NUR 253 Exam 3 V3 | Mental
Health Nursing Q&A with Rationale
| Galen College of Nursing
1. A client is prescribed fluoxetine for depression. Which statement by the client indicates a
need for further teaching?
A. ‘I will stop taking the medication as soon as my mood improves.’
B. ‘I should take this medication in the morning to prevent insomnia.’
C. ‘It might take four weeks or longer to feel the full effect of this drug.’
D. ‘I need to let my doctor know if I start having suicidal thoughts.’
Correct Answer: A
Expert Explanation: Fluoxetine is an SSRI that should not be discontinued abruptly due to
the risk of withdrawal symptoms. Clients should continue the medication even after feeling
better to prevent relapse. Education must emphasize that the therapeutic effects take
several weeks to manifest fully.
2. A nurse is assessing a client with bipolar disorder who is taking lithium carbonate. The
client’s lithium level is 1.9 mEq/L. Which action should the nurse take?
A. Hold the medication and notify the provider immediately.
B. Encourage the client to increase fluid intake.
,C. Administer the next scheduled dose as ordered.
D. Request a repeat blood draw for verification.
Correct Answer: A
Expert Explanation: A lithium level of 1.9 mEq/L indicates moderate to severe toxicity, as
the therapeutic range is 0.6 to 1.2 mEq/L. The nurse must prioritize patient safety by
withholding the drug to prevent further elevation. Immediate notification of the provider is
required to initiate toxicity management protocols.
3. A client with borderline personality disorder is observed ‘splitting’ staff members. How
should the nursing team respond?
A. Allow the client to choose which nurse they prefer to work with.
B. Assign a different nurse to the client every shift.
C. Avoid interacting with the client until the behavior stops.
D. Hold a staff meeting to ensure a consistent approach is used.
Correct Answer: D
Expert Explanation: Splitting is a defense mechanism where the client views individuals
as all good or all bad. Consistent communication among the treatment team is vital to
prevent the client from playing staff against one another. Regular meetings ensure
everyone follows the same care plan and limit-setting strategies.
, 4. Which of the following is a priority assessment for a client experiencing alcohol withdrawal
delirium?
A. Dietary intake and nutritional status.
B. Level of social support and family involvement.
C. History of previous alcohol consumption.
D. Vital signs and neurological status.
Correct Answer: D
Expert Explanation: Alcohol withdrawal delirium is a medical emergency that can lead to
death. Monitoring vital signs is crucial because autonomic hyperactivity, such as
tachycardia and hypertension, can lead to cardiovascular collapse. Assessing neurological
status helps track the progression of disorientation and potential seizure activity.
5. A client taking haloperidol develops acute dystonia. Which medication should the nurse
anticipate administering?
A. Risperidone
B. Lorazepam
C. Benztropine
D. Fluoxetine
Correct Answer: C
Health Nursing Q&A with Rationale
| Galen College of Nursing
1. A client is prescribed fluoxetine for depression. Which statement by the client indicates a
need for further teaching?
A. ‘I will stop taking the medication as soon as my mood improves.’
B. ‘I should take this medication in the morning to prevent insomnia.’
C. ‘It might take four weeks or longer to feel the full effect of this drug.’
D. ‘I need to let my doctor know if I start having suicidal thoughts.’
Correct Answer: A
Expert Explanation: Fluoxetine is an SSRI that should not be discontinued abruptly due to
the risk of withdrawal symptoms. Clients should continue the medication even after feeling
better to prevent relapse. Education must emphasize that the therapeutic effects take
several weeks to manifest fully.
2. A nurse is assessing a client with bipolar disorder who is taking lithium carbonate. The
client’s lithium level is 1.9 mEq/L. Which action should the nurse take?
A. Hold the medication and notify the provider immediately.
B. Encourage the client to increase fluid intake.
,C. Administer the next scheduled dose as ordered.
D. Request a repeat blood draw for verification.
Correct Answer: A
Expert Explanation: A lithium level of 1.9 mEq/L indicates moderate to severe toxicity, as
the therapeutic range is 0.6 to 1.2 mEq/L. The nurse must prioritize patient safety by
withholding the drug to prevent further elevation. Immediate notification of the provider is
required to initiate toxicity management protocols.
3. A client with borderline personality disorder is observed ‘splitting’ staff members. How
should the nursing team respond?
A. Allow the client to choose which nurse they prefer to work with.
B. Assign a different nurse to the client every shift.
C. Avoid interacting with the client until the behavior stops.
D. Hold a staff meeting to ensure a consistent approach is used.
Correct Answer: D
Expert Explanation: Splitting is a defense mechanism where the client views individuals
as all good or all bad. Consistent communication among the treatment team is vital to
prevent the client from playing staff against one another. Regular meetings ensure
everyone follows the same care plan and limit-setting strategies.
, 4. Which of the following is a priority assessment for a client experiencing alcohol withdrawal
delirium?
A. Dietary intake and nutritional status.
B. Level of social support and family involvement.
C. History of previous alcohol consumption.
D. Vital signs and neurological status.
Correct Answer: D
Expert Explanation: Alcohol withdrawal delirium is a medical emergency that can lead to
death. Monitoring vital signs is crucial because autonomic hyperactivity, such as
tachycardia and hypertension, can lead to cardiovascular collapse. Assessing neurological
status helps track the progression of disorientation and potential seizure activity.
5. A client taking haloperidol develops acute dystonia. Which medication should the nurse
anticipate administering?
A. Risperidone
B. Lorazepam
C. Benztropine
D. Fluoxetine
Correct Answer: C
