NUR 253 Exam 4 Concepts Mental Health
Nursing 2026/2027 – Questions and
Answers | 100% Verified | Detailed
Rationales – Pass Guaranteed – A+ Graded
A client with major depressive disorder tells the nurse, “Everyone would be better
off without me.” Which response by the nurse is most appropriate?
A. “You should focus on the positive things in your life.”
B. “Are you thinking about killing yourself?”
C. “Why do you believe everyone would be better off without you?”
D. “You need to remember that suicide is a permanent solution.”
Answer: _B. “Are you thinking about killing yourself?”_**
Rationale: Directly asking about suicidal thoughts does not increase suicide risk
and allows the nurse to assess the client's immediate safety. Further assessment
should include intent, plan, means, and previous attempts.
Which finding in a client taking lithium requires the nurse to notify the healthcare
provider immediately?
A. Mild thirst
B. Fine hand tremor
C. Severe diarrhea and vomiting
D. Increased appetite
Answer: _C. Severe diarrhea and vomiting**
,Rationale: Severe gastrointestinal symptoms can indicate lithium toxicity and may
lead to dangerous elevations in serum lithium levels. Lithium toxicity requires
prompt evaluation and intervention.
A client experiencing a panic attack is pacing rapidly and reports feeling unable to
breathe. Which nursing intervention is the priority?
A. Encourage the client to discuss the source of the anxiety.
B. Leave the client alone in a quiet room.
C. Stay with the client and use short, simple statements.
D. Teach the client about long-term anxiety-management techniques.
Answer: _C. Stay with the client and use short, simple statements.*
Rationale: During severe anxiety or panic, concentration and information
processing are impaired. Remaining with the client provides reassurance and
safety while brief, simple communication helps reduce stimulation.
Which behavior is most characteristic of a client experiencing mania?
A. Social withdrawal
B. Increased need for sleep
C. Rapid speech and decreased need for sleep
D. Slow thought processes
Answer: _C. Rapid speech and decreased need for sleep**
Rationale: Mania commonly involves elevated or irritable mood, pressured or
rapid speech, decreased need for sleep, increased activity, distractibility, and
impulsive or risky behavior.
A client with schizophrenia reports hearing voices commanding the client to harm
another person. What should the nurse do first?
A. Tell the client that the voices are not real.
,B. Determine whether the client intends to act on the command.
C. Encourage the client to ignore the voices.
D. Ask the client to describe the voices in detail.
Answer: _B. Determine whether the client intends to act on the command.*
Rationale: Command hallucinations involving harm require immediate assessment
of potential danger. The nurse should determine the content of the hallucination,
the client's intent, ability to resist the command, and access to potential means.
Which statement by a client demonstrates understanding of cognitive behavioral
therapy?
A. “My therapist will make decisions for me.”
B. “I will learn to identify and challenge unhealthy thought patterns.”
C. “The therapy will focus only on events from my childhood.”
D. “I should avoid thinking about stressful situations.”
Answer: _B. “I will learn to identify and challenge unhealthy thought
patterns.”_**
Rationale: Cognitive behavioral therapy focuses on identifying maladaptive
thoughts and behaviors and replacing them with healthier patterns. The client
actively participates in recognizing and modifying distorted thinking.
A client taking an antipsychotic medication develops muscle rigidity, high fever,
altered consciousness, and unstable blood pressure. Which complication should the
nurse suspect?
A. Serotonin syndrome
B. Neuroleptic malignant syndrome
C. Acute dystonia
D. Tardive dyskinesia
, Answer: _B. Neuroleptic malignant syndrome**
Rationale: Neuroleptic malignant syndrome is a potentially life-threatening
reaction associated with antipsychotic medications. Classic findings include severe
muscle rigidity, hyperthermia, altered mental status, and autonomic instability.
Which intervention is most appropriate for a client experiencing acute alcohol
withdrawal?
A. Place the client in a stimulating environment.
B. Encourage unrestricted caffeine intake.
C. Monitor vital signs and assess for withdrawal complications.
D. Restrict fluids to prevent electrolyte abnormalities.
Answer: _C. Monitor vital signs and assess for withdrawal complications.*
Rationale: Alcohol withdrawal can progress to seizures, severe autonomic
instability, and delirium tremens. Frequent assessment of vital signs, mental status,
and withdrawal severity is essential.
A client with anorexia nervosa has a significantly low body weight. Which nursing
intervention is most appropriate?
A. Allow the client to skip meals when anxious.
B. Establish a structured nutritional plan and monitor intake.
C. Encourage vigorous exercise after meals.
D. Focus exclusively on the client's body image.
Answer: _B. Establish a structured nutritional plan and monitor intake.*
Rationale: Nutritional restoration is a primary treatment goal for anorexia
nervosa. Structured meals, monitoring of intake, and assessment for complications
of malnutrition are important components of care.
Which finding is most consistent with post-traumatic stress disorder?
Nursing 2026/2027 – Questions and
Answers | 100% Verified | Detailed
Rationales – Pass Guaranteed – A+ Graded
A client with major depressive disorder tells the nurse, “Everyone would be better
off without me.” Which response by the nurse is most appropriate?
A. “You should focus on the positive things in your life.”
B. “Are you thinking about killing yourself?”
C. “Why do you believe everyone would be better off without you?”
D. “You need to remember that suicide is a permanent solution.”
Answer: _B. “Are you thinking about killing yourself?”_**
Rationale: Directly asking about suicidal thoughts does not increase suicide risk
and allows the nurse to assess the client's immediate safety. Further assessment
should include intent, plan, means, and previous attempts.
Which finding in a client taking lithium requires the nurse to notify the healthcare
provider immediately?
A. Mild thirst
B. Fine hand tremor
C. Severe diarrhea and vomiting
D. Increased appetite
Answer: _C. Severe diarrhea and vomiting**
,Rationale: Severe gastrointestinal symptoms can indicate lithium toxicity and may
lead to dangerous elevations in serum lithium levels. Lithium toxicity requires
prompt evaluation and intervention.
A client experiencing a panic attack is pacing rapidly and reports feeling unable to
breathe. Which nursing intervention is the priority?
A. Encourage the client to discuss the source of the anxiety.
B. Leave the client alone in a quiet room.
C. Stay with the client and use short, simple statements.
D. Teach the client about long-term anxiety-management techniques.
Answer: _C. Stay with the client and use short, simple statements.*
Rationale: During severe anxiety or panic, concentration and information
processing are impaired. Remaining with the client provides reassurance and
safety while brief, simple communication helps reduce stimulation.
Which behavior is most characteristic of a client experiencing mania?
A. Social withdrawal
B. Increased need for sleep
C. Rapid speech and decreased need for sleep
D. Slow thought processes
Answer: _C. Rapid speech and decreased need for sleep**
Rationale: Mania commonly involves elevated or irritable mood, pressured or
rapid speech, decreased need for sleep, increased activity, distractibility, and
impulsive or risky behavior.
A client with schizophrenia reports hearing voices commanding the client to harm
another person. What should the nurse do first?
A. Tell the client that the voices are not real.
,B. Determine whether the client intends to act on the command.
C. Encourage the client to ignore the voices.
D. Ask the client to describe the voices in detail.
Answer: _B. Determine whether the client intends to act on the command.*
Rationale: Command hallucinations involving harm require immediate assessment
of potential danger. The nurse should determine the content of the hallucination,
the client's intent, ability to resist the command, and access to potential means.
Which statement by a client demonstrates understanding of cognitive behavioral
therapy?
A. “My therapist will make decisions for me.”
B. “I will learn to identify and challenge unhealthy thought patterns.”
C. “The therapy will focus only on events from my childhood.”
D. “I should avoid thinking about stressful situations.”
Answer: _B. “I will learn to identify and challenge unhealthy thought
patterns.”_**
Rationale: Cognitive behavioral therapy focuses on identifying maladaptive
thoughts and behaviors and replacing them with healthier patterns. The client
actively participates in recognizing and modifying distorted thinking.
A client taking an antipsychotic medication develops muscle rigidity, high fever,
altered consciousness, and unstable blood pressure. Which complication should the
nurse suspect?
A. Serotonin syndrome
B. Neuroleptic malignant syndrome
C. Acute dystonia
D. Tardive dyskinesia
, Answer: _B. Neuroleptic malignant syndrome**
Rationale: Neuroleptic malignant syndrome is a potentially life-threatening
reaction associated with antipsychotic medications. Classic findings include severe
muscle rigidity, hyperthermia, altered mental status, and autonomic instability.
Which intervention is most appropriate for a client experiencing acute alcohol
withdrawal?
A. Place the client in a stimulating environment.
B. Encourage unrestricted caffeine intake.
C. Monitor vital signs and assess for withdrawal complications.
D. Restrict fluids to prevent electrolyte abnormalities.
Answer: _C. Monitor vital signs and assess for withdrawal complications.*
Rationale: Alcohol withdrawal can progress to seizures, severe autonomic
instability, and delirium tremens. Frequent assessment of vital signs, mental status,
and withdrawal severity is essential.
A client with anorexia nervosa has a significantly low body weight. Which nursing
intervention is most appropriate?
A. Allow the client to skip meals when anxious.
B. Establish a structured nutritional plan and monitor intake.
C. Encourage vigorous exercise after meals.
D. Focus exclusively on the client's body image.
Answer: _B. Establish a structured nutritional plan and monitor intake.*
Rationale: Nutritional restoration is a primary treatment goal for anorexia
nervosa. Structured meals, monitoring of intake, and assessment for complications
of malnutrition are important components of care.
Which finding is most consistent with post-traumatic stress disorder?
