NUR 253 Exam 4 Mental Health (2026 /
2027) PDF | Galen College of Nursing
A client with major depressive disorder tells the nurse, “Everyone would be better
off without me.” What is the nurse’s priority response?
A. “You have many people who care about you.”
B. “Why do you feel that your family does not care?”
C. “Are you thinking about killing yourself?”
D. “You should focus on the positive things in your life.”
Answer: C. “Are you thinking about killing yourself?”
Rationale: Directly assessing suicidal thoughts is appropriate and does not
increase suicide risk. The nurse should determine the presence of suicidal ideation,
plan, means, and intent so immediate safety measures can be implemented.
Which intervention is most appropriate for a client experiencing acute mania?
A. Encourage participation in lengthy group activities.
B. Provide a quiet environment with reduced stimulation.
C. Allow the client to make all decisions independently.
D. Encourage caffeinated beverages to maintain energy.
Answer: B. Provide a quiet environment with reduced stimulation.
Rationale: Clients experiencing mania are highly distractible and overstimulated.
A calm, structured environment with limited stimulation can decrease agitation
and promote behavioral control.
,A client taking lithium reports severe diarrhea, vomiting, coarse hand tremors, and
difficulty walking. Which action should the nurse take first?
A. Administer the next scheduled dose.
B. Encourage the client to increase sodium restriction.
C. Hold lithium and notify the healthcare provider.
D. Reassure the client that these effects are expected.
_Answer: C. Hold lithium and notify the healthcare provider.
Rationale: Severe gastrointestinal symptoms, coarse tremor, and ataxia may
indicate lithium toxicity. Lithium should be withheld and the provider notified
promptly for further evaluation and serum-level testing.
Which finding is most characteristic of serotonin syndrome?
A. Bradycardia and hypothermia
B. Muscle rigidity, hyperreflexia, and fever
C. Constipation and urinary retention
D. Dry skin and dilated pupils
_Answer: B. Muscle rigidity, hyperreflexia, and fever
Rationale: Serotonin syndrome can cause autonomic instability, hyperthermia,
agitation, tremor, hyperreflexia, and muscle rigidity. It may become life-
threatening and requires prompt intervention.
A client prescribed an SSRI asks when improvement in depressive symptoms
should be expected. Which response is most appropriate?
A. “You should feel completely better after the first dose.”
B. “Therapeutic effects may take several weeks to become noticeable.”
C. “The medication works only when you feel anxious.”
,D. “Stop taking the medication when your mood improves.”
Answer: B. “Therapeutic effects may take several weeks to become noticeable.”
Rationale: Antidepressant effects from SSRIs generally develop gradually. Clients
should continue taking the medication as prescribed and report concerning
adverse effects or worsening suicidal thoughts.
A client with schizophrenia says, “The voices are telling me that I am worthless.”
Which response by the nurse is therapeutic?
A. “The voices are not real, so ignore them.”
B. “I do not hear the voices, but I understand that you are experiencing them.”
C. “What did you do to make the voices angry?”
D. “You should listen to the voices if they are giving you advice.”
Answer: B. “I do not hear the voices, but I understand that you are experiencing
them.”
Rationale: The nurse acknowledges the client’s experience without validating the
hallucination as reality. This approach promotes trust and helps maintain a
therapeutic relationship.
Which assessment finding requires immediate intervention in a client taking an
antipsychotic medication?
A. Mild dry mouth
B. Increased appetite
C. Fever, severe muscle rigidity, and altered mental status
D. Mild drowsiness after administration
_Answer: C. Fever, severe muscle rigidity, and altered mental status
Rationale: These findings are characteristic of neuroleptic malignant syndrome
(NMS), a potentially fatal reaction to antipsychotic medications. The medication
should be stopped and emergency medical management initiated.
, A client taking clozapine reports a sore throat and fever. What should the nurse do?
A. Tell the client to continue the medication without concern.
B. Encourage strenuous exercise.
C. Notify the healthcare provider promptly for evaluation.
D. Recommend taking the medication with grapefruit juice.
_Answer: C. Notify the healthcare provider promptly for evaluation.
Rationale: Clozapine can cause severe neutropenia or agranulocytosis. Fever and
sore throat may indicate infection associated with a dangerously low white blood
cell count and require prompt evaluation.
A client with panic disorder is experiencing an acute panic attack. Which nursing
intervention is most appropriate?
A. Ask the client to explain the cause of the anxiety in detail.
B. Leave the client alone to decrease stimulation.
C. Remain with the client and use short, simple statements.
D. Encourage the client to make important decisions immediately.
Answer: C. Remain with the client and use short, simple statements.
Rationale: During severe anxiety or panic, the client's ability to process
information is impaired. Staying with the client provides safety, while brief and
simple communication helps reduce stimulation.
Which behavior is most consistent with obsessive-compulsive disorder?
A. Repeatedly checking that a door is locked despite knowing it is locked
B. Experiencing elevated mood and decreased need for sleep
C. Hearing voices commenting on behavior
D. Avoiding all social interaction because of suspiciousness
2027) PDF | Galen College of Nursing
A client with major depressive disorder tells the nurse, “Everyone would be better
off without me.” What is the nurse’s priority response?
A. “You have many people who care about you.”
B. “Why do you feel that your family does not care?”
C. “Are you thinking about killing yourself?”
D. “You should focus on the positive things in your life.”
Answer: C. “Are you thinking about killing yourself?”
Rationale: Directly assessing suicidal thoughts is appropriate and does not
increase suicide risk. The nurse should determine the presence of suicidal ideation,
plan, means, and intent so immediate safety measures can be implemented.
Which intervention is most appropriate for a client experiencing acute mania?
A. Encourage participation in lengthy group activities.
B. Provide a quiet environment with reduced stimulation.
C. Allow the client to make all decisions independently.
D. Encourage caffeinated beverages to maintain energy.
Answer: B. Provide a quiet environment with reduced stimulation.
Rationale: Clients experiencing mania are highly distractible and overstimulated.
A calm, structured environment with limited stimulation can decrease agitation
and promote behavioral control.
,A client taking lithium reports severe diarrhea, vomiting, coarse hand tremors, and
difficulty walking. Which action should the nurse take first?
A. Administer the next scheduled dose.
B. Encourage the client to increase sodium restriction.
C. Hold lithium and notify the healthcare provider.
D. Reassure the client that these effects are expected.
_Answer: C. Hold lithium and notify the healthcare provider.
Rationale: Severe gastrointestinal symptoms, coarse tremor, and ataxia may
indicate lithium toxicity. Lithium should be withheld and the provider notified
promptly for further evaluation and serum-level testing.
Which finding is most characteristic of serotonin syndrome?
A. Bradycardia and hypothermia
B. Muscle rigidity, hyperreflexia, and fever
C. Constipation and urinary retention
D. Dry skin and dilated pupils
_Answer: B. Muscle rigidity, hyperreflexia, and fever
Rationale: Serotonin syndrome can cause autonomic instability, hyperthermia,
agitation, tremor, hyperreflexia, and muscle rigidity. It may become life-
threatening and requires prompt intervention.
A client prescribed an SSRI asks when improvement in depressive symptoms
should be expected. Which response is most appropriate?
A. “You should feel completely better after the first dose.”
B. “Therapeutic effects may take several weeks to become noticeable.”
C. “The medication works only when you feel anxious.”
,D. “Stop taking the medication when your mood improves.”
Answer: B. “Therapeutic effects may take several weeks to become noticeable.”
Rationale: Antidepressant effects from SSRIs generally develop gradually. Clients
should continue taking the medication as prescribed and report concerning
adverse effects or worsening suicidal thoughts.
A client with schizophrenia says, “The voices are telling me that I am worthless.”
Which response by the nurse is therapeutic?
A. “The voices are not real, so ignore them.”
B. “I do not hear the voices, but I understand that you are experiencing them.”
C. “What did you do to make the voices angry?”
D. “You should listen to the voices if they are giving you advice.”
Answer: B. “I do not hear the voices, but I understand that you are experiencing
them.”
Rationale: The nurse acknowledges the client’s experience without validating the
hallucination as reality. This approach promotes trust and helps maintain a
therapeutic relationship.
Which assessment finding requires immediate intervention in a client taking an
antipsychotic medication?
A. Mild dry mouth
B. Increased appetite
C. Fever, severe muscle rigidity, and altered mental status
D. Mild drowsiness after administration
_Answer: C. Fever, severe muscle rigidity, and altered mental status
Rationale: These findings are characteristic of neuroleptic malignant syndrome
(NMS), a potentially fatal reaction to antipsychotic medications. The medication
should be stopped and emergency medical management initiated.
, A client taking clozapine reports a sore throat and fever. What should the nurse do?
A. Tell the client to continue the medication without concern.
B. Encourage strenuous exercise.
C. Notify the healthcare provider promptly for evaluation.
D. Recommend taking the medication with grapefruit juice.
_Answer: C. Notify the healthcare provider promptly for evaluation.
Rationale: Clozapine can cause severe neutropenia or agranulocytosis. Fever and
sore throat may indicate infection associated with a dangerously low white blood
cell count and require prompt evaluation.
A client with panic disorder is experiencing an acute panic attack. Which nursing
intervention is most appropriate?
A. Ask the client to explain the cause of the anxiety in detail.
B. Leave the client alone to decrease stimulation.
C. Remain with the client and use short, simple statements.
D. Encourage the client to make important decisions immediately.
Answer: C. Remain with the client and use short, simple statements.
Rationale: During severe anxiety or panic, the client's ability to process
information is impaired. Staying with the client provides safety, while brief and
simple communication helps reduce stimulation.
Which behavior is most consistent with obsessive-compulsive disorder?
A. Repeatedly checking that a door is locked despite knowing it is locked
B. Experiencing elevated mood and decreased need for sleep
C. Hearing voices commenting on behavior
D. Avoiding all social interaction because of suspiciousness
