NUR253 Exam 2 V1 | Mental Health
Nursing Q&A with Rationale | Galen
College of Nursing
1. A nurse is caring for a client with major depressive disorder who has just started taking a
Selective Serotonin Reuptake Inhibitor (SSRI). Which statement by the nurse is most
appropriate regarding the medication’s onset?
A. You should feel significantly better within 24 to 48 hours.
B. It may take 2 to 4 weeks for you to feel the full therapeutic effect.
C. If you don’t feel better in 3 days, we will need to change the dose.
D. This medication works immediately to balance your brain chemicals.
Answer: B
Rationale: SSRIs do not produce an immediate shift in mood and require a steady build-up
in the system. Patients need to be educated that it typically takes several weeks to observe
significant clinical improvement. Monitoring for increased energy without mood
improvement is vital during this period due to potential suicide risk.
2. A client is admitted to the psychiatric unit in an acute manic phase of Bipolar I Disorder.
Which meal choice is most appropriate for this client?
A. Spaghetti with meatballs and a side salad.
B. A beef and vegetable stew with a roll.
,C. Steak, mashed potatoes, and corn on the cob.
D. A chicken wrap and an apple.
Answer: D
Rationale: Clients in a manic state are often too hyperactive to sit down for a formal meal.
High-calorie, high-protein finger foods allow the client to eat while moving around the unit.
This strategy helps maintain nutritional intake and prevents weight loss during periods of
extreme physical activity.
3. A nurse is monitoring a client taking Lithium Carbonate for Bipolar Disorder. Which
laboratory value should the nurse report to the provider immediately?
A. Lithium level of 0.8 mEq/L.
B. Sodium level of 140 mEq/L.
C. Creatinine level of 0.9 mg/dL.
D. Lithium level of 1.8 mEq/L.
Answer: D
Rationale: The therapeutic range for Lithium is narrow, generally between 0.6 and 1.2
mEq/L for maintenance. A level of 1.8 mEq/L indicates toxicity and requires immediate
medical intervention to prevent complications like seizures or coma. The nurse must also
monitor sodium levels as hyponatremia can lead to increased lithium retention.
, 4. A client with Schizophrenia tells the nurse, ‘The FBI is monitoring my thoughts through the
television.’ Which response by the nurse is therapeutic?
A. The FBI does not have the technology to monitor thoughts through the TV.
B. Why would the FBI want to monitor your thoughts specifically?
C. I understand that you believe this is happening, but I don’t see any evidence of it.
D. Let’s turn off the television so they can stop watching you.
Answer: C
Rationale: This response acknowledges the client’s feelings while presenting reality
without being argumentative. Arguing with a delusion is counterproductive and can
damage the therapeutic relationship. The goal is to provide a safe environment where the
client feels heard but is gently guided toward reality.
5. Which of the following is considered a ‘positive symptom’ of Schizophrenia?
A. Auditory hallucinations.
B. Anhedonia (inability to feel pleasure).
C. Alogia (poverty of speech).
D. Flat affect.
Answer: A
Rationale: Positive symptoms refer to an excess or distortion of normal functions, such as
hallucinations or delusions. Negative symptoms represent a loss or deficit in normal
Nursing Q&A with Rationale | Galen
College of Nursing
1. A nurse is caring for a client with major depressive disorder who has just started taking a
Selective Serotonin Reuptake Inhibitor (SSRI). Which statement by the nurse is most
appropriate regarding the medication’s onset?
A. You should feel significantly better within 24 to 48 hours.
B. It may take 2 to 4 weeks for you to feel the full therapeutic effect.
C. If you don’t feel better in 3 days, we will need to change the dose.
D. This medication works immediately to balance your brain chemicals.
Answer: B
Rationale: SSRIs do not produce an immediate shift in mood and require a steady build-up
in the system. Patients need to be educated that it typically takes several weeks to observe
significant clinical improvement. Monitoring for increased energy without mood
improvement is vital during this period due to potential suicide risk.
2. A client is admitted to the psychiatric unit in an acute manic phase of Bipolar I Disorder.
Which meal choice is most appropriate for this client?
A. Spaghetti with meatballs and a side salad.
B. A beef and vegetable stew with a roll.
,C. Steak, mashed potatoes, and corn on the cob.
D. A chicken wrap and an apple.
Answer: D
Rationale: Clients in a manic state are often too hyperactive to sit down for a formal meal.
High-calorie, high-protein finger foods allow the client to eat while moving around the unit.
This strategy helps maintain nutritional intake and prevents weight loss during periods of
extreme physical activity.
3. A nurse is monitoring a client taking Lithium Carbonate for Bipolar Disorder. Which
laboratory value should the nurse report to the provider immediately?
A. Lithium level of 0.8 mEq/L.
B. Sodium level of 140 mEq/L.
C. Creatinine level of 0.9 mg/dL.
D. Lithium level of 1.8 mEq/L.
Answer: D
Rationale: The therapeutic range for Lithium is narrow, generally between 0.6 and 1.2
mEq/L for maintenance. A level of 1.8 mEq/L indicates toxicity and requires immediate
medical intervention to prevent complications like seizures or coma. The nurse must also
monitor sodium levels as hyponatremia can lead to increased lithium retention.
, 4. A client with Schizophrenia tells the nurse, ‘The FBI is monitoring my thoughts through the
television.’ Which response by the nurse is therapeutic?
A. The FBI does not have the technology to monitor thoughts through the TV.
B. Why would the FBI want to monitor your thoughts specifically?
C. I understand that you believe this is happening, but I don’t see any evidence of it.
D. Let’s turn off the television so they can stop watching you.
Answer: C
Rationale: This response acknowledges the client’s feelings while presenting reality
without being argumentative. Arguing with a delusion is counterproductive and can
damage the therapeutic relationship. The goal is to provide a safe environment where the
client feels heard but is gently guided toward reality.
5. Which of the following is considered a ‘positive symptom’ of Schizophrenia?
A. Auditory hallucinations.
B. Anhedonia (inability to feel pleasure).
C. Alogia (poverty of speech).
D. Flat affect.
Answer: A
Rationale: Positive symptoms refer to an excess or distortion of normal functions, such as
hallucinations or delusions. Negative symptoms represent a loss or deficit in normal
