NUR253 Final Exam V2 | Mental Health
Nursing Q&A with Rationale | Galen
College of Nursing
1. A nurse is caring for a client who is experiencing auditory hallucinations. Which of the
following responses by the nurse is therapeutic?
A. “The voices are just a symptom of your illness and aren’t real.”
B. “I don’t hear the voices, but I can see that you are frightened.”
C. “What are the voices telling you to do right now?”
D. “Try to ignore the voices and focus on the music playing here.”
Answer: B
Rationale: This response acknowledges the client’s feelings and provides reality
orientation without arguing with the hallucination. It validates the emotional experience
while maintaining a professional boundary regarding the sensory perception. The nurse
should avoid dismissing the client’s reality directly to maintain rapport.
2. A client is prescribed lithium carbonate for bipolar disorder. Which of the following lab
values should the nurse prioritize?
A. Sodium 130 mEq/L
B. Potassium 4.0 mEq/L
C. BUN 15 mg/dL
,D. Lithium level 0.8 mEq/L
Answer: A
Rationale: Lithium is a salt, and low sodium levels can lead to lithium retention and
toxicity. A sodium level of 130 mEq/L is below the normal range and increases the risk for
the client. The nurse must monitor electrolyte balance closely to ensure safe medication
administration.
3. A nurse is assessing a client for clozapine-induced adverse effects. Which laboratory result
is most critical to monitor?
A. Platelet count
B. Liver enzymes
C. Hemoglobin level
D. White blood cell (WBC) count
Answer: D
Rationale: Clozapine carries a high risk of agranulocytosis, which is a dangerous decrease
in white blood cells. Clients must have weekly WBC monitoring during the initial months of
treatment to prevent life-threatening infections. This monitoring is mandated by strict
protocols to ensure patient safety.
4. A client taking phenelzine (an MAOI) should avoid which of the following foods?
A. Fresh chicken breast
, B. Steamed broccoli
C. Whole wheat bread
D. Aged cheddar cheese
Answer: D
Rationale: MAOIs interact with tyramine-rich foods like aged cheeses, cured meats, and
red wine to cause a hypertensive crisis. This interaction occurs because the medication
prevents the breakdown of tyramine in the body. Education on a low-tyramine diet is
essential for any client starting this medication class.
5. Which assessment finding should the nurse report immediately for a client starting
fluoxetine?
A. Dry mouth
B. Mild nausea
C. Increased energy with agitation
D. Occasional headaches
Answer: C
Rationale: Increased energy combined with agitation or suicidal ideation can occur shortly
after starting SSRIs. This is a critical safety concern as the client may now have the energy
to act on suicidal thoughts. The nurse must monitor for these behavioral changes closely
during the first few weeks of therapy.
Nursing Q&A with Rationale | Galen
College of Nursing
1. A nurse is caring for a client who is experiencing auditory hallucinations. Which of the
following responses by the nurse is therapeutic?
A. “The voices are just a symptom of your illness and aren’t real.”
B. “I don’t hear the voices, but I can see that you are frightened.”
C. “What are the voices telling you to do right now?”
D. “Try to ignore the voices and focus on the music playing here.”
Answer: B
Rationale: This response acknowledges the client’s feelings and provides reality
orientation without arguing with the hallucination. It validates the emotional experience
while maintaining a professional boundary regarding the sensory perception. The nurse
should avoid dismissing the client’s reality directly to maintain rapport.
2. A client is prescribed lithium carbonate for bipolar disorder. Which of the following lab
values should the nurse prioritize?
A. Sodium 130 mEq/L
B. Potassium 4.0 mEq/L
C. BUN 15 mg/dL
,D. Lithium level 0.8 mEq/L
Answer: A
Rationale: Lithium is a salt, and low sodium levels can lead to lithium retention and
toxicity. A sodium level of 130 mEq/L is below the normal range and increases the risk for
the client. The nurse must monitor electrolyte balance closely to ensure safe medication
administration.
3. A nurse is assessing a client for clozapine-induced adverse effects. Which laboratory result
is most critical to monitor?
A. Platelet count
B. Liver enzymes
C. Hemoglobin level
D. White blood cell (WBC) count
Answer: D
Rationale: Clozapine carries a high risk of agranulocytosis, which is a dangerous decrease
in white blood cells. Clients must have weekly WBC monitoring during the initial months of
treatment to prevent life-threatening infections. This monitoring is mandated by strict
protocols to ensure patient safety.
4. A client taking phenelzine (an MAOI) should avoid which of the following foods?
A. Fresh chicken breast
, B. Steamed broccoli
C. Whole wheat bread
D. Aged cheddar cheese
Answer: D
Rationale: MAOIs interact with tyramine-rich foods like aged cheeses, cured meats, and
red wine to cause a hypertensive crisis. This interaction occurs because the medication
prevents the breakdown of tyramine in the body. Education on a low-tyramine diet is
essential for any client starting this medication class.
5. Which assessment finding should the nurse report immediately for a client starting
fluoxetine?
A. Dry mouth
B. Mild nausea
C. Increased energy with agitation
D. Occasional headaches
Answer: C
Rationale: Increased energy combined with agitation or suicidal ideation can occur shortly
after starting SSRIs. This is a critical safety concern as the client may now have the energy
to act on suicidal thoughts. The nurse must monitor for these behavioral changes closely
during the first few weeks of therapy.
