NUR 256 Exam 2 V1 | NUR 256 Concepts
of Mental Health Nursing | Q&A with
Rationale (NUR256 Exam 2) | Galen
College of Nursing
1. A nurse is caring for a client with Generalized Anxiety Disorder (GAD). Which of the
following medications is most appropriate for long-term management of this condition?
A. Alprazolam
B. Diazepam
C. Lorazepam
D. Buspirone
Answer: D
Rationale: Buspirone is a non-benzodiazepine anxiolytic that is ideal for long-term
treatment because it does not carry a risk for physical dependence. Unlike benzodiazepines
like Alprazolam or Lorazepam, it does not cause immediate sedation. The client should be
informed that it may take 2 to 4 weeks for the full therapeutic effect to be felt.
2. Which clinical manifestation should the nurse prioritize when assessing a client suspected
of having Lithium toxicity with a blood level of 2.2 mEq/L?
A. Mild hand tremors
B. Polyuria
,C. Gastrointestinal upset
D. Course tremors and seizure activity
Answer: D
Rationale: A lithium level of 2.2 mEq/L indicates severe toxicity, which can lead to
neurological emergencies such as seizures or coma. While mild tremors are common at
therapeutic levels, coarse tremors are a red flag for toxicity. The nurse must prioritize
safety and prepare for interventions such as hemodialysis as ordered.
3. A client is admitted for Anorexia Nervosa with a BMI of 15. What is the priority nursing
intervention during the first week of treatment?
A. Encouraging the client to exercise to reduce anxiety
B. Providing high-calorie snacks between meals immediately
C. Monitoring for electrolyte imbalances and cardiac arrhythmias
D. Discussing the client’s distorted body image
Answer: C
Rationale: The primary risk during the initial refeeding phase of Anorexia Nervosa is
Refeeding Syndrome, which can cause fatal cardiac issues. Monitoring electrolytes like
potassium, phosphate, and magnesium is vital for physical stabilization. Psychological
interventions like discussing body image are secondary to physiological safety in the acute
phase.
, 4. The nurse is educating a client who is starting Phenelzine for depression. Which food item
must the client be instructed to avoid?
A. Fresh chicken
B. Whole wheat bread
C. Canned green beans
D. Aged cheddar cheese
Answer: D
Rationale: Phenelzine is a Monoamine Oxidase Inhibitor (MAOI) that requires a low-
tyramine diet to prevent hypertensive crisis. Aged cheeses, cured meats, and fermented
products are high in tyramine and must be strictly avoided. The nurse should emphasize
that this diet must be maintained for two weeks even after stopping the medication.
5. A client with Borderline Personality Disorder (BPD) tells the day-shift nurse that the night-
shift nurse was ‘horrible’ and ‘mean,’ while the day-shift nurse is ‘an angel.’ This is an
example of which defense mechanism?
A. Splitting
B. Projection
C. Reaction Formation
D. Intellectualization
Answer: A
of Mental Health Nursing | Q&A with
Rationale (NUR256 Exam 2) | Galen
College of Nursing
1. A nurse is caring for a client with Generalized Anxiety Disorder (GAD). Which of the
following medications is most appropriate for long-term management of this condition?
A. Alprazolam
B. Diazepam
C. Lorazepam
D. Buspirone
Answer: D
Rationale: Buspirone is a non-benzodiazepine anxiolytic that is ideal for long-term
treatment because it does not carry a risk for physical dependence. Unlike benzodiazepines
like Alprazolam or Lorazepam, it does not cause immediate sedation. The client should be
informed that it may take 2 to 4 weeks for the full therapeutic effect to be felt.
2. Which clinical manifestation should the nurse prioritize when assessing a client suspected
of having Lithium toxicity with a blood level of 2.2 mEq/L?
A. Mild hand tremors
B. Polyuria
,C. Gastrointestinal upset
D. Course tremors and seizure activity
Answer: D
Rationale: A lithium level of 2.2 mEq/L indicates severe toxicity, which can lead to
neurological emergencies such as seizures or coma. While mild tremors are common at
therapeutic levels, coarse tremors are a red flag for toxicity. The nurse must prioritize
safety and prepare for interventions such as hemodialysis as ordered.
3. A client is admitted for Anorexia Nervosa with a BMI of 15. What is the priority nursing
intervention during the first week of treatment?
A. Encouraging the client to exercise to reduce anxiety
B. Providing high-calorie snacks between meals immediately
C. Monitoring for electrolyte imbalances and cardiac arrhythmias
D. Discussing the client’s distorted body image
Answer: C
Rationale: The primary risk during the initial refeeding phase of Anorexia Nervosa is
Refeeding Syndrome, which can cause fatal cardiac issues. Monitoring electrolytes like
potassium, phosphate, and magnesium is vital for physical stabilization. Psychological
interventions like discussing body image are secondary to physiological safety in the acute
phase.
, 4. The nurse is educating a client who is starting Phenelzine for depression. Which food item
must the client be instructed to avoid?
A. Fresh chicken
B. Whole wheat bread
C. Canned green beans
D. Aged cheddar cheese
Answer: D
Rationale: Phenelzine is a Monoamine Oxidase Inhibitor (MAOI) that requires a low-
tyramine diet to prevent hypertensive crisis. Aged cheeses, cured meats, and fermented
products are high in tyramine and must be strictly avoided. The nurse should emphasize
that this diet must be maintained for two weeks even after stopping the medication.
5. A client with Borderline Personality Disorder (BPD) tells the day-shift nurse that the night-
shift nurse was ‘horrible’ and ‘mean,’ while the day-shift nurse is ‘an angel.’ This is an
example of which defense mechanism?
A. Splitting
B. Projection
C. Reaction Formation
D. Intellectualization
Answer: A
