,NUR253/NUR 253 Mental Health Nursing Exam 3 |
Galen College of Nursing | 2026/2027 Edition (PDF)
1. A nurse is caring for a client with post-traumatic stress disorder (PTSD) following a motor vehicle
accident. Which finding is consistent with the DSM-5 diagnostic criteria for this disorder?
A) The client reports feeling detached from the accident and has no memory of it
B) The client experiences recurrent, involuntary, and intrusive distressing memories of the accident
C) The client expresses gratitude for surviving the accident and feels optimistic about the future
D) The client repeatedly drives past the accident site to process the trauma
Correct Answer: The client experiences recurrent, involuntary, and intrusive distressing memories of the
accident
Rationale: Intrusive symptoms—including recurrent, involuntary, and distressing memories, flashbacks,
and nightmares—are hallmark diagnostic criteria for PTSD. Detachment (dissociative amnesia) can occur
but is not the defining feature; avoidance, not revisiting, is typical; and optimism is inconsistent with the
disorder.
2. What is the priority nursing intervention for a client newly diagnosed with major depressive disorder
who states, "I don't see the point in going on"?
A) Encourage the client to attend group therapy sessions
B) Assess the client for risk of suicide or self-harm
C) Teach the client about the side effects of prescribed antidepressants
D) Ensure the client maintains adequate nutritional intake
Correct Answer: Assess the client for risk of suicide or self-harm
Rationale: Safety is always the priority in mental health nursing. A client with major depressive disorder
who expresses hopelessness is at high risk for suicide. Before addressing coping, education, or nutrition,
the nurse must ensure the client is safe from self-harm.
,3. A client with major depressive disorder has been prescribed fluoxetine (Prozac) and reports nausea,
headache, and insomnia. Which response by the nurse is most appropriate?
A) "You should stop taking the medication immediately."
B) "These are common side effects that often resolve in a few weeks."
C) "I will ask the provider to switch you to a different medication."
D) "You need to go to the emergency room immediately."
Correct Answer: "These are common side effects that often resolve in a few weeks."
Rationale: Nausea, headache, and insomnia are common, mild side effects of SSRIs like fluoxetine. These
usually subside after a few weeks of therapy. The client should be encouraged to continue the
medication and not abruptly stop it, which can cause withdrawal symptoms.
4. A client with bipolar disorder is experiencing a manic episode. Which nursing intervention is most
appropriate for managing this client's behavior?
A) Place the client in a room with a highly stimulating environment
B) Engage the client in competitive activities to channel energy
C) Provide a structured environment with clear limits and decreased stimulation
D) Allow the client to make all decisions about their daily routine
Correct Answer: Provide a structured environment with clear limits and decreased stimulation
Rationale: Clients in a manic episode require a calm, structured environment with decreased stimulation
to reduce agitation. Clear, firm limits help maintain safety, while competitive activities and
overstimulation can escalate manic behavior.
5. A client diagnosed with schizophrenia tells the nurse, "The FBI is monitoring my thoughts through the
television." Which term best describes this statement?
A) Illusion
B) Delusion of persecution
C) Hallucination
, D) Ideas of reference
Correct Answer: Delusion of persecution
Rationale: A delusion of persecution is a fixed, false belief that one is being targeted, harassed, or
monitored by external forces. An illusion is a misperception of a real stimulus; a hallucination is a
sensory experience without external stimulus; and ideas of reference involve believing neutral events
have personal meaning.
6. The nurse is caring for a client with schizophrenia who is experiencing auditory hallucinations. Which
response by the nurse is most therapeutic?
A) "I don't hear any voices. You must be imagining things."
B) "Tell me more about what the voices are saying to you."
C) "I understand you are hearing voices, but I do not hear them. I am here to help keep you safe."
D) "Try to ignore the voices and focus on something else."
Correct Answer: "I understand you are hearing voices, but I do not hear them. I am here to help keep
you safe."
Rationale: This response validates the client's experience without reinforcing the hallucination,
maintains reality orientation, and offers support. Telling the client the voices are imaginary is dismissive,
and asking for details may reinforce the hallucination.
7. A client with schizophrenia is prescribed risperidone. Which adverse effect should the nurse monitor
for and report to the healthcare provider?
A) Weight loss and insomnia
B) Extrapyramidal symptoms and metabolic changes
C) Hypertension and tachycardia
D) Urinary retention and constipation
Correct Answer: Extrapyramidal symptoms and metabolic changes
Galen College of Nursing | 2026/2027 Edition (PDF)
1. A nurse is caring for a client with post-traumatic stress disorder (PTSD) following a motor vehicle
accident. Which finding is consistent with the DSM-5 diagnostic criteria for this disorder?
A) The client reports feeling detached from the accident and has no memory of it
B) The client experiences recurrent, involuntary, and intrusive distressing memories of the accident
C) The client expresses gratitude for surviving the accident and feels optimistic about the future
D) The client repeatedly drives past the accident site to process the trauma
Correct Answer: The client experiences recurrent, involuntary, and intrusive distressing memories of the
accident
Rationale: Intrusive symptoms—including recurrent, involuntary, and distressing memories, flashbacks,
and nightmares—are hallmark diagnostic criteria for PTSD. Detachment (dissociative amnesia) can occur
but is not the defining feature; avoidance, not revisiting, is typical; and optimism is inconsistent with the
disorder.
2. What is the priority nursing intervention for a client newly diagnosed with major depressive disorder
who states, "I don't see the point in going on"?
A) Encourage the client to attend group therapy sessions
B) Assess the client for risk of suicide or self-harm
C) Teach the client about the side effects of prescribed antidepressants
D) Ensure the client maintains adequate nutritional intake
Correct Answer: Assess the client for risk of suicide or self-harm
Rationale: Safety is always the priority in mental health nursing. A client with major depressive disorder
who expresses hopelessness is at high risk for suicide. Before addressing coping, education, or nutrition,
the nurse must ensure the client is safe from self-harm.
,3. A client with major depressive disorder has been prescribed fluoxetine (Prozac) and reports nausea,
headache, and insomnia. Which response by the nurse is most appropriate?
A) "You should stop taking the medication immediately."
B) "These are common side effects that often resolve in a few weeks."
C) "I will ask the provider to switch you to a different medication."
D) "You need to go to the emergency room immediately."
Correct Answer: "These are common side effects that often resolve in a few weeks."
Rationale: Nausea, headache, and insomnia are common, mild side effects of SSRIs like fluoxetine. These
usually subside after a few weeks of therapy. The client should be encouraged to continue the
medication and not abruptly stop it, which can cause withdrawal symptoms.
4. A client with bipolar disorder is experiencing a manic episode. Which nursing intervention is most
appropriate for managing this client's behavior?
A) Place the client in a room with a highly stimulating environment
B) Engage the client in competitive activities to channel energy
C) Provide a structured environment with clear limits and decreased stimulation
D) Allow the client to make all decisions about their daily routine
Correct Answer: Provide a structured environment with clear limits and decreased stimulation
Rationale: Clients in a manic episode require a calm, structured environment with decreased stimulation
to reduce agitation. Clear, firm limits help maintain safety, while competitive activities and
overstimulation can escalate manic behavior.
5. A client diagnosed with schizophrenia tells the nurse, "The FBI is monitoring my thoughts through the
television." Which term best describes this statement?
A) Illusion
B) Delusion of persecution
C) Hallucination
, D) Ideas of reference
Correct Answer: Delusion of persecution
Rationale: A delusion of persecution is a fixed, false belief that one is being targeted, harassed, or
monitored by external forces. An illusion is a misperception of a real stimulus; a hallucination is a
sensory experience without external stimulus; and ideas of reference involve believing neutral events
have personal meaning.
6. The nurse is caring for a client with schizophrenia who is experiencing auditory hallucinations. Which
response by the nurse is most therapeutic?
A) "I don't hear any voices. You must be imagining things."
B) "Tell me more about what the voices are saying to you."
C) "I understand you are hearing voices, but I do not hear them. I am here to help keep you safe."
D) "Try to ignore the voices and focus on something else."
Correct Answer: "I understand you are hearing voices, but I do not hear them. I am here to help keep
you safe."
Rationale: This response validates the client's experience without reinforcing the hallucination,
maintains reality orientation, and offers support. Telling the client the voices are imaginary is dismissive,
and asking for details may reinforce the hallucination.
7. A client with schizophrenia is prescribed risperidone. Which adverse effect should the nurse monitor
for and report to the healthcare provider?
A) Weight loss and insomnia
B) Extrapyramidal symptoms and metabolic changes
C) Hypertension and tachycardia
D) Urinary retention and constipation
Correct Answer: Extrapyramidal symptoms and metabolic changes
