NUR 253 Exam 4 Actual Exam V1 | NUR 253 Mental Health Nursing
(NUR253 Exam 4) | Galen College of Nursing
1. A nurse is assessing a client who has been taking lithium carbonate for the treatment of
bipolar disorder. Which of the following laboratory findings should the nurse identify as a
sign of lithium toxicity?
A. Lithium level of 0.8 mEq/L
B. Lithium level of 1.6 mEq/L
C. Serum sodium level of 140 mEq/L
D. Potassium level of 4.2 mEq/L
Answer: B
Rationale: A lithium level of 1.6 mEq/L is above the therapeutic range of 0.6 to 1.2 mEq/L
and indicates early toxicity. The nurse should monitor for symptoms such as blurred vision,
ataxia, and severe diarrhea. Maintaining adequate sodium intake is crucial as low sodium
can further increase lithium levels.
2. A client diagnosed with schizophrenia is experiencing auditory hallucinations and states,
‘The voices are telling me that you are a spy.’ Which response by the nurse is therapeutic?
A. I don’t hear the voices, but I understand that they are real to you.
B. Why do you think the voices would say something like that about me?
C. I am not a spy; I am your nurse and I am here to help you.
D. You should try to ignore the voices and focus on our group activity.
Answer: A
Rationale: This response acknowledges the client’s perception of reality without validating
the hallucination as fact. It demonstrates empathy while maintaining a grounding in reality,
which is a core psychiatric nursing intervention. Avoid challenging the hallucination
directly as it may increase the client’s anxiety or defensive behaviors.
3. A nurse is caring for a client who was involuntarily committed to a psychiatric facility.
Which of the following rights does the client retain?
A. The right to leave the facility against medical advice at any time.
B. The right to bypass the facility’s safety search protocols.
C. The right to possess unlimited personal belongings in their room.
D. The right to refuse prescribed psychiatric medications.
,Answer: D
Rationale: Even under involuntary commitment, clients generally retain the right to refuse
medication unless they are a danger to themselves or others and a court order is obtained.
Involuntary status primarily restricts the right to leave the facility (freedom of movement).
The nurse must respect patient autonomy while ensuring the safety of the milieu.
4. A client with borderline personality disorder is using ‘splitting’ behavior by telling a day-
shift nurse that the night-shift nurse is ‘terrible and incompetent.’ How should the nurse
respond?
A. The staff works together as a team to provide your care.
B. You should tell the unit manager about your concerns.
C. I agree that the night nurse can be difficult sometimes.
D. Why are you always trying to cause trouble between the staff?
Answer: A
Rationale: Splitting is a common defense mechanism in borderline personality disorder
where people are viewed as all good or all bad. The nurse should use a matter-of-fact
approach and reinforce the unity of the treatment team to prevent staff manipulation. This
intervention helps maintain professional boundaries and consistency in the therapeutic
environment.
5. A nurse is evaluating a client for potential Serotonin Syndrome. Which of the following
clinical manifestations should the nurse expect to find?
A. Hyporeflexia and bradycardia
B. Hyperreflexia and agitation
C. Muscular rigidity and high fever
D. Urinary retention and constipation
Answer: B
Rationale: Serotonin Syndrome is characterized by mental status changes, autonomic
hyperactivity, and neuromuscular abnormalities such as hyperreflexia and tremors. It often
occurs when multiple serotonergic agents are combined. Immediate discontinuation of the
causative agent and supportive care are the primary treatments.
6. A client is prescribed Clozapine for treatment-resistant schizophrenia. Which monitoring
parameter is the highest priority for the nurse to follow?
A. Blood glucose levels
B. Body mass index (BMI)
C. White blood cell count
, D. Blood pressure
Answer: C
Rationale: Clozapine carries a significant risk for agranulocytosis, a life-threatening
reduction in white blood cells. Mandatory blood monitoring of the absolute neutrophil
count (ANC) is required by law. Nurses must educate clients to report any signs of
infection, such as fever or sore throat, immediately.
7. During a group therapy session, a client becomes increasingly agitated and starts pacing
the room. What is the nurse’s priority action?
A. Ask the other clients to leave the room for their safety.
B. Administer a PRN dose of haloperidol immediately.
C. Accompany the client to a quiet area to decrease stimuli.
D. Place the client in physical restraints to prevent injury.
Answer: C
Rationale: The least restrictive intervention should always be attempted first in crisis
management. Moving the client to a low-stimulus environment can help de-escalate the
situation and prevents the agitation from spreading to other group members. Restraints
and seclusion should only be used as a last resort when the client is an imminent danger.
8. A nurse is assessing a client with Anorexia Nervosa. Which of the following physiological
findings is most consistent with this diagnosis?
A. Hypertension
B. Tachycardia
C. Lanugo
D. Hyperkalemia
Answer: C
Rationale: Lanugo is the growth of fine, downy hair on the face and back as the body
attempts to insulate itself due to the loss of subcutaneous fat. Other signs include
bradycardia, hypotension, and electrolyte imbalances such as hypokalemia. These physical
symptoms reflect the severity of malnutrition and metabolic dysfunction.
9. A client is admitted for alcohol withdrawal. Which medication should the nurse anticipate
administering to prevent seizures and delirium tremens?
A. Lorazepam
B. Disulfiram
C. Methadone
(NUR253 Exam 4) | Galen College of Nursing
1. A nurse is assessing a client who has been taking lithium carbonate for the treatment of
bipolar disorder. Which of the following laboratory findings should the nurse identify as a
sign of lithium toxicity?
A. Lithium level of 0.8 mEq/L
B. Lithium level of 1.6 mEq/L
C. Serum sodium level of 140 mEq/L
D. Potassium level of 4.2 mEq/L
Answer: B
Rationale: A lithium level of 1.6 mEq/L is above the therapeutic range of 0.6 to 1.2 mEq/L
and indicates early toxicity. The nurse should monitor for symptoms such as blurred vision,
ataxia, and severe diarrhea. Maintaining adequate sodium intake is crucial as low sodium
can further increase lithium levels.
2. A client diagnosed with schizophrenia is experiencing auditory hallucinations and states,
‘The voices are telling me that you are a spy.’ Which response by the nurse is therapeutic?
A. I don’t hear the voices, but I understand that they are real to you.
B. Why do you think the voices would say something like that about me?
C. I am not a spy; I am your nurse and I am here to help you.
D. You should try to ignore the voices and focus on our group activity.
Answer: A
Rationale: This response acknowledges the client’s perception of reality without validating
the hallucination as fact. It demonstrates empathy while maintaining a grounding in reality,
which is a core psychiatric nursing intervention. Avoid challenging the hallucination
directly as it may increase the client’s anxiety or defensive behaviors.
3. A nurse is caring for a client who was involuntarily committed to a psychiatric facility.
Which of the following rights does the client retain?
A. The right to leave the facility against medical advice at any time.
B. The right to bypass the facility’s safety search protocols.
C. The right to possess unlimited personal belongings in their room.
D. The right to refuse prescribed psychiatric medications.
,Answer: D
Rationale: Even under involuntary commitment, clients generally retain the right to refuse
medication unless they are a danger to themselves or others and a court order is obtained.
Involuntary status primarily restricts the right to leave the facility (freedom of movement).
The nurse must respect patient autonomy while ensuring the safety of the milieu.
4. A client with borderline personality disorder is using ‘splitting’ behavior by telling a day-
shift nurse that the night-shift nurse is ‘terrible and incompetent.’ How should the nurse
respond?
A. The staff works together as a team to provide your care.
B. You should tell the unit manager about your concerns.
C. I agree that the night nurse can be difficult sometimes.
D. Why are you always trying to cause trouble between the staff?
Answer: A
Rationale: Splitting is a common defense mechanism in borderline personality disorder
where people are viewed as all good or all bad. The nurse should use a matter-of-fact
approach and reinforce the unity of the treatment team to prevent staff manipulation. This
intervention helps maintain professional boundaries and consistency in the therapeutic
environment.
5. A nurse is evaluating a client for potential Serotonin Syndrome. Which of the following
clinical manifestations should the nurse expect to find?
A. Hyporeflexia and bradycardia
B. Hyperreflexia and agitation
C. Muscular rigidity and high fever
D. Urinary retention and constipation
Answer: B
Rationale: Serotonin Syndrome is characterized by mental status changes, autonomic
hyperactivity, and neuromuscular abnormalities such as hyperreflexia and tremors. It often
occurs when multiple serotonergic agents are combined. Immediate discontinuation of the
causative agent and supportive care are the primary treatments.
6. A client is prescribed Clozapine for treatment-resistant schizophrenia. Which monitoring
parameter is the highest priority for the nurse to follow?
A. Blood glucose levels
B. Body mass index (BMI)
C. White blood cell count
, D. Blood pressure
Answer: C
Rationale: Clozapine carries a significant risk for agranulocytosis, a life-threatening
reduction in white blood cells. Mandatory blood monitoring of the absolute neutrophil
count (ANC) is required by law. Nurses must educate clients to report any signs of
infection, such as fever or sore throat, immediately.
7. During a group therapy session, a client becomes increasingly agitated and starts pacing
the room. What is the nurse’s priority action?
A. Ask the other clients to leave the room for their safety.
B. Administer a PRN dose of haloperidol immediately.
C. Accompany the client to a quiet area to decrease stimuli.
D. Place the client in physical restraints to prevent injury.
Answer: C
Rationale: The least restrictive intervention should always be attempted first in crisis
management. Moving the client to a low-stimulus environment can help de-escalate the
situation and prevents the agitation from spreading to other group members. Restraints
and seclusion should only be used as a last resort when the client is an imminent danger.
8. A nurse is assessing a client with Anorexia Nervosa. Which of the following physiological
findings is most consistent with this diagnosis?
A. Hypertension
B. Tachycardia
C. Lanugo
D. Hyperkalemia
Answer: C
Rationale: Lanugo is the growth of fine, downy hair on the face and back as the body
attempts to insulate itself due to the loss of subcutaneous fat. Other signs include
bradycardia, hypotension, and electrolyte imbalances such as hypokalemia. These physical
symptoms reflect the severity of malnutrition and metabolic dysfunction.
9. A client is admitted for alcohol withdrawal. Which medication should the nurse anticipate
administering to prevent seizures and delirium tremens?
A. Lorazepam
B. Disulfiram
C. Methadone
