NUR 253 Exam 3 Actual Exam V3 | NUR 253 Mental Health Nursing
(NUR253 Exam 3) | Galen College of Nursing
1. A nurse is assessing a client with Major Depressive Disorder who states, ‘I just can’t do
anything right anymore.’ Which response by the nurse demonstrates therapeutic
communication?
A. Why do you feel like you cannot do anything right?
B. It sounds like you are feeling very frustrated and overwhelmed right now.
C. You should focus on the things you have accomplished in the past.
D. Everyone feels that way sometimes when they are depressed.
Answer: B
Rationale: Reflecting the client’s feelings validates their experience and encourages
further expression. This response avoids ‘why’ questions which can be perceived as
accusatory. The nurse uses an empathetic approach to build rapport and assess the depth
of the client’s hopelessness.
2. A client with Bipolar I Disorder is experiencing acute mania and is moving constantly
around the unit. Which nutritional intervention is most appropriate?
A. Schedule the client for three large, high-protein meals in the dining room.
B. Allow the client to choose whatever they want from the vending machine.
C. Withhold food until the client can sit down and eat a full meal quietly.
D. Provide high-calorie, high-protein finger foods that can be eaten while walking.
Answer: D
Rationale: During acute mania, clients are often too hyperactive to sit for meals, putting
them at risk for exhaustion and weight loss. Finger foods allow the client to maintain
caloric intake while meeting their need for movement. This intervention addresses
physiological safety and nutritional requirements during the manic phase.
3. A client is prescribed Lithium Carbonate for the treatment of Bipolar Disorder. Which
laboratory value should the nurse prioritize for review before administering the morning
dose?
A. Serum Potassium level
B. Hemoglobin and Hematocrit
C. Alanine aminotransferase (ALT)
D. Serum Sodium level
,Answer: D
Rationale: Lithium is a salt and has an inverse relationship with sodium; low sodium levels
can lead to lithium toxicity. The nurse must monitor sodium to ensure the client is not at
risk for toxic accumulation of the medication. This assessment is critical for preventing life-
threatening neurological and renal complications.
4. A client diagnosed with Schizophrenia tells the nurse, ‘The voices are telling me that the
food is poisoned.’ Which action should the nurse take first?
A. Tell the client that the hospital food is safe and inspected regularly.
B. Ask the client, ‘What specifically are the voices saying to you?’
C. Offer to taste the food in front of the client to prove it is safe.
D. Ignore the statement to avoid reinforcing the hallucination.
Answer: B
Rationale: Assessment of command hallucinations is the priority to determine the level of
risk to the client or others. By asking for specifics, the nurse can identify if the voices are
directing the client to perform dangerous acts. This clinical reasoning focuses on
immediate safety and risk stratification.
5. A nurse is caring for a client who has been taking Haloperidol for two days. The client is
now experiencing neck spasms and their eyes are rolling upward. What is the nurse’s priority
action?
A. Document the findings as a common side effect of the medication.
B. Administer the PRN dose of Benztropine as ordered.
C. Instruct the client to practice deep breathing and relaxation techniques.
D. Place the client on seizure precautions immediately.
Answer: B
Rationale: The client is exhibiting symptoms of an acute dystonic reaction, which is an
extrapyramidal side effect (EPS) of typical antipsychotics. Benztropine, an anticholinergic,
is the standard treatment to reverse these distressing and potentially dangerous muscle
spasms. Prompt intervention is necessary to prevent airway compromise if the spasms
involve the laryngeal muscles.
6. A client with Borderline Personality Disorder is observed ‘splitting’ staff members, praising
one nurse while demeaning another. How should the nursing team respond?
A. Allow the client to work only with the nurse they currently prefer.
B. Hold a staff meeting to ensure a consistent, unified approach to the client’s care.
C. Explain to the client why their behavior is manipulative and hurtful.
, D. Ignore the behavior so the client does not receive extra attention for it.
Answer: B
Rationale: Splitting is a common defense mechanism in Borderline Personality Disorder
used to play individuals against each other. Consistency and limit-setting among the entire
healthcare team are essential to provide a stable therapeutic environment. This
collaborative approach prevents the client from successfully manipulating the staff and
destabilizing the unit.
7. A client is admitted for Alcohol Withdrawal. Which assessment finding would indicate the
client is progressing to Delirium Tremens (DTs)?
A. Mild tremors and a headache
B. Hypotension and bradycardia
C. Complaints of nausea and persistent fatigue
D. Tachycardia, hypertension, and hallucinations
Answer: D
Rationale: Delirium Tremens is a medical emergency characterized by severe autonomic
hyperactivity and sensorium changes. The presence of tachycardia, high blood pressure,
and hallucinations signals a dangerous progression of withdrawal. The nurse must
recognize these signs to initiate intensive monitoring and pharmacological intervention.
8. An adolescent client with Anorexia Nervosa has a BMI of 15. What is the priority nursing
diagnosis for this client?
A. Disturbed Body Image
B. Imbalanced Nutrition: Less Than Body Requirements
C. Chronic Low Self-Esteem
D. Deficient Knowledge regarding nutrition
Answer: B
Rationale: Maslow’s Hierarchy of Needs dictates that physiological stability is the first
priority. A BMI of 15 indicates severe malnutrition and places the client at risk for cardiac
arrest and electrolyte imbalances. While psychological issues are important, physical
stabilization must occur first to ensure survival.
9. A client is being started on Phenelzine for treatment-resistant depression. Which food item
must the nurse instruct the client to avoid?
A. Fresh green leafy vegetables
B. Citrus fruits like oranges and grapefruits
(NUR253 Exam 3) | Galen College of Nursing
1. A nurse is assessing a client with Major Depressive Disorder who states, ‘I just can’t do
anything right anymore.’ Which response by the nurse demonstrates therapeutic
communication?
A. Why do you feel like you cannot do anything right?
B. It sounds like you are feeling very frustrated and overwhelmed right now.
C. You should focus on the things you have accomplished in the past.
D. Everyone feels that way sometimes when they are depressed.
Answer: B
Rationale: Reflecting the client’s feelings validates their experience and encourages
further expression. This response avoids ‘why’ questions which can be perceived as
accusatory. The nurse uses an empathetic approach to build rapport and assess the depth
of the client’s hopelessness.
2. A client with Bipolar I Disorder is experiencing acute mania and is moving constantly
around the unit. Which nutritional intervention is most appropriate?
A. Schedule the client for three large, high-protein meals in the dining room.
B. Allow the client to choose whatever they want from the vending machine.
C. Withhold food until the client can sit down and eat a full meal quietly.
D. Provide high-calorie, high-protein finger foods that can be eaten while walking.
Answer: D
Rationale: During acute mania, clients are often too hyperactive to sit for meals, putting
them at risk for exhaustion and weight loss. Finger foods allow the client to maintain
caloric intake while meeting their need for movement. This intervention addresses
physiological safety and nutritional requirements during the manic phase.
3. A client is prescribed Lithium Carbonate for the treatment of Bipolar Disorder. Which
laboratory value should the nurse prioritize for review before administering the morning
dose?
A. Serum Potassium level
B. Hemoglobin and Hematocrit
C. Alanine aminotransferase (ALT)
D. Serum Sodium level
,Answer: D
Rationale: Lithium is a salt and has an inverse relationship with sodium; low sodium levels
can lead to lithium toxicity. The nurse must monitor sodium to ensure the client is not at
risk for toxic accumulation of the medication. This assessment is critical for preventing life-
threatening neurological and renal complications.
4. A client diagnosed with Schizophrenia tells the nurse, ‘The voices are telling me that the
food is poisoned.’ Which action should the nurse take first?
A. Tell the client that the hospital food is safe and inspected regularly.
B. Ask the client, ‘What specifically are the voices saying to you?’
C. Offer to taste the food in front of the client to prove it is safe.
D. Ignore the statement to avoid reinforcing the hallucination.
Answer: B
Rationale: Assessment of command hallucinations is the priority to determine the level of
risk to the client or others. By asking for specifics, the nurse can identify if the voices are
directing the client to perform dangerous acts. This clinical reasoning focuses on
immediate safety and risk stratification.
5. A nurse is caring for a client who has been taking Haloperidol for two days. The client is
now experiencing neck spasms and their eyes are rolling upward. What is the nurse’s priority
action?
A. Document the findings as a common side effect of the medication.
B. Administer the PRN dose of Benztropine as ordered.
C. Instruct the client to practice deep breathing and relaxation techniques.
D. Place the client on seizure precautions immediately.
Answer: B
Rationale: The client is exhibiting symptoms of an acute dystonic reaction, which is an
extrapyramidal side effect (EPS) of typical antipsychotics. Benztropine, an anticholinergic,
is the standard treatment to reverse these distressing and potentially dangerous muscle
spasms. Prompt intervention is necessary to prevent airway compromise if the spasms
involve the laryngeal muscles.
6. A client with Borderline Personality Disorder is observed ‘splitting’ staff members, praising
one nurse while demeaning another. How should the nursing team respond?
A. Allow the client to work only with the nurse they currently prefer.
B. Hold a staff meeting to ensure a consistent, unified approach to the client’s care.
C. Explain to the client why their behavior is manipulative and hurtful.
, D. Ignore the behavior so the client does not receive extra attention for it.
Answer: B
Rationale: Splitting is a common defense mechanism in Borderline Personality Disorder
used to play individuals against each other. Consistency and limit-setting among the entire
healthcare team are essential to provide a stable therapeutic environment. This
collaborative approach prevents the client from successfully manipulating the staff and
destabilizing the unit.
7. A client is admitted for Alcohol Withdrawal. Which assessment finding would indicate the
client is progressing to Delirium Tremens (DTs)?
A. Mild tremors and a headache
B. Hypotension and bradycardia
C. Complaints of nausea and persistent fatigue
D. Tachycardia, hypertension, and hallucinations
Answer: D
Rationale: Delirium Tremens is a medical emergency characterized by severe autonomic
hyperactivity and sensorium changes. The presence of tachycardia, high blood pressure,
and hallucinations signals a dangerous progression of withdrawal. The nurse must
recognize these signs to initiate intensive monitoring and pharmacological intervention.
8. An adolescent client with Anorexia Nervosa has a BMI of 15. What is the priority nursing
diagnosis for this client?
A. Disturbed Body Image
B. Imbalanced Nutrition: Less Than Body Requirements
C. Chronic Low Self-Esteem
D. Deficient Knowledge regarding nutrition
Answer: B
Rationale: Maslow’s Hierarchy of Needs dictates that physiological stability is the first
priority. A BMI of 15 indicates severe malnutrition and places the client at risk for cardiac
arrest and electrolyte imbalances. While psychological issues are important, physical
stabilization must occur first to ensure survival.
9. A client is being started on Phenelzine for treatment-resistant depression. Which food item
must the nurse instruct the client to avoid?
A. Fresh green leafy vegetables
B. Citrus fruits like oranges and grapefruits
