,GCN|NUR 256 Exam 4 | Mental Health Nursing |
Galen College of Nursing | 26/27 Edition (PDF)
1. A client with major depressive disorder reports a lack of interest in previously enjoyed activities.
Which term accurately describes this symptom?
A) Anergia
B) Anhedonia
C) Apathy
D) Alexithymia
Correct Answer: Anhedonia
Rationale: Anhedonia is the loss of interest or pleasure in previously enjoyed activities, a core
symptom of major depressive disorder. Anergia refers to lack of energy, apathy is indifference, and
alexithymia is difficulty identifying emotions.
2. A client with bipolar disorder in a manic episode has not slept for three days and is pacing rapidly.
Which nursing action is the priority?
A) Ask the client to sit down and be quiet
B) Provide high-calorie finger foods and fluids
C) Place the client in seclusion
D) Challenge the client's grandiose beliefs
Correct Answer: Provide high-calorie finger foods and fluids
Rationale: Manic clients expend high energy and may forget to eat and drink, leading to dehydration
and malnutrition. Finger foods allow for movement while eating. Seclusion is a last resort, and
challenging delusions increases agitation.
3. A nurse is assessing a client for suicide risk. According to current epidemiological data, which
demographic group has the highest risk for suicide?
,A) Children aged 5 to 9 years
B) Adolescents aged 15 to 24 years
C) Adults aged 25 to 44 years
D) Older adults aged 65 years and older
Correct Answer: Adolescents aged 15 to 24 years
Rationale: Suicide is the third leading cause of death among individuals aged 15 to 24. While older
adults also have elevated rates, the 15–24 age group represents a significant peak in suicide mortality.
Children under 10 have lower rates.
4. A nurse is evaluating a client's risk factors for suicide. Which finding is the strongest biological
predictor of suicidal behavior?
A) History of childhood trauma
B) Low serotonin levels
C) Recent job loss
D) Family history of cancer
Correct Answer: Low serotonin levels
Rationale: Low serotonin levels are associated with depressed mood and increased suicide risk.
Childhood trauma and job loss are psychosocial factors, and family history of cancer is not a
recognized suicide predictor.
5. According to Beck's cognitive theory, which emotional state is the central factor in suicide risk?
A) Anger
B) Guilt
C) Hopelessness
D) Anxiety
, Correct Answer: Hopelessness
Rationale: Aaron Beck identified hopelessness as the central emotional factor in suicide risk. While
anger, guilt, and anxiety may coexist, hopelessness is the strongest cognitive predictor of suicidal
intent.
6. A nurse is conducting a suicide risk assessment. Which question is the priority for determining
imminent risk?
A) "Have you ever thought about suicide before?"
B) "Do you have a specific plan and the means to carry it out?"
C) "How would you describe your mood today?"
D) "Do you have supportive family members?"
Correct Answer: "Do you have a specific plan and the means to carry it out?"
Rationale: The presence of a specific plan with access to means is the strongest predictor of imminent
suicide risk. Previous thoughts, current mood, and social support are important but do not indicate
immediate danger as directly.
7. A nurse is implementing the SAFETY protocol for a client at risk for suicide. Which intervention is
included in the implementation phase?
A) Diagnosing the client with risk for injury
B) Performing a comprehensive nursing assessment
C) Assisting with proper health management
D) Evaluating the client's response to treatment
Correct Answer: Assisting with proper health management
Rationale: Implementation of the SAFETY protocol includes assisting with proper health management
to eradicate the underlying cause, using supportive measures to relieve distress, and preventing
physical harm. Diagnosis occurs in the assessment phase, and evaluation is a separate phase.
Galen College of Nursing | 26/27 Edition (PDF)
1. A client with major depressive disorder reports a lack of interest in previously enjoyed activities.
Which term accurately describes this symptom?
A) Anergia
B) Anhedonia
C) Apathy
D) Alexithymia
Correct Answer: Anhedonia
Rationale: Anhedonia is the loss of interest or pleasure in previously enjoyed activities, a core
symptom of major depressive disorder. Anergia refers to lack of energy, apathy is indifference, and
alexithymia is difficulty identifying emotions.
2. A client with bipolar disorder in a manic episode has not slept for three days and is pacing rapidly.
Which nursing action is the priority?
A) Ask the client to sit down and be quiet
B) Provide high-calorie finger foods and fluids
C) Place the client in seclusion
D) Challenge the client's grandiose beliefs
Correct Answer: Provide high-calorie finger foods and fluids
Rationale: Manic clients expend high energy and may forget to eat and drink, leading to dehydration
and malnutrition. Finger foods allow for movement while eating. Seclusion is a last resort, and
challenging delusions increases agitation.
3. A nurse is assessing a client for suicide risk. According to current epidemiological data, which
demographic group has the highest risk for suicide?
,A) Children aged 5 to 9 years
B) Adolescents aged 15 to 24 years
C) Adults aged 25 to 44 years
D) Older adults aged 65 years and older
Correct Answer: Adolescents aged 15 to 24 years
Rationale: Suicide is the third leading cause of death among individuals aged 15 to 24. While older
adults also have elevated rates, the 15–24 age group represents a significant peak in suicide mortality.
Children under 10 have lower rates.
4. A nurse is evaluating a client's risk factors for suicide. Which finding is the strongest biological
predictor of suicidal behavior?
A) History of childhood trauma
B) Low serotonin levels
C) Recent job loss
D) Family history of cancer
Correct Answer: Low serotonin levels
Rationale: Low serotonin levels are associated with depressed mood and increased suicide risk.
Childhood trauma and job loss are psychosocial factors, and family history of cancer is not a
recognized suicide predictor.
5. According to Beck's cognitive theory, which emotional state is the central factor in suicide risk?
A) Anger
B) Guilt
C) Hopelessness
D) Anxiety
, Correct Answer: Hopelessness
Rationale: Aaron Beck identified hopelessness as the central emotional factor in suicide risk. While
anger, guilt, and anxiety may coexist, hopelessness is the strongest cognitive predictor of suicidal
intent.
6. A nurse is conducting a suicide risk assessment. Which question is the priority for determining
imminent risk?
A) "Have you ever thought about suicide before?"
B) "Do you have a specific plan and the means to carry it out?"
C) "How would you describe your mood today?"
D) "Do you have supportive family members?"
Correct Answer: "Do you have a specific plan and the means to carry it out?"
Rationale: The presence of a specific plan with access to means is the strongest predictor of imminent
suicide risk. Previous thoughts, current mood, and social support are important but do not indicate
immediate danger as directly.
7. A nurse is implementing the SAFETY protocol for a client at risk for suicide. Which intervention is
included in the implementation phase?
A) Diagnosing the client with risk for injury
B) Performing a comprehensive nursing assessment
C) Assisting with proper health management
D) Evaluating the client's response to treatment
Correct Answer: Assisting with proper health management
Rationale: Implementation of the SAFETY protocol includes assisting with proper health management
to eradicate the underlying cause, using supportive measures to relieve distress, and preventing
physical harm. Diagnosis occurs in the assessment phase, and evaluation is a separate phase.
