NUR 253 Exam 2 V2 | Mental
Health Nursing Q&A with Rationale
| Galen College of Nursing
1. A nurse is caring for a client who is experiencing a panic attack. Which of the following is
the priority nursing action?
A. Stay with the client and maintain a calm demeanor.
B. Teach the client deep breathing techniques.
C. Administer a prescribed PRN dose of lorazepam.
D. Ask the client to explain what triggered the attack.
Correct Answer: A
Expert Explanation: The immediate priority during a panic attack is to ensure the client’s
safety and provide a sense of security. Staying with the client helps reduce their fear and
prevents further escalation of anxiety. A calm demeanor by the nurse assists the client in
grounding themselves and feeling supported during the acute episode.
2. A nurse is reviewing the laboratory results for a client taking lithium carbonate for bipolar
disorder. The lithium level is 1.8 mEq/L. Which action should the nurse take first?
A. Withhold the medication and notify the healthcare provider.
B. Administer the next scheduled dose of lithium.
,C. Document the result as being within the therapeutic range.
D. Increase the client’s daily fluid intake to 3 liters.
Correct Answer: A
Expert Explanation: The therapeutic range for lithium is generally 0.6 to 1.2 mEq/L,
making 1.8 mEq/L a toxic level. Toxic levels of lithium can lead to severe neurological and
cardiac complications if left untreated. The nurse must hold the dose to prevent further
toxicity and seek immediate medical intervention for the client.
3. A nurse is planning care for a client in the manic phase of bipolar disorder. Which
intervention is most appropriate for meeting the client’s nutritional needs?
A. Encourage the client to sit in the dining hall for all meals.
B. Offer high-calorie finger foods that can be eaten while walking.
C. Provide a high-fiber diet to prevent constipation.
D. Limit fluid intake to prevent electrolyte imbalances.
Correct Answer: B
Expert Explanation: Clients in a manic state often have high energy levels and a difficult
time sitting still long enough to eat a full meal. Finger foods allow the client to consume
necessary calories while remaining active and moving around the unit. This strategy helps
maintain nutritional status and prevents physical exhaustion due to hyperactivity.
,4. A client with Obsessive-Compulsive Disorder (OCD) spends several hours a day
handwashing. Initially, how should the nurse handle this behavior?
A. Forbid the client from using the bathroom more than twice a day.
B. Explain to the client that their hands are already clean.
C. Distract the client with group activities during washing times.
D. Allow the client enough time to perform the ritual to avoid high anxiety.
Correct Answer: D
Expert Explanation: At the beginning of treatment, stopping a ritualistic behavior
abruptly can cause the client’s anxiety to reach panic levels. The nurse should allow time
for the ritual while gradually working on a plan to reduce the frequency and duration. Over
time, the nurse helps the client develop healthier coping mechanisms to manage the
underlying anxiety.
5. A nurse is assessing a client with schizophrenia who is experiencing auditory hallucinations.
Which question is most important for the nurse to ask?
A. ‘How long have you been hearing these voices?’
B. ‘What are the voices telling you to do?’
C. ‘Do the voices sound like people you know?’
D. ‘Why do you think the voices are talking to you?’
Correct Answer: B
, Expert Explanation: It is critical to determine if the hallucinations are ‘command
hallucinations’ that might instruct the client to harm themselves or others. Safety is the
primary concern in psychiatric nursing, and identifying the content of the hallucination
helps assess risk. Knowing the instructions provided by the voices allows the nurse to
implement appropriate safety precautions.
6. A client is prescribed haloperidol for the treatment of schizophrenia. The nurse notes the
client is experiencing a sudden, painful muscle contraction of the neck. What is the nurse’s
priority action?
A. Apply a warm compress to the client’s neck muscles.
B. Perform a complete range-of-motion assessment on the neck.
C. Advise the client that this is a normal side effect of the drug.
D. Notify the provider and prepare to administer diphenhydramine.
Correct Answer: D
Expert Explanation: The client is likely experiencing an acute dystonic reaction, which is
an extrapyramidal side effect (EPS) of typical antipsychotics. This condition requires
immediate treatment with an anticholinergic medication like diphenhydramine or
benztropine to reverse the muscle spasms. Failure to treat quickly can lead to airway
compromise if the laryngeal muscles become involved.
Health Nursing Q&A with Rationale
| Galen College of Nursing
1. A nurse is caring for a client who is experiencing a panic attack. Which of the following is
the priority nursing action?
A. Stay with the client and maintain a calm demeanor.
B. Teach the client deep breathing techniques.
C. Administer a prescribed PRN dose of lorazepam.
D. Ask the client to explain what triggered the attack.
Correct Answer: A
Expert Explanation: The immediate priority during a panic attack is to ensure the client’s
safety and provide a sense of security. Staying with the client helps reduce their fear and
prevents further escalation of anxiety. A calm demeanor by the nurse assists the client in
grounding themselves and feeling supported during the acute episode.
2. A nurse is reviewing the laboratory results for a client taking lithium carbonate for bipolar
disorder. The lithium level is 1.8 mEq/L. Which action should the nurse take first?
A. Withhold the medication and notify the healthcare provider.
B. Administer the next scheduled dose of lithium.
,C. Document the result as being within the therapeutic range.
D. Increase the client’s daily fluid intake to 3 liters.
Correct Answer: A
Expert Explanation: The therapeutic range for lithium is generally 0.6 to 1.2 mEq/L,
making 1.8 mEq/L a toxic level. Toxic levels of lithium can lead to severe neurological and
cardiac complications if left untreated. The nurse must hold the dose to prevent further
toxicity and seek immediate medical intervention for the client.
3. A nurse is planning care for a client in the manic phase of bipolar disorder. Which
intervention is most appropriate for meeting the client’s nutritional needs?
A. Encourage the client to sit in the dining hall for all meals.
B. Offer high-calorie finger foods that can be eaten while walking.
C. Provide a high-fiber diet to prevent constipation.
D. Limit fluid intake to prevent electrolyte imbalances.
Correct Answer: B
Expert Explanation: Clients in a manic state often have high energy levels and a difficult
time sitting still long enough to eat a full meal. Finger foods allow the client to consume
necessary calories while remaining active and moving around the unit. This strategy helps
maintain nutritional status and prevents physical exhaustion due to hyperactivity.
,4. A client with Obsessive-Compulsive Disorder (OCD) spends several hours a day
handwashing. Initially, how should the nurse handle this behavior?
A. Forbid the client from using the bathroom more than twice a day.
B. Explain to the client that their hands are already clean.
C. Distract the client with group activities during washing times.
D. Allow the client enough time to perform the ritual to avoid high anxiety.
Correct Answer: D
Expert Explanation: At the beginning of treatment, stopping a ritualistic behavior
abruptly can cause the client’s anxiety to reach panic levels. The nurse should allow time
for the ritual while gradually working on a plan to reduce the frequency and duration. Over
time, the nurse helps the client develop healthier coping mechanisms to manage the
underlying anxiety.
5. A nurse is assessing a client with schizophrenia who is experiencing auditory hallucinations.
Which question is most important for the nurse to ask?
A. ‘How long have you been hearing these voices?’
B. ‘What are the voices telling you to do?’
C. ‘Do the voices sound like people you know?’
D. ‘Why do you think the voices are talking to you?’
Correct Answer: B
, Expert Explanation: It is critical to determine if the hallucinations are ‘command
hallucinations’ that might instruct the client to harm themselves or others. Safety is the
primary concern in psychiatric nursing, and identifying the content of the hallucination
helps assess risk. Knowing the instructions provided by the voices allows the nurse to
implement appropriate safety precautions.
6. A client is prescribed haloperidol for the treatment of schizophrenia. The nurse notes the
client is experiencing a sudden, painful muscle contraction of the neck. What is the nurse’s
priority action?
A. Apply a warm compress to the client’s neck muscles.
B. Perform a complete range-of-motion assessment on the neck.
C. Advise the client that this is a normal side effect of the drug.
D. Notify the provider and prepare to administer diphenhydramine.
Correct Answer: D
Expert Explanation: The client is likely experiencing an acute dystonic reaction, which is
an extrapyramidal side effect (EPS) of typical antipsychotics. This condition requires
immediate treatment with an anticholinergic medication like diphenhydramine or
benztropine to reverse the muscle spasms. Failure to treat quickly can lead to airway
compromise if the laryngeal muscles become involved.
