients be worried about the food too?
Correct Answer: C
Expert Explanation: This response acknowledges the client’s feelings while presenting
reality without arguing with the hallucination. By focusing on the client’s anxiety, the nurse
validates the emotional experience without validating the false perception. Arguing or
using logic (options B and D) is usually ineffective for patients experiencing psychosis.
2. A client is prescribed Lithium Carbonate for the treatment of Bipolar I Disorder. Which
laboratory value should the nurse monitor most closely to prevent toxicity?
A. Serum Sodium
B. Serum Potassium
,C. Serum Calcium
D. Serum Magnesium
Correct Answer: A
Expert Explanation: Lithium is a salt, and its excretion is closely linked to sodium levels in
the body. If sodium levels are low, the kidneys retain lithium, which can quickly lead to
toxic levels. Patients must maintain a consistent intake of salt and fluids to ensure safe
lithium levels.
3. Which clinical manifestation is considered a ‘negative’ symptom of schizophrenia?
A. Auditory hallucinations
B. Avolition (lack of motivation)
C. Delusions of grandeur
D. Disorganized speech
Correct Answer: B
Expert Explanation: Negative symptoms represent a loss or deficit of normal functions,
such as avolition, flat affect, or alogia. Positive symptoms, like hallucinations and delusions,
are additions to normal experiences. Recognizing the difference helps nurses tailor
interventions to either manage agitation or encourage social engagement.
, 4. A client with Borderline Personality Disorder (BPD) is praised by one nurse but later tells
another nurse that the first nurse is ‘the worst person alive.’ This behavior is known as:
A. Projection
B. Splitting
C. Reaction Formation
D. Sublimation
Correct Answer: B
Expert Explanation: Splitting is a primitive defense mechanism common in BPD where
individuals view others as either all good or all bad. This behavior often leads to conflict
within the healthcare team as the patient plays staff against one another. Consistent team
communication and boundaries are essential to manage this specific behavior.
5. A patient is admitted to the emergency department with a suspected opioid overdose.
Which medication should the nurse anticipate administering immediately?
A. Naloxone
B. Flumazenil
C. Methadone
D. Disulfiram
Correct Answer: A
