NUR 253 Final Exam Actual Exam V1 | NUR 253 Mental Health Nursing
(NUR253 Final Exam) | Galen College of Nursing
1. A nurse is conducting a mental status examination on a newly admitted client. Which of
the following statements by the client indicates a disturbance in ‘content of thought’?
A. My name is John, and today is Tuesday, 2023.
B. I feel very sad and hopless most of the time.
C. The client stops speaking mid-sentence and looks at the wall.
D. I am the secret leader of the international space program.
Answer: D
Rationale: Disturbance in thought content involves what the person is thinking, such as
delusions or obsessions. Being a ‘secret leader’ is a delusion of grandeur. Mood (sadness)
refers to affect, while stopping mid-sentence refers to thought process (blocking).
2. A client with schizophrenia is experiencing auditory hallucinations and tells the nurse, ‘The
voices are telling me to hurt my roommate.’ Which action should the nurse take first?
A. Place the client in physical restraints immediately.
B. Tell the client that the voices are not real and to ignore them.
C. Administer an extra dose of an antipsychotic medication.
D. Initiate one-on-one observation and notify the treatment team.
Answer: D
Rationale: Safety is the priority. When a client reports command hallucinations that
threaten others, immediate close observation is required to prevent harm. Restraints are a
last resort, and medications require an order.
3. The nurse is caring for a client with Bipolar I Disorder who is in an acute manic phase.
Which meal choice is most appropriate for this client?
A. A bowl of vegetable soup and a side salad.
B. Chicken nuggets, an apple, and a carton of milk.
C. A large steak with mashed potatoes and gravy.
D. Spaghetti and meatballs with a glass of juice.
Answer: B
, Rationale: Clients in a manic phase often have high energy and cannot sit still to eat.
‘Finger foods’ that are high in protein and calories allow the client to eat while moving.
4. A client is prescribed Lithium Carbonate for the treatment of Bipolar Disorder. Which of the
following findings should the nurse report to the provider as a sign of lithium toxicity?
A. Fine hand tremors and mild thirst.
B. Occasional nausea and weight gain of 2 lbs.
C. Polyuria and a metallic taste in the mouth.
D. Blurred vision, ataxia, and persistent diarrhea.
Answer: D
Rationale: Ataxia, blurred vision, and severe gastrointestinal upset (diarrhea/vomiting)
are signs of moderate to severe lithium toxicity. Fine tremors and mild thirst are common
side effects, not toxic signs.
5. A nurse is preparing to administer Haloperidol to a client. Which extrapyramidal side effect
(EPS) is characterized by a painful, involuntary upward deviation of the eyes?
A. Oculogyric crisis
B. Akathisia
C. Tardive Dyskinesia
D. Pseudoparkinsonism
Answer: A
Rationale: An oculogyric crisis is a type of acute dystonia where the eyes are fixed in an
upward gaze. It is a medical emergency often treated with Benztropine.
6. A client was admitted 24 hours ago after a long history of heavy alcohol use. The client is
now tremulous, tachycardic, and reporting ‘bugs crawling on the bed.’ What is the nurse’s
priority?
A. Provide a quiet, dark environment to reduce stimuli.
B. Obtain a blood sample for a liver function test.
C. Explain that there are no bugs on the bed.
D. Administer Diazepam as prescribed for alcohol withdrawal.
Answer: D
Rationale: The client is showing signs of alcohol withdrawal delirium (DTs).
Pharmacological intervention with benzodiazepines like Diazepam is the priority to
prevent seizures and death.
(NUR253 Final Exam) | Galen College of Nursing
1. A nurse is conducting a mental status examination on a newly admitted client. Which of
the following statements by the client indicates a disturbance in ‘content of thought’?
A. My name is John, and today is Tuesday, 2023.
B. I feel very sad and hopless most of the time.
C. The client stops speaking mid-sentence and looks at the wall.
D. I am the secret leader of the international space program.
Answer: D
Rationale: Disturbance in thought content involves what the person is thinking, such as
delusions or obsessions. Being a ‘secret leader’ is a delusion of grandeur. Mood (sadness)
refers to affect, while stopping mid-sentence refers to thought process (blocking).
2. A client with schizophrenia is experiencing auditory hallucinations and tells the nurse, ‘The
voices are telling me to hurt my roommate.’ Which action should the nurse take first?
A. Place the client in physical restraints immediately.
B. Tell the client that the voices are not real and to ignore them.
C. Administer an extra dose of an antipsychotic medication.
D. Initiate one-on-one observation and notify the treatment team.
Answer: D
Rationale: Safety is the priority. When a client reports command hallucinations that
threaten others, immediate close observation is required to prevent harm. Restraints are a
last resort, and medications require an order.
3. The nurse is caring for a client with Bipolar I Disorder who is in an acute manic phase.
Which meal choice is most appropriate for this client?
A. A bowl of vegetable soup and a side salad.
B. Chicken nuggets, an apple, and a carton of milk.
C. A large steak with mashed potatoes and gravy.
D. Spaghetti and meatballs with a glass of juice.
Answer: B
, Rationale: Clients in a manic phase often have high energy and cannot sit still to eat.
‘Finger foods’ that are high in protein and calories allow the client to eat while moving.
4. A client is prescribed Lithium Carbonate for the treatment of Bipolar Disorder. Which of the
following findings should the nurse report to the provider as a sign of lithium toxicity?
A. Fine hand tremors and mild thirst.
B. Occasional nausea and weight gain of 2 lbs.
C. Polyuria and a metallic taste in the mouth.
D. Blurred vision, ataxia, and persistent diarrhea.
Answer: D
Rationale: Ataxia, blurred vision, and severe gastrointestinal upset (diarrhea/vomiting)
are signs of moderate to severe lithium toxicity. Fine tremors and mild thirst are common
side effects, not toxic signs.
5. A nurse is preparing to administer Haloperidol to a client. Which extrapyramidal side effect
(EPS) is characterized by a painful, involuntary upward deviation of the eyes?
A. Oculogyric crisis
B. Akathisia
C. Tardive Dyskinesia
D. Pseudoparkinsonism
Answer: A
Rationale: An oculogyric crisis is a type of acute dystonia where the eyes are fixed in an
upward gaze. It is a medical emergency often treated with Benztropine.
6. A client was admitted 24 hours ago after a long history of heavy alcohol use. The client is
now tremulous, tachycardic, and reporting ‘bugs crawling on the bed.’ What is the nurse’s
priority?
A. Provide a quiet, dark environment to reduce stimuli.
B. Obtain a blood sample for a liver function test.
C. Explain that there are no bugs on the bed.
D. Administer Diazepam as prescribed for alcohol withdrawal.
Answer: D
Rationale: The client is showing signs of alcohol withdrawal delirium (DTs).
Pharmacological intervention with benzodiazepines like Diazepam is the priority to
prevent seizures and death.
