NUR 253 Exam 2 Actual Exam V3 | NUR 253 Mental Health Nursing
(NUR253 Exam 2) | Galen College of Nursing
1. A nurse is caring for a client with Bipolar I Disorder who is experiencing a manic episode.
The client is moving rapidly, talking loudly, and interrupting others. Which nursing
intervention is the priority?
A. Encouraging the client to participate in a group exercise session.
B. Asking the client to lead a discussion on their feelings.
C. Providing a quiet environment with low stimuli.
D. Setting up a detailed schedule for the client’s daily tasks.
Answer: C
Rationale: During a manic episode, clients are easily overwhelmed by environmental
stimuli which can further escalate their agitation. Providing a low-stimulus environment
helps to decrease neurological overstimulation and promotes safety. This approach is
prioritized over group activities or complex discussions that the client cannot focus on at
this time.
2. A client is prescribed Lithium Carbonate for the management of Bipolar Disorder. Which
laboratory result should the nurse report to the healthcare provider immediately?
A. Serum sodium level of 128 mEq/L
B. Serum lithium level of 0.8 mEq/L
C. Fast blood glucose of 105 mg/dL
D. White blood cell count of 8,000/mm3
Answer: A
Rationale: Lithium is a salt, and its excretion is closely tied to sodium levels in the body. A
low sodium level (hyponatremia) decreases lithium excretion, which significantly increases
the risk of lithium toxicity. The nurse must monitor electrolyte levels closely to ensure the
client stays within a safe therapeutic range.
3. The nurse is assessing a client for potential suicidal ideation. Which statement by the client
represents the highest immediate risk?
A. I have been feeling very down lately and nothing seems to help.
B. I wish I could just go to sleep and never wake up again.
C. I have a bottle of pills at home and I plan to take them tonight.
D. My family would be much better off if I wasn’t around anymore.
,Answer: C
Rationale: This statement indicates a specific plan, a lethal method, and a designated
timeframe, which are the hallmarks of high suicide lethality. While the other statements
show hopelessness or passive ideation, they lack the immediate ‘lethality’ of a concrete
plan. The nurse must implement one-to-one observation immediately for this client.
4. A client being treated with Haloperidol (Haldol) develops muscular rigidity, a temperature
of 103°F, and a rapid heart rate. What is the nurse’s first action?
A. Notify the provider and prepare to hold the medication.
B. Apply a cooling blanket to reduce the fever.
C. Administer the next dose of Haloperidol as scheduled.
D. Encourage the client to increase oral fluid intake.
Answer: A
Rationale: These symptoms are indicative of Neuroleptic Malignant Syndrome (NMS), a
life-threatening complication of antipsychotic medications. The immediate priority is to
stop the causative agent and notify the medical team for emergency intervention. NMS
requires intensive medical care to manage cardiovascular stability and muscle breakdown.
5. A client with Borderline Personality Disorder is praising one nurse while telling another
nurse that they are ‘incompetent and mean.’ This behavior is known as:
A. Regression
B. Reaction Formation
C. Projection
D. Splitting
Answer: D
Rationale: Splitting is a common defense mechanism in Borderline Personality Disorder
where the individual views people or situations as either all good or all bad. This behavior
often creates conflict among the nursing staff and disrupts the therapeutic milieu.
Consistency and frequent staff communication are essential to manage this behavior
effectively.
6. A client is starting a Monoamine Oxidase Inhibitor (MAOI) for depression. Which food
choice should the nurse instruct the client to avoid?
A. Fresh grilled chicken breast
B. Aged cheddar cheese and pepperoni
C. Steamed broccoli and carrots
, D. Whole grain bread and butter
Answer: B
Rationale: MAOIs interact with tyramine-rich foods, which can trigger a hypertensive
crisis. Aged cheeses and cured meats like pepperoni are high in tyramine and must be
strictly avoided. The nurse must provide comprehensive education on dietary restrictions
to prevent life-threatening cardiovascular events.
7. A nurse is performing a mental status examination (MSE) on a new client. Which
component assesses the client’s ability to think abstractly?
A. Asking the client to count backward from 100 by sevens.
B. Asking the client where they were born and their current address.
C. Asking the client to interpret the proverb ‘A rolling stone gathers no moss.’
D. Observing the client’s grooming and hygiene standards.
Answer: C
Rationale: Proverb interpretation is a standard method used to assess abstract versus
concrete thinking. A client with impaired cognition or certain psychotic disorders may
provide a literal or concrete explanation. Assessing abstract reasoning helps determine the
level of cognitive functioning and executive processing.
8. A client with schizophrenia is hearing voices telling them that the food is poisoned. Which
response by the nurse is therapeutic?
A. The food isn’t poisoned; I am eating it too, see?
B. I don’t hear the voices, but I understand that they are real to you.
C. Why do you think the kitchen staff would want to hurt you?
D. You shouldn’t listen to those voices because they are not real.
Answer: B
Rationale: This response acknowledges the client’s experience without validating the
hallucination as reality, a technique known as ‘presenting reality.’ It avoids arguing with
the client, which is usually counterproductive and can increase paranoia. By validating the
client’s feelings, the nurse maintains a therapeutic relationship while grounding the client
in the present.
9. A nurse is caring for a client in the emergency department who was just sexually assaulted.
What is the priority nursing action?
A. Assisting the client in calling their family members.
B. Providing a safe, private environment and staying with the client.
(NUR253 Exam 2) | Galen College of Nursing
1. A nurse is caring for a client with Bipolar I Disorder who is experiencing a manic episode.
The client is moving rapidly, talking loudly, and interrupting others. Which nursing
intervention is the priority?
A. Encouraging the client to participate in a group exercise session.
B. Asking the client to lead a discussion on their feelings.
C. Providing a quiet environment with low stimuli.
D. Setting up a detailed schedule for the client’s daily tasks.
Answer: C
Rationale: During a manic episode, clients are easily overwhelmed by environmental
stimuli which can further escalate their agitation. Providing a low-stimulus environment
helps to decrease neurological overstimulation and promotes safety. This approach is
prioritized over group activities or complex discussions that the client cannot focus on at
this time.
2. A client is prescribed Lithium Carbonate for the management of Bipolar Disorder. Which
laboratory result should the nurse report to the healthcare provider immediately?
A. Serum sodium level of 128 mEq/L
B. Serum lithium level of 0.8 mEq/L
C. Fast blood glucose of 105 mg/dL
D. White blood cell count of 8,000/mm3
Answer: A
Rationale: Lithium is a salt, and its excretion is closely tied to sodium levels in the body. A
low sodium level (hyponatremia) decreases lithium excretion, which significantly increases
the risk of lithium toxicity. The nurse must monitor electrolyte levels closely to ensure the
client stays within a safe therapeutic range.
3. The nurse is assessing a client for potential suicidal ideation. Which statement by the client
represents the highest immediate risk?
A. I have been feeling very down lately and nothing seems to help.
B. I wish I could just go to sleep and never wake up again.
C. I have a bottle of pills at home and I plan to take them tonight.
D. My family would be much better off if I wasn’t around anymore.
,Answer: C
Rationale: This statement indicates a specific plan, a lethal method, and a designated
timeframe, which are the hallmarks of high suicide lethality. While the other statements
show hopelessness or passive ideation, they lack the immediate ‘lethality’ of a concrete
plan. The nurse must implement one-to-one observation immediately for this client.
4. A client being treated with Haloperidol (Haldol) develops muscular rigidity, a temperature
of 103°F, and a rapid heart rate. What is the nurse’s first action?
A. Notify the provider and prepare to hold the medication.
B. Apply a cooling blanket to reduce the fever.
C. Administer the next dose of Haloperidol as scheduled.
D. Encourage the client to increase oral fluid intake.
Answer: A
Rationale: These symptoms are indicative of Neuroleptic Malignant Syndrome (NMS), a
life-threatening complication of antipsychotic medications. The immediate priority is to
stop the causative agent and notify the medical team for emergency intervention. NMS
requires intensive medical care to manage cardiovascular stability and muscle breakdown.
5. A client with Borderline Personality Disorder is praising one nurse while telling another
nurse that they are ‘incompetent and mean.’ This behavior is known as:
A. Regression
B. Reaction Formation
C. Projection
D. Splitting
Answer: D
Rationale: Splitting is a common defense mechanism in Borderline Personality Disorder
where the individual views people or situations as either all good or all bad. This behavior
often creates conflict among the nursing staff and disrupts the therapeutic milieu.
Consistency and frequent staff communication are essential to manage this behavior
effectively.
6. A client is starting a Monoamine Oxidase Inhibitor (MAOI) for depression. Which food
choice should the nurse instruct the client to avoid?
A. Fresh grilled chicken breast
B. Aged cheddar cheese and pepperoni
C. Steamed broccoli and carrots
, D. Whole grain bread and butter
Answer: B
Rationale: MAOIs interact with tyramine-rich foods, which can trigger a hypertensive
crisis. Aged cheeses and cured meats like pepperoni are high in tyramine and must be
strictly avoided. The nurse must provide comprehensive education on dietary restrictions
to prevent life-threatening cardiovascular events.
7. A nurse is performing a mental status examination (MSE) on a new client. Which
component assesses the client’s ability to think abstractly?
A. Asking the client to count backward from 100 by sevens.
B. Asking the client where they were born and their current address.
C. Asking the client to interpret the proverb ‘A rolling stone gathers no moss.’
D. Observing the client’s grooming and hygiene standards.
Answer: C
Rationale: Proverb interpretation is a standard method used to assess abstract versus
concrete thinking. A client with impaired cognition or certain psychotic disorders may
provide a literal or concrete explanation. Assessing abstract reasoning helps determine the
level of cognitive functioning and executive processing.
8. A client with schizophrenia is hearing voices telling them that the food is poisoned. Which
response by the nurse is therapeutic?
A. The food isn’t poisoned; I am eating it too, see?
B. I don’t hear the voices, but I understand that they are real to you.
C. Why do you think the kitchen staff would want to hurt you?
D. You shouldn’t listen to those voices because they are not real.
Answer: B
Rationale: This response acknowledges the client’s experience without validating the
hallucination as reality, a technique known as ‘presenting reality.’ It avoids arguing with
the client, which is usually counterproductive and can increase paranoia. By validating the
client’s feelings, the nurse maintains a therapeutic relationship while grounding the client
in the present.
9. A nurse is caring for a client in the emergency department who was just sexually assaulted.
What is the priority nursing action?
A. Assisting the client in calling their family members.
B. Providing a safe, private environment and staying with the client.
