NUR253 Final Exam V3 | Mental Health
Nursing Q&A with Rationale | Galen
College of Nursing
1. A nurse is caring for a client who is experiencing a manic episode. What is the priority
nursing intervention?
A. Encourage the client to join a group therapy session.
B. Administer a sedative as the first line of treatment.
C. Ask the client to explain their current feelings.
D. Provide the client with high-calorie finger foods.
Answer: D
Rationale: Clients in a manic state often have high energy levels and cannot sit down to eat
full meals. Providing high-calorie finger foods allows them to maintain nutrition while on
the move. This intervention addresses physiological needs which are a priority in the acute
phase of mania.
2. Which of the following findings should a nurse expect in a client experiencing Lithium
toxicity?
A. Increased appetite and weight gain.
B. Constipation and urinary retention.
C. Hyperactivity and talkativeness.
,D. Coarse hand tremors and confusion.
Answer: D
Rationale: Coarse hand tremors, confusion, and ataxia are classic signs of lithium toxicity.
The nurse must monitor lithium levels closely because the therapeutic index is very
narrow. Immediate medical intervention is required if these symptoms occur to prevent
permanent damage or death.
3. A nurse is conducting a suicide risk assessment. Which statement by the client indicates the
highest risk?
A. I have a gun in my garage and I am going to use it tonight.
B. I think my family would be better off without me.
C. I have been feeling very sad for the last few weeks.
D. I don’t really see a future for myself anymore.
Answer: A
Rationale: This statement indicates a specific plan, a lethal method, and a definitive
timeframe, which represents the highest level of lethality. Assessing the lethality of a plan
is a critical component of suicide risk management. The nurse must take immediate action
to ensure the client’s safety in a controlled environment.
4. What is the primary goal of the orientation phase of the nurse-client relationship?
A. Promote the client’s problem-solving skills.
, B. Encourage the client to practice new behaviors.
C. Evaluate the progress toward the client’s goals.
D. Establish trust and define the boundaries of the relationship.
Answer: D
Rationale: The orientation phase is the first stage where the nurse and client get to know
each other. Establishing trust is essential for the success of the subsequent phases of the
therapeutic relationship. During this time, the nurse also sets the contract, including
meeting times and confidentiality rules.
5. A client with schizophrenia reports hearing voices telling them that the food is poisoned.
How should the nurse respond?
A. I don’t hear the voices, but I can see that you are frightened.
B. The food is fine; I saw the chef prepare it myself.
C. You should listen to the voices because they are trying to help you.
D. Why do you think the voices are saying the food is poisoned?
Answer: A
Rationale: This response validates the client’s feelings without agreeing with the
hallucination. Presenting reality in a non-confrontational way helps maintain the
therapeutic relationship. It is important to acknowledge the emotional impact of the
hallucination on the client.
Nursing Q&A with Rationale | Galen
College of Nursing
1. A nurse is caring for a client who is experiencing a manic episode. What is the priority
nursing intervention?
A. Encourage the client to join a group therapy session.
B. Administer a sedative as the first line of treatment.
C. Ask the client to explain their current feelings.
D. Provide the client with high-calorie finger foods.
Answer: D
Rationale: Clients in a manic state often have high energy levels and cannot sit down to eat
full meals. Providing high-calorie finger foods allows them to maintain nutrition while on
the move. This intervention addresses physiological needs which are a priority in the acute
phase of mania.
2. Which of the following findings should a nurse expect in a client experiencing Lithium
toxicity?
A. Increased appetite and weight gain.
B. Constipation and urinary retention.
C. Hyperactivity and talkativeness.
,D. Coarse hand tremors and confusion.
Answer: D
Rationale: Coarse hand tremors, confusion, and ataxia are classic signs of lithium toxicity.
The nurse must monitor lithium levels closely because the therapeutic index is very
narrow. Immediate medical intervention is required if these symptoms occur to prevent
permanent damage or death.
3. A nurse is conducting a suicide risk assessment. Which statement by the client indicates the
highest risk?
A. I have a gun in my garage and I am going to use it tonight.
B. I think my family would be better off without me.
C. I have been feeling very sad for the last few weeks.
D. I don’t really see a future for myself anymore.
Answer: A
Rationale: This statement indicates a specific plan, a lethal method, and a definitive
timeframe, which represents the highest level of lethality. Assessing the lethality of a plan
is a critical component of suicide risk management. The nurse must take immediate action
to ensure the client’s safety in a controlled environment.
4. What is the primary goal of the orientation phase of the nurse-client relationship?
A. Promote the client’s problem-solving skills.
, B. Encourage the client to practice new behaviors.
C. Evaluate the progress toward the client’s goals.
D. Establish trust and define the boundaries of the relationship.
Answer: D
Rationale: The orientation phase is the first stage where the nurse and client get to know
each other. Establishing trust is essential for the success of the subsequent phases of the
therapeutic relationship. During this time, the nurse also sets the contract, including
meeting times and confidentiality rules.
5. A client with schizophrenia reports hearing voices telling them that the food is poisoned.
How should the nurse respond?
A. I don’t hear the voices, but I can see that you are frightened.
B. The food is fine; I saw the chef prepare it myself.
C. You should listen to the voices because they are trying to help you.
D. Why do you think the voices are saying the food is poisoned?
Answer: A
Rationale: This response validates the client’s feelings without agreeing with the
hallucination. Presenting reality in a non-confrontational way helps maintain the
therapeutic relationship. It is important to acknowledge the emotional impact of the
hallucination on the client.
