NUR 253 Exam 4 Mental Health PDF |
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Questions and Ansẉers with
rationales 2026\2027 update
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Questions and Ansẉers
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,───────────────────────────────────────────────────────
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A client diagnosed with schizophrenia is experiencing auditory
hallucinations. The nurse observes the client talking to the wall and
asks, "Who are you talking to?" The client replies, "The voices tell me
what to do." What is the nurse’s best initial response?
A) "There are no voices; you are imagining things."
B) "I do not hear any voices, but I understand you do."
C) "Stop listening to the voices right now."
D) "What exactly are the voices telling you to do?"
Answer: B
Rationale: The nurse should acknowledge the client's reality without
validating the hallucination. Saying "I do not hear them, but I know
you do" builds trust and uses reality testing without arguing.
A client with schizophrenia is taking haloperidol (Haldol). The nurse
assesses the client and notes rhythmic, involuntary movements of
the mouth and tongue. The nurse correctly identifies this as:
A) Akathisia
B) Dystonia
C) Tardive dyskinesia
D) Neuroleptic malignant syndrome
Answer: C
Rationale: Tardive dyskinesia is characterized by involuntary,
rhythmic movements of the face, mouth, and tongue, often a late
side effect of typical antipsychotics like haloperidol. Akathisia is
restlessness, dystonia is acute muscle spasms, and NMS is a life-
threatening hyperthermic emergency.
,Which client statement demonstrates the use of a defense
mechanism commonly seen in schizophrenia known as "clanging"?
A) "I am the president of the United States."
B) "I eat meat, meet my friends, and greet the day."
C) "The CIA is putting lasers in my brain."
D) "I didn't steal the car; the car stole me."
Answer: B
Rationale: Clanging involves choosing words based on their sound
rather than their meaning. "Meat, meet, greet" are examples of
clanging.
A client on an inpatient psychiatric unit says, "I need to leave right
now. The FBI is waiting for me outside." What nursing intervention is
most appropriate?
A) Tell the client the FBI is not outside and lock the doors.
B) Explore the client’s feelings of paranoia in a quiet room.
C) Accompany the client to a less stimulating area and offer a PRN
antianxiety medication if prescribed.
D) Reason with the client using logical arguments about why the FBI
would not be there.
Answer: C
Rationale: When a client is experiencing paranoid delusions, the
nurse should reduce environmental stimuli, ensure safety
(accompanying the client), and use pharmacological intervention if
anxiety is high. Logical reasoning does not work on delusions.
A client diagnosed with schizoaffective disorder is prescribed
clozapine (Clozaril). Which laboratory finding requires immediate
intervention by the nurse?
A) WBC count of 2,500/mm³
B) Hemoglobin of 12 g/dL
C) Platelet count of 200,000/mm³
D) Blood glucose of 110 mg/dL
Answer: A
, Rationale: Clozapine carries a risk for agranulocytosis (severely low
white blood cell count). A WBC below 3,000/mm³ (or severely
dropping neutrophils) requires immediate medical intervention and
discontinuation of the drug.
The nurse is educating a client newly prescribed risperidone
(Risperdal). Which statement by the client indicates a need for
further teaching?
A) "I should stand up slowly from a sitting position."
B) "I might experience some weight gain."
C) "I can drink alcohol as long as it's only on weekends."
D) "I need to report any unusual muscle movements to my doctor."
Answer: C
Rationale: Alcohol should be strictly avoided when taking
antipsychotics due to the additive CNS depressant effects, which can
lead to severe sedation and respiratory depression.
A client with schizophrenia exhibits a flat affect, poverty of speech,
and anhedonia. The nurse recognizes these as:
A) Positive symptoms
B) Negative symptoms
C) Catatonic symptoms
D) Disorganized symptoms
Answer: B
Rationale: Negative symptoms represent a loss of normal
functioning. Flat affect, alogia (poverty of speech), and anhedonia
(inability to feel pleasure) are classic negative symptoms.
During an admission assessment, a client with schizophrenia
repeatedly echoes the nurse's words exactly as they are spoken. The
nurse documents this as:
A) Echolalia
B) Neologism
C) Word salad
Galen
Questions and Ansẉers with
rationales 2026\2027 update
This Exam contains:
Guarantee passing score
Questions and Ansẉers
format set of multiple-choice
Expert-Verified rationales
Verified ẉith trusted textbooks
,───────────────────────────────────────────────────────
─
A client diagnosed with schizophrenia is experiencing auditory
hallucinations. The nurse observes the client talking to the wall and
asks, "Who are you talking to?" The client replies, "The voices tell me
what to do." What is the nurse’s best initial response?
A) "There are no voices; you are imagining things."
B) "I do not hear any voices, but I understand you do."
C) "Stop listening to the voices right now."
D) "What exactly are the voices telling you to do?"
Answer: B
Rationale: The nurse should acknowledge the client's reality without
validating the hallucination. Saying "I do not hear them, but I know
you do" builds trust and uses reality testing without arguing.
A client with schizophrenia is taking haloperidol (Haldol). The nurse
assesses the client and notes rhythmic, involuntary movements of
the mouth and tongue. The nurse correctly identifies this as:
A) Akathisia
B) Dystonia
C) Tardive dyskinesia
D) Neuroleptic malignant syndrome
Answer: C
Rationale: Tardive dyskinesia is characterized by involuntary,
rhythmic movements of the face, mouth, and tongue, often a late
side effect of typical antipsychotics like haloperidol. Akathisia is
restlessness, dystonia is acute muscle spasms, and NMS is a life-
threatening hyperthermic emergency.
,Which client statement demonstrates the use of a defense
mechanism commonly seen in schizophrenia known as "clanging"?
A) "I am the president of the United States."
B) "I eat meat, meet my friends, and greet the day."
C) "The CIA is putting lasers in my brain."
D) "I didn't steal the car; the car stole me."
Answer: B
Rationale: Clanging involves choosing words based on their sound
rather than their meaning. "Meat, meet, greet" are examples of
clanging.
A client on an inpatient psychiatric unit says, "I need to leave right
now. The FBI is waiting for me outside." What nursing intervention is
most appropriate?
A) Tell the client the FBI is not outside and lock the doors.
B) Explore the client’s feelings of paranoia in a quiet room.
C) Accompany the client to a less stimulating area and offer a PRN
antianxiety medication if prescribed.
D) Reason with the client using logical arguments about why the FBI
would not be there.
Answer: C
Rationale: When a client is experiencing paranoid delusions, the
nurse should reduce environmental stimuli, ensure safety
(accompanying the client), and use pharmacological intervention if
anxiety is high. Logical reasoning does not work on delusions.
A client diagnosed with schizoaffective disorder is prescribed
clozapine (Clozaril). Which laboratory finding requires immediate
intervention by the nurse?
A) WBC count of 2,500/mm³
B) Hemoglobin of 12 g/dL
C) Platelet count of 200,000/mm³
D) Blood glucose of 110 mg/dL
Answer: A
, Rationale: Clozapine carries a risk for agranulocytosis (severely low
white blood cell count). A WBC below 3,000/mm³ (or severely
dropping neutrophils) requires immediate medical intervention and
discontinuation of the drug.
The nurse is educating a client newly prescribed risperidone
(Risperdal). Which statement by the client indicates a need for
further teaching?
A) "I should stand up slowly from a sitting position."
B) "I might experience some weight gain."
C) "I can drink alcohol as long as it's only on weekends."
D) "I need to report any unusual muscle movements to my doctor."
Answer: C
Rationale: Alcohol should be strictly avoided when taking
antipsychotics due to the additive CNS depressant effects, which can
lead to severe sedation and respiratory depression.
A client with schizophrenia exhibits a flat affect, poverty of speech,
and anhedonia. The nurse recognizes these as:
A) Positive symptoms
B) Negative symptoms
C) Catatonic symptoms
D) Disorganized symptoms
Answer: B
Rationale: Negative symptoms represent a loss of normal
functioning. Flat affect, alogia (poverty of speech), and anhedonia
(inability to feel pleasure) are classic negative symptoms.
During an admission assessment, a client with schizophrenia
repeatedly echoes the nurse's words exactly as they are spoken. The
nurse documents this as:
A) Echolalia
B) Neologism
C) Word salad
