NUR253 Final Exam V2 | NUR 253 Mental
Health Nursing Exam Q&A | Galen College
of Nursing
1. A nurse is caring for a client with schizophrenia who reports hearing voices. Which of the
following is the priority nursing intervention?
A. Ask the client what the voices are saying.
B. Inform the client that the voices are not real.
C. Administer a PRN dose of an antipsychotic.
D. Provide a quiet environment with minimal stimuli.
Answer: A
Rationale: The nurse’s priority is to assess the content of the hallucinations to determine
the risk of harm to the client or others. This assessment allows the nurse to identify
command hallucinations that might instruct the client to perform dangerous acts. Safety is
always the primary concern in the care of a psychiatric patient.
2. A client is prescribed lithium carbonate for bipolar disorder. Which laboratory value should
the nurse monitor most closely to prevent toxicity?
A. Serum potassium levels
B. Serum sodium levels
C. Fast blood glucose
,D. Liver function tests
Answer: B
Rationale: Lithium is a salt and is handled by the kidneys similarly to sodium. If sodium
levels are low, the kidneys will retain lithium, which can lead to toxic levels in the blood.
Educating the client on maintaining a consistent salt and fluid intake is a vital nursing
responsibility.
3. Which defense mechanism is a client using when they transfer emotions from a stressful
situation to a less threatening person?
A. Projection
B. Sublimation
C. Displacement
D. Rationalization
Answer: C
Rationale: Displacement involves redirecting emotions from the original source to a safer
target. This allows the individual to release tension without facing the direct consequences
of the primary conflict. Recognizing these mechanisms helps the nurse understand the
client’s coping strategies.
4. A nurse is reviewing the rights of a client who has been involuntarily committed. Which
right does this client typically retain?
A. The right to leave the facility against medical advice.
, B. The right to possess personal items that may be dangerous.
C. The right to have visitors at any time of the day.
D. The right to refuse psychotropic medications.
Answer: D
Rationale: Involuntarily committed clients still retain the right to refuse medication unless
they are an immediate danger to themselves or others. This right is protected under the
principle of autonomy and legal standards of care. Nurses must document the refusal and
follow facility policy for subsequent interventions.
5. A client with Obsessive-Compulsive Disorder (OCD) spends several hours daily washing
their hands. What is the primary purpose of this ritual?
A. To reduce anxiety caused by intrusive thoughts.
B. To gain attention from the nursing staff.
C. To improve skin hygiene and prevent infection.
D. To assert control over the hospital environment.
Answer: A
Rationale: In OCD, compulsions are repetitive behaviors performed to neutralize the
anxiety generated by obsessions. While the relief is only temporary, the client feels driven
to perform the ritual to manage their distress. The nurse should allow time for the ritual
initially while working on cognitive behavioral strategies.
Health Nursing Exam Q&A | Galen College
of Nursing
1. A nurse is caring for a client with schizophrenia who reports hearing voices. Which of the
following is the priority nursing intervention?
A. Ask the client what the voices are saying.
B. Inform the client that the voices are not real.
C. Administer a PRN dose of an antipsychotic.
D. Provide a quiet environment with minimal stimuli.
Answer: A
Rationale: The nurse’s priority is to assess the content of the hallucinations to determine
the risk of harm to the client or others. This assessment allows the nurse to identify
command hallucinations that might instruct the client to perform dangerous acts. Safety is
always the primary concern in the care of a psychiatric patient.
2. A client is prescribed lithium carbonate for bipolar disorder. Which laboratory value should
the nurse monitor most closely to prevent toxicity?
A. Serum potassium levels
B. Serum sodium levels
C. Fast blood glucose
,D. Liver function tests
Answer: B
Rationale: Lithium is a salt and is handled by the kidneys similarly to sodium. If sodium
levels are low, the kidneys will retain lithium, which can lead to toxic levels in the blood.
Educating the client on maintaining a consistent salt and fluid intake is a vital nursing
responsibility.
3. Which defense mechanism is a client using when they transfer emotions from a stressful
situation to a less threatening person?
A. Projection
B. Sublimation
C. Displacement
D. Rationalization
Answer: C
Rationale: Displacement involves redirecting emotions from the original source to a safer
target. This allows the individual to release tension without facing the direct consequences
of the primary conflict. Recognizing these mechanisms helps the nurse understand the
client’s coping strategies.
4. A nurse is reviewing the rights of a client who has been involuntarily committed. Which
right does this client typically retain?
A. The right to leave the facility against medical advice.
, B. The right to possess personal items that may be dangerous.
C. The right to have visitors at any time of the day.
D. The right to refuse psychotropic medications.
Answer: D
Rationale: Involuntarily committed clients still retain the right to refuse medication unless
they are an immediate danger to themselves or others. This right is protected under the
principle of autonomy and legal standards of care. Nurses must document the refusal and
follow facility policy for subsequent interventions.
5. A client with Obsessive-Compulsive Disorder (OCD) spends several hours daily washing
their hands. What is the primary purpose of this ritual?
A. To reduce anxiety caused by intrusive thoughts.
B. To gain attention from the nursing staff.
C. To improve skin hygiene and prevent infection.
D. To assert control over the hospital environment.
Answer: A
Rationale: In OCD, compulsions are repetitive behaviors performed to neutralize the
anxiety generated by obsessions. While the relief is only temporary, the client feels driven
to perform the ritual to manage their distress. The nurse should allow time for the ritual
initially while working on cognitive behavioral strategies.
