NUR253 Final Exam V1 | 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
actions should the nurse take first?
A. Ask the client to explain what triggered the attack
B. Administer a PRN dose of lorazepam
C. Stay with the client and remain calm
D. Teach the client deep breathing techniques
Answer: C
Rationale: The nurse’s priority during a panic attack is to ensure the client’s safety and
reduce anxiety by staying with them. A calm, non-threatening presence helps the client feel
more secure in a frightening situation. Other interventions like teaching or questioning are
more effective once the acute panic has subsided.
2. A client is admitted to the psychiatric unit with a diagnosis of bipolar disorder and is in a
manic phase. Which of the following snack options is most appropriate?
A. A bowl of vegetable soup
B. A fruit salad with a fork
C. A cup of hot coffee
,D. A chicken wrap or finger foods
Answer: D
Rationale: Clients in a manic phase often have high energy levels and cannot sit still long
enough to eat a full meal. Providing high-calorie finger foods allows the client to eat while
on the move, meeting their nutritional needs. Soup and salads require the use of utensils
and sitting down, which may be difficult for the manic client.
3. A nurse is assessing a client taking lithium carbonate for bipolar disorder. The client reports
blurred vision, vomiting, and diarrhea. What should the nurse suspect?
A. Expected side effects of the medication
B. An allergic reaction to lithium
C. Symptoms of a new manic episode
D. Lithium toxicity
Answer: D
Rationale: Gastrointestinal distress, blurred vision, and ataxia are classic early signs of
lithium toxicity. The nurse must hold the medication and notify the provider to obtain a
serum lithium level immediately. Therapeutic levels are narrow, and toxicity can lead to
seizures or even death if untreated.
4. A client with schizophrenia is hearing voices that say, ‘You are a bad person.’ Which of the
following responses by the nurse is therapeutic?
A. ‘Don’t listen to them; they are just part of your illness.’
, B. ‘Why do you think the voices are saying that?’
C. ‘I do not hear the voices, but I understand they are real to you.’
D. ‘I can hear them too, and they are wrong about you.’
Answer: C
Rationale: This response acknowledges the client’s experience without validating the
hallucination as reality. It provides a reality check while maintaining a supportive and non-
judgmental stance. Agreeing with the hallucination or arguing about it can increase the
client’s confusion or defensiveness.
5. A nurse is caring for a client who has borderline personality disorder. The client says, ‘You
are the only nurse who really cares about me; the others are mean.’ This is an example of
which defense mechanism?
A. Reaction formation
B. Displacement
C. Splitting
D. Projection
Answer: C
Rationale: Splitting is a common defense mechanism in borderline personality disorder
where individuals perceive others as all good or all bad. This behavior often creates conflict
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
actions should the nurse take first?
A. Ask the client to explain what triggered the attack
B. Administer a PRN dose of lorazepam
C. Stay with the client and remain calm
D. Teach the client deep breathing techniques
Answer: C
Rationale: The nurse’s priority during a panic attack is to ensure the client’s safety and
reduce anxiety by staying with them. A calm, non-threatening presence helps the client feel
more secure in a frightening situation. Other interventions like teaching or questioning are
more effective once the acute panic has subsided.
2. A client is admitted to the psychiatric unit with a diagnosis of bipolar disorder and is in a
manic phase. Which of the following snack options is most appropriate?
A. A bowl of vegetable soup
B. A fruit salad with a fork
C. A cup of hot coffee
,D. A chicken wrap or finger foods
Answer: D
Rationale: Clients in a manic phase often have high energy levels and cannot sit still long
enough to eat a full meal. Providing high-calorie finger foods allows the client to eat while
on the move, meeting their nutritional needs. Soup and salads require the use of utensils
and sitting down, which may be difficult for the manic client.
3. A nurse is assessing a client taking lithium carbonate for bipolar disorder. The client reports
blurred vision, vomiting, and diarrhea. What should the nurse suspect?
A. Expected side effects of the medication
B. An allergic reaction to lithium
C. Symptoms of a new manic episode
D. Lithium toxicity
Answer: D
Rationale: Gastrointestinal distress, blurred vision, and ataxia are classic early signs of
lithium toxicity. The nurse must hold the medication and notify the provider to obtain a
serum lithium level immediately. Therapeutic levels are narrow, and toxicity can lead to
seizures or even death if untreated.
4. A client with schizophrenia is hearing voices that say, ‘You are a bad person.’ Which of the
following responses by the nurse is therapeutic?
A. ‘Don’t listen to them; they are just part of your illness.’
, B. ‘Why do you think the voices are saying that?’
C. ‘I do not hear the voices, but I understand they are real to you.’
D. ‘I can hear them too, and they are wrong about you.’
Answer: C
Rationale: This response acknowledges the client’s experience without validating the
hallucination as reality. It provides a reality check while maintaining a supportive and non-
judgmental stance. Agreeing with the hallucination or arguing about it can increase the
client’s confusion or defensiveness.
5. A nurse is caring for a client who has borderline personality disorder. The client says, ‘You
are the only nurse who really cares about me; the others are mean.’ This is an example of
which defense mechanism?
A. Reaction formation
B. Displacement
C. Splitting
D. Projection
Answer: C
Rationale: Splitting is a common defense mechanism in borderline personality disorder
where individuals perceive others as all good or all bad. This behavior often creates conflict
