NUR 253 Exam 3 Actual Exam V1 | NUR 253 Mental Health Nursing
(NUR253 Exam 3) | Galen College of Nursing
1. A nurse is assessing a client prescribed Lithium carbonate for Bipolar I Disorder. The client
reports blurred vision, a coarse hand tremor, and severe diarrhea. Which action should the
nurse take first?
A. Request a stat serum Lithium level and withhold the dose.
B. Administer the next scheduled dose of Lithium as prescribed.
C. Advise the client to increase their sodium intake immediately.
D. Document the findings as expected side effects of the medication.
Answer: A
Rationale: The symptoms described, including blurred vision, coarse tremors, and severe
diarrhea, indicate advanced Lithium toxicity, which typically occurs at levels above 1.5
mEq/L. The nurse must prioritize patient safety by withholding the medication to prevent
further toxicity and obtaining a serum level to confirm the diagnosis. Advanced toxicity can
lead to seizures, coma, or death if not addressed immediately.
2. A client with Schizophrenia is experiencing auditory hallucinations and tells the nurse, ‘The
voices are telling me I am a bad person.’ Which response by the nurse is therapeutic?
A. ‘I don’t hear the voices, but I understand they are real to you.’
B. ‘Why do you think the voices are saying that to you?’
C. ‘Don’t listen to them; you are actually a very kind person.’
D. ‘What exactly are the voices telling you to do right now?’
Answer: A
Rationale: This response acknowledges the client’s internal experience without validating
the hallucination as external reality, a technique known as presenting reality. It provides
support while maintaining the nurse’s own perception of environment. Avoid asking ‘why’
questions or dismissing the client’s feelings, as these are non-therapeutic.
3. A nurse is caring for a client admitted with Major Depressive Disorder (MDD). The client
began taking Fluoxetine 20 mg daily three days ago. Which assessment finding requires
immediate intervention?
A. The client states they have a sudden increase in energy.
B. The client reports a dry mouth and mild nausea.
C. The client expresses hope that the medication will work soon.
,D. The client reports difficulty falling asleep at night.
Answer: A
Rationale: A sudden increase in energy in a client with MDD shortly after starting an SSRI
can indicate an increased risk for suicide. The client may now have the physical energy to
carry out a suicide plan that they previously lacked the motivation to execute. The nurse
must immediately perform a suicide risk assessment and implement safety precautions.
4. A client is diagnosed with Anorexia Nervosa and has a Body Mass Index (BMI) of 14. Which
nursing diagnosis is the priority for this client?
A. Disturbed Body Image related to cognitive distortion.
B. Imbalanced Nutrition: Less than body requirements.
C. Low Self-Esteem related to perceived lack of control.
D. Risk for Electrolyte Imbalance and Cardiac Dysrhythmias.
Answer: D
Rationale: While all options are relevant to Anorexia Nervosa, the physiological risk to life
is the priority according to Maslow’s Hierarchy of Needs. A BMI of 14 indicates severe
malnutrition, which often leads to life-threatening complications such as hypokalemia and
bradycardia. Monitoring for cardiac instability and electrolyte shifts (Refeeding Syndrome)
is the most critical nursing action.
5. During a group therapy session, a client with Borderline Personality Disorder (BPD) tells the
nurse, ‘You are the only good nurse here; all the others are incompetent.’ The nurse
recognizes this as:
A. Reaction formation.
B. Altruism.
C. Projective identification.
D. Splitting.
Answer: D
Rationale: Splitting is a common defense mechanism in BPD where the individual views
people or situations as either all good or all bad. It is a failure to integrate the positive and
negative qualities of self and others into a cohesive whole. The nurse should maintain
consistent boundaries and communicate with the rest of the treatment team to prevent
staff manipulation.
6. A client is receiving Clozapine for treatment-resistant Schizophrenia. Which laboratory
value must the nurse monitor weekly during the first six months of therapy?
A. Serum Potassium level.
, B. Blood Urea Nitrogen (BUN).
C. Absolute Neutrophil Count (ANC).
D. Aspartate Aminotransferase (AST).
Answer: C
Rationale: Clozapine carries a black box warning for agranulocytosis, a life-threatening
decrease in white blood cells. National registries require mandatory weekly ANC
monitoring to ensure the client is not developing severe neutropenia. If the ANC falls below
a specific threshold (usually 1,500/mm³), the medication must be discontinued.
7. A nurse is assessing a client for suspected Alcohol Withdrawal Delirium. Which of the
following findings should the nurse anticipate?
A. Bradycardia and hypotension.
B. Somnolence and constricted pupils.
C. Hypertension, diaphoresis, and hallucinations.
D. Hypothermia and increased appetite.
Answer: C
Rationale: Alcohol Withdrawal Delirium (Delirium Tremens) is a medical emergency
characterized by autonomic hyperactivity. Symptoms include severe hypertension,
tachycardia, diaphoresis, fever, agitation, and visual or tactile hallucinations. These
typically manifest 48 to 72 hours after the last drink and require aggressive treatment with
benzodiazepines.
8. A client with Obsessive-Compulsive Disorder (OCD) spends two hours daily washing their
hands. Which initial nursing intervention is most appropriate?
A. Physically preventing the client from using the sink.
B. Telling the client that their hands are clean and the behavior is irrational.
C. Allowing the ritual but gradually setting limits on the time spent.
D. Assigning the client a task to perform during their usual hand-washing time.
Answer: C
Rationale: In the initial phase of treatment for OCD, rituals should be allowed to prevent
overwhelming anxiety. However, the nurse should collaborate with the client to gradually
reduce the time spent on rituals as coping skills are developed. Abruptly stopping the ritual
can cause panic and hinder the therapeutic relationship.
(NUR253 Exam 3) | Galen College of Nursing
1. A nurse is assessing a client prescribed Lithium carbonate for Bipolar I Disorder. The client
reports blurred vision, a coarse hand tremor, and severe diarrhea. Which action should the
nurse take first?
A. Request a stat serum Lithium level and withhold the dose.
B. Administer the next scheduled dose of Lithium as prescribed.
C. Advise the client to increase their sodium intake immediately.
D. Document the findings as expected side effects of the medication.
Answer: A
Rationale: The symptoms described, including blurred vision, coarse tremors, and severe
diarrhea, indicate advanced Lithium toxicity, which typically occurs at levels above 1.5
mEq/L. The nurse must prioritize patient safety by withholding the medication to prevent
further toxicity and obtaining a serum level to confirm the diagnosis. Advanced toxicity can
lead to seizures, coma, or death if not addressed immediately.
2. A client with Schizophrenia is experiencing auditory hallucinations and tells the nurse, ‘The
voices are telling me I am a bad person.’ Which response by the nurse is therapeutic?
A. ‘I don’t hear the voices, but I understand they are real to you.’
B. ‘Why do you think the voices are saying that to you?’
C. ‘Don’t listen to them; you are actually a very kind person.’
D. ‘What exactly are the voices telling you to do right now?’
Answer: A
Rationale: This response acknowledges the client’s internal experience without validating
the hallucination as external reality, a technique known as presenting reality. It provides
support while maintaining the nurse’s own perception of environment. Avoid asking ‘why’
questions or dismissing the client’s feelings, as these are non-therapeutic.
3. A nurse is caring for a client admitted with Major Depressive Disorder (MDD). The client
began taking Fluoxetine 20 mg daily three days ago. Which assessment finding requires
immediate intervention?
A. The client states they have a sudden increase in energy.
B. The client reports a dry mouth and mild nausea.
C. The client expresses hope that the medication will work soon.
,D. The client reports difficulty falling asleep at night.
Answer: A
Rationale: A sudden increase in energy in a client with MDD shortly after starting an SSRI
can indicate an increased risk for suicide. The client may now have the physical energy to
carry out a suicide plan that they previously lacked the motivation to execute. The nurse
must immediately perform a suicide risk assessment and implement safety precautions.
4. A client is diagnosed with Anorexia Nervosa and has a Body Mass Index (BMI) of 14. Which
nursing diagnosis is the priority for this client?
A. Disturbed Body Image related to cognitive distortion.
B. Imbalanced Nutrition: Less than body requirements.
C. Low Self-Esteem related to perceived lack of control.
D. Risk for Electrolyte Imbalance and Cardiac Dysrhythmias.
Answer: D
Rationale: While all options are relevant to Anorexia Nervosa, the physiological risk to life
is the priority according to Maslow’s Hierarchy of Needs. A BMI of 14 indicates severe
malnutrition, which often leads to life-threatening complications such as hypokalemia and
bradycardia. Monitoring for cardiac instability and electrolyte shifts (Refeeding Syndrome)
is the most critical nursing action.
5. During a group therapy session, a client with Borderline Personality Disorder (BPD) tells the
nurse, ‘You are the only good nurse here; all the others are incompetent.’ The nurse
recognizes this as:
A. Reaction formation.
B. Altruism.
C. Projective identification.
D. Splitting.
Answer: D
Rationale: Splitting is a common defense mechanism in BPD where the individual views
people or situations as either all good or all bad. It is a failure to integrate the positive and
negative qualities of self and others into a cohesive whole. The nurse should maintain
consistent boundaries and communicate with the rest of the treatment team to prevent
staff manipulation.
6. A client is receiving Clozapine for treatment-resistant Schizophrenia. Which laboratory
value must the nurse monitor weekly during the first six months of therapy?
A. Serum Potassium level.
, B. Blood Urea Nitrogen (BUN).
C. Absolute Neutrophil Count (ANC).
D. Aspartate Aminotransferase (AST).
Answer: C
Rationale: Clozapine carries a black box warning for agranulocytosis, a life-threatening
decrease in white blood cells. National registries require mandatory weekly ANC
monitoring to ensure the client is not developing severe neutropenia. If the ANC falls below
a specific threshold (usually 1,500/mm³), the medication must be discontinued.
7. A nurse is assessing a client for suspected Alcohol Withdrawal Delirium. Which of the
following findings should the nurse anticipate?
A. Bradycardia and hypotension.
B. Somnolence and constricted pupils.
C. Hypertension, diaphoresis, and hallucinations.
D. Hypothermia and increased appetite.
Answer: C
Rationale: Alcohol Withdrawal Delirium (Delirium Tremens) is a medical emergency
characterized by autonomic hyperactivity. Symptoms include severe hypertension,
tachycardia, diaphoresis, fever, agitation, and visual or tactile hallucinations. These
typically manifest 48 to 72 hours after the last drink and require aggressive treatment with
benzodiazepines.
8. A client with Obsessive-Compulsive Disorder (OCD) spends two hours daily washing their
hands. Which initial nursing intervention is most appropriate?
A. Physically preventing the client from using the sink.
B. Telling the client that their hands are clean and the behavior is irrational.
C. Allowing the ritual but gradually setting limits on the time spent.
D. Assigning the client a task to perform during their usual hand-washing time.
Answer: C
Rationale: In the initial phase of treatment for OCD, rituals should be allowed to prevent
overwhelming anxiety. However, the nurse should collaborate with the client to gradually
reduce the time spent on rituals as coping skills are developed. Abruptly stopping the ritual
can cause panic and hinder the therapeutic relationship.
