NUR 253 Final Exam Actual Exam V2 | NUR 253 Mental Health Nursing
(NUR253 Final Exam) | Galen College of Nursing
1. A client with schizophrenia is started on clozapine. Which laboratory result is the most
critical for the nurse to monitor to ensure patient safety?
A. Absolute neutrophil count (ANC)
B. Blood urea nitrogen (BUN)
C. Platelet count
D. Serum potassium levels
Answer: A
Rationale: Clozapine carries a significant risk of agranulocytosis, which is a life-
threatening decrease in white blood cells. The Absolute Neutrophil Count (ANC) must be
monitored weekly initially to detect neutropenia before it leads to fatal infection. If the ANC
falls below a specific threshold, the medication must be discontinued immediately to
prevent sepsis.
2. A client hospitalized with severe depression says, ‘I am a burden to everyone; they would
be better off without me.’ What is the most therapeutic response by the nurse?
A. You shouldn’t feel that way; your family loves you very much.
B. I will tell your family to visit more often so you feel less alone.
C. Why do you think you are a burden to your family?
D. It sounds like you are feeling very hopeless right now. Are you thinking of harming
yourself?
Answer: D
Rationale: The nurse’s priority is to assess for suicidal ideation when a client expresses
feelings of worthlessness or being a burden. This response uses the therapeutic technique
of verbalizing the implied and asks a direct question about safety. Validating the client’s
feelings while directly addressing the risk of self-harm is the standard of care in psychiatric
nursing.
3. A client is receiving lithium carbonate for bipolar disorder. The nurse notes the client has
coarse hand tremors, diarrhea, and confusion. Which action should the nurse take first?
A. Administer the next dose as scheduled.
B. Encourage the client to increase fluid intake.
C. Withhold the medication and notify the provider.
,D. Reassure the client that these are common side effects.
Answer: C
Rationale: Coarse tremors, gastrointestinal upset, and mental status changes are classic
signs of lithium toxicity. Lithium has a narrow therapeutic index, and these symptoms
suggest levels may be exceeding 1.5 mEq/L. The nurse must immediately stop the
medication to prevent permanent neurological damage or death while awaiting a serum
lithium level test.
4. A client is admitted to the psychiatric unit with a diagnosis of Borderline Personality
Disorder. The client tells the nurse, ‘The night nurse is so mean, but you are the best nurse I
have ever had.’ The nurse recognizes this as which defense mechanism?
A. Projection
B. Sublimation
C. Reaction Formation
D. Splitting
Answer: D
Rationale: Splitting is a common defense mechanism in Borderline Personality Disorder
where individuals view others as entirely good or entirely bad. This behavior often creates
conflict among staff members on a treatment team. The nursing priority is to maintain
consistent boundaries and use a team-based approach to minimize the impact of splitting.
5. Which assessment finding would lead the nurse to suspect that a client is experiencing
Neuroleptic Malignant Syndrome (NMS)?
A. Urinary retention and dry mouth
B. Hypotension and bradycardia
C. Hyperpyrexia and muscle rigidity
D. Increased appetite and weight gain
Answer: C
Rationale: NMS is a medical emergency associated with antipsychotic medication use
characterized by high fever (hyperpyrexia), lead-pipe muscle rigidity, and autonomic
instability. This condition requires immediate cessation of the causative agent and
supportive care in an intensive care setting. Failure to recognize these symptoms early can
lead to rhabdomyolysis and renal failure.
6. A nurse is caring for a client experiencing a manic episode. Which meal choice is most
appropriate for this client?
A. A bowl of soup and a side salad
, B. Spaghetti with meatballs and garlic bread
C. A chicken sandwich and an apple
D. Steak with mashed potatoes and gravy
Answer: C
Rationale: Clients in a manic state are often too hyperactive to sit down for a full meal and
may experience nutritional deficits. High-protein, high-calorie ‘finger foods’ allow the client
to eat while moving around the unit. This approach supports the client’s physiological
needs without forcing them into a restrictive environment that could escalate agitation.
7. A client with Obsessive-Compulsive Disorder (OCD) spends 2 hours washing their hands
every morning. What is the best initial nursing intervention?
A. Allow enough time for the ritual early in treatment.
B. Tell the client that their hands are clean and they must stop.
C. Lock the bathroom door to prevent the client from washing.
D. Administer an anti-anxiety medication every time they start washing.
Answer: A
Rationale: In the initial phase of treatment for OCD, the nurse should allow the client to
perform rituals to prevent overwhelming anxiety. Abruptly stopping a ritual can cause a
panic attack or extreme distress. Over time, the nurse works with the client to implement
behavioral therapies, such as exposure and response prevention, to gradually reduce the
time spent on rituals.
8. The nurse is preparing to administer phenelzine, an MAOI, to a client. Which food item
should the nurse instruct the client to avoid?
A. Cottage cheese
B. Fresh chicken
C. Aged cheddar cheese
D. Green leafy vegetables
Answer: C
Rationale: Clients taking Monoamine Oxidase Inhibitors (MAOIs) must strictly avoid foods
high in tyramine, such as aged cheeses, cured meats, and red wine. Consumption of
tyramine while on an MAOI can trigger a hypertensive crisis, which is a life-threatening
elevation in blood pressure. The nurse must provide extensive education on dietary
restrictions to ensure patient safety.
(NUR253 Final Exam) | Galen College of Nursing
1. A client with schizophrenia is started on clozapine. Which laboratory result is the most
critical for the nurse to monitor to ensure patient safety?
A. Absolute neutrophil count (ANC)
B. Blood urea nitrogen (BUN)
C. Platelet count
D. Serum potassium levels
Answer: A
Rationale: Clozapine carries a significant risk of agranulocytosis, which is a life-
threatening decrease in white blood cells. The Absolute Neutrophil Count (ANC) must be
monitored weekly initially to detect neutropenia before it leads to fatal infection. If the ANC
falls below a specific threshold, the medication must be discontinued immediately to
prevent sepsis.
2. A client hospitalized with severe depression says, ‘I am a burden to everyone; they would
be better off without me.’ What is the most therapeutic response by the nurse?
A. You shouldn’t feel that way; your family loves you very much.
B. I will tell your family to visit more often so you feel less alone.
C. Why do you think you are a burden to your family?
D. It sounds like you are feeling very hopeless right now. Are you thinking of harming
yourself?
Answer: D
Rationale: The nurse’s priority is to assess for suicidal ideation when a client expresses
feelings of worthlessness or being a burden. This response uses the therapeutic technique
of verbalizing the implied and asks a direct question about safety. Validating the client’s
feelings while directly addressing the risk of self-harm is the standard of care in psychiatric
nursing.
3. A client is receiving lithium carbonate for bipolar disorder. The nurse notes the client has
coarse hand tremors, diarrhea, and confusion. Which action should the nurse take first?
A. Administer the next dose as scheduled.
B. Encourage the client to increase fluid intake.
C. Withhold the medication and notify the provider.
,D. Reassure the client that these are common side effects.
Answer: C
Rationale: Coarse tremors, gastrointestinal upset, and mental status changes are classic
signs of lithium toxicity. Lithium has a narrow therapeutic index, and these symptoms
suggest levels may be exceeding 1.5 mEq/L. The nurse must immediately stop the
medication to prevent permanent neurological damage or death while awaiting a serum
lithium level test.
4. A client is admitted to the psychiatric unit with a diagnosis of Borderline Personality
Disorder. The client tells the nurse, ‘The night nurse is so mean, but you are the best nurse I
have ever had.’ The nurse recognizes this as which defense mechanism?
A. Projection
B. Sublimation
C. Reaction Formation
D. Splitting
Answer: D
Rationale: Splitting is a common defense mechanism in Borderline Personality Disorder
where individuals view others as entirely good or entirely bad. This behavior often creates
conflict among staff members on a treatment team. The nursing priority is to maintain
consistent boundaries and use a team-based approach to minimize the impact of splitting.
5. Which assessment finding would lead the nurse to suspect that a client is experiencing
Neuroleptic Malignant Syndrome (NMS)?
A. Urinary retention and dry mouth
B. Hypotension and bradycardia
C. Hyperpyrexia and muscle rigidity
D. Increased appetite and weight gain
Answer: C
Rationale: NMS is a medical emergency associated with antipsychotic medication use
characterized by high fever (hyperpyrexia), lead-pipe muscle rigidity, and autonomic
instability. This condition requires immediate cessation of the causative agent and
supportive care in an intensive care setting. Failure to recognize these symptoms early can
lead to rhabdomyolysis and renal failure.
6. A nurse is caring for a client experiencing a manic episode. Which meal choice is most
appropriate for this client?
A. A bowl of soup and a side salad
, B. Spaghetti with meatballs and garlic bread
C. A chicken sandwich and an apple
D. Steak with mashed potatoes and gravy
Answer: C
Rationale: Clients in a manic state are often too hyperactive to sit down for a full meal and
may experience nutritional deficits. High-protein, high-calorie ‘finger foods’ allow the client
to eat while moving around the unit. This approach supports the client’s physiological
needs without forcing them into a restrictive environment that could escalate agitation.
7. A client with Obsessive-Compulsive Disorder (OCD) spends 2 hours washing their hands
every morning. What is the best initial nursing intervention?
A. Allow enough time for the ritual early in treatment.
B. Tell the client that their hands are clean and they must stop.
C. Lock the bathroom door to prevent the client from washing.
D. Administer an anti-anxiety medication every time they start washing.
Answer: A
Rationale: In the initial phase of treatment for OCD, the nurse should allow the client to
perform rituals to prevent overwhelming anxiety. Abruptly stopping a ritual can cause a
panic attack or extreme distress. Over time, the nurse works with the client to implement
behavioral therapies, such as exposure and response prevention, to gradually reduce the
time spent on rituals.
8. The nurse is preparing to administer phenelzine, an MAOI, to a client. Which food item
should the nurse instruct the client to avoid?
A. Cottage cheese
B. Fresh chicken
C. Aged cheddar cheese
D. Green leafy vegetables
Answer: C
Rationale: Clients taking Monoamine Oxidase Inhibitors (MAOIs) must strictly avoid foods
high in tyramine, such as aged cheeses, cured meats, and red wine. Consumption of
tyramine while on an MAOI can trigger a hypertensive crisis, which is a life-threatening
elevation in blood pressure. The nurse must provide extensive education on dietary
restrictions to ensure patient safety.
