NUR 256 Exam 3 V1 | NUR 256 Concepts of Mental
Health Nursing | Q&A with Rationale (NUR256
Exam 3) | Galen College of Nursing
1. A patient with Bipolar I Disorder is experiencing an acute manic episode. Which nursing
intervention should be prioritized to ensure a safe milieu?
A. Providing high-calorie finger foods for the patient to eat while moving.
B. Encouraging the patient to lead a group therapy session.
C. Setting strict limits on behavior in a loud, crowded common area.
D. Engaging the patient in competitive sports to burn off excess energy.
Correct Answer: A
Explanation: During a manic episode, patients are often too hyperactive to sit down for full
meals, making finger foods essential for maintaining nutrition. Providing high-calorie
options helps prevent physical exhaustion and weight loss associated with constant
movement. Competitive activities or crowded areas should be avoided as they can further
overstimulate the patient and lead to escalation.
2. A nurse is caring for a client receiving Lithium Carbonate. The client’s most recent serum
level is 1.8 mEq/L. Which action should the nurse take first?
A. Administer the next scheduled dose as prescribed.
B. Withhold the dose and notify the healthcare provider immediately.
,C. Request a repeat blood draw for confirmation.
D. Increase fluid intake to 3,000 mL per day.
Correct Answer: B
Explanation: The therapeutic range for Lithium is narrow, typically between 0.6 and 1.2
mEq/L, and a level of 1.8 mEq/L indicates moderate toxicity. Symptoms of toxicity can be
severe and life-threatening, necessitating an immediate hold on the medication. The nurse
must prioritize patient safety by informing the provider to prevent further physiological
damage.
3. A client diagnosed with Schizophrenia is experiencing auditory hallucinations, telling the
nurse, ‘The voices are telling me I am dangerous.’ Which response by the nurse is
therapeutic?
A. I don’t hear any voices; you are just having a hallucination.
B. What exactly are the voices telling you to do?
C. Don’t worry, the medication will make those voices go away soon.
D. I understand the voices are real to you, but I do not hear them.
Correct Answer: D
Explanation: This response acknowledges the client’s subjective experience without
validating the hallucination as an external reality. It presents reality in a non-
confrontational manner, which helps build trust in the nurse-client relationship. Simply
, dismissing the voices or making promises about medication may decrease the client’s sense
of safety and rapport.
4. A patient is prescribed Clozapine for treatment-resistant schizophrenia. Which laboratory
result must the nurse monitor most closely?
A. Serum potassium levels.
B. White blood cell (WBC) count and absolute neutrophil count (ANC).
C. Blood urea nitrogen (BUN) and creatinine.
D. Aspartate aminotransferase (AST) levels.
Correct Answer: B
Explanation: Clozapine carries a significant risk of agranulocytosis, a potentially fatal drop
in white blood cell counts. Regular monitoring of the WBC and ANC is a legal and clinical
requirement for patients receiving this medication. If levels fall below specific thresholds,
the medication must be discontinued to prevent life-threatening infections.
5. A nurse observes a client with Borderline Personality Disorder (BPD) praising one nurse
while demeaning another. Which term describes this defense mechanism?
A. Reaction formation.
B. Intellectualization.
C. Projection.
D. Splitting.
Health Nursing | Q&A with Rationale (NUR256
Exam 3) | Galen College of Nursing
1. A patient with Bipolar I Disorder is experiencing an acute manic episode. Which nursing
intervention should be prioritized to ensure a safe milieu?
A. Providing high-calorie finger foods for the patient to eat while moving.
B. Encouraging the patient to lead a group therapy session.
C. Setting strict limits on behavior in a loud, crowded common area.
D. Engaging the patient in competitive sports to burn off excess energy.
Correct Answer: A
Explanation: During a manic episode, patients are often too hyperactive to sit down for full
meals, making finger foods essential for maintaining nutrition. Providing high-calorie
options helps prevent physical exhaustion and weight loss associated with constant
movement. Competitive activities or crowded areas should be avoided as they can further
overstimulate the patient and lead to escalation.
2. A nurse is caring for a client receiving Lithium Carbonate. The client’s most recent serum
level is 1.8 mEq/L. Which action should the nurse take first?
A. Administer the next scheduled dose as prescribed.
B. Withhold the dose and notify the healthcare provider immediately.
,C. Request a repeat blood draw for confirmation.
D. Increase fluid intake to 3,000 mL per day.
Correct Answer: B
Explanation: The therapeutic range for Lithium is narrow, typically between 0.6 and 1.2
mEq/L, and a level of 1.8 mEq/L indicates moderate toxicity. Symptoms of toxicity can be
severe and life-threatening, necessitating an immediate hold on the medication. The nurse
must prioritize patient safety by informing the provider to prevent further physiological
damage.
3. A client diagnosed with Schizophrenia is experiencing auditory hallucinations, telling the
nurse, ‘The voices are telling me I am dangerous.’ Which response by the nurse is
therapeutic?
A. I don’t hear any voices; you are just having a hallucination.
B. What exactly are the voices telling you to do?
C. Don’t worry, the medication will make those voices go away soon.
D. I understand the voices are real to you, but I do not hear them.
Correct Answer: D
Explanation: This response acknowledges the client’s subjective experience without
validating the hallucination as an external reality. It presents reality in a non-
confrontational manner, which helps build trust in the nurse-client relationship. Simply
, dismissing the voices or making promises about medication may decrease the client’s sense
of safety and rapport.
4. A patient is prescribed Clozapine for treatment-resistant schizophrenia. Which laboratory
result must the nurse monitor most closely?
A. Serum potassium levels.
B. White blood cell (WBC) count and absolute neutrophil count (ANC).
C. Blood urea nitrogen (BUN) and creatinine.
D. Aspartate aminotransferase (AST) levels.
Correct Answer: B
Explanation: Clozapine carries a significant risk of agranulocytosis, a potentially fatal drop
in white blood cell counts. Regular monitoring of the WBC and ANC is a legal and clinical
requirement for patients receiving this medication. If levels fall below specific thresholds,
the medication must be discontinued to prevent life-threatening infections.
5. A nurse observes a client with Borderline Personality Disorder (BPD) praising one nurse
while demeaning another. Which term describes this defense mechanism?
A. Reaction formation.
B. Intellectualization.
C. Projection.
D. Splitting.
