NUR 253 Exam 2 V1 | Mental
Health Nursing Q&A with Rationale
| Galen College of Nursing
1. A patient with schizophrenia is hearing voices telling them that the food is poisoned. Which
nursing intervention is most appropriate?
A. Taste the food in front of the patient to prove it is safe.
B. Ignore the comment and leave the tray on the table.
C. Tell the patient that their imagination is playing tricks on them.
D. Acknowledge the patient’s fear but state that you do not hear the voices.
Correct Answer: D
Expert Explanation: This response acknowledges the patient’s feelings without validating
the hallucination. It is important to present reality while remaining supportive and non-
confrontational. Validating the hallucination or arguing with the patient can increase their
anxiety and distrust.
2. Which lab value is most critical for a nurse to monitor in a patient taking Lithium
carbonate?
A. Serum potassium levels
B. Blood glucose levels
,C. Serum sodium levels
D. White blood cell count
Correct Answer: C
Expert Explanation: Lithium is a salt, and its excretion is closely tied to sodium levels in
the body. If sodium levels drop, the kidneys retain lithium, leading to toxicity. Maintaining a
consistent intake of sodium and fluids is essential for safety during therapy.
3. A patient is admitted for a major depressive episode and expresses feelings of
worthlessness. What is the priority nursing assessment?
A. Ability to perform activities of daily living
B. Assessment of suicidal ideation and intent
C. Sleep patterns and quality
D. Nutritional intake and weight changes
Correct Answer: B
Expert Explanation: Safety is always the primary concern in mental health nursing for
patients with depression. Feelings of worthlessness are a high-risk factor for self-harm and
suicidal behavior. The nurse must directly ask the patient if they have a plan to hurt
themselves.
, 4. A nurse is caring for a patient who is experiencing a panic attack. What should be the
nurse’s first action?
A. Teach the patient deep breathing techniques.
B. Stay with the patient and provide a calm environment.
C. Administer an ordered PRN benzodiazepine immediately.
D. Ask the patient to explain what triggered the attack.
Correct Answer: B
Expert Explanation: Presence is the most effective intervention during the height of a
panic attack to ensure the patient’s safety. Short, simple instructions are necessary because
the patient cannot process complex information during severe anxiety. Providing a low-
stimulus environment helps to decrease the physiological symptoms of panic.
5. Which side effect of first-generation antipsychotics is characterized by involuntary
movements of the tongue and face?
A. Akathisia
B. Pseudoparkinsonism
C. Dystonia
D. Tardive Dyskinesia
Correct Answer: D
Health Nursing Q&A with Rationale
| Galen College of Nursing
1. A patient with schizophrenia is hearing voices telling them that the food is poisoned. Which
nursing intervention is most appropriate?
A. Taste the food in front of the patient to prove it is safe.
B. Ignore the comment and leave the tray on the table.
C. Tell the patient that their imagination is playing tricks on them.
D. Acknowledge the patient’s fear but state that you do not hear the voices.
Correct Answer: D
Expert Explanation: This response acknowledges the patient’s feelings without validating
the hallucination. It is important to present reality while remaining supportive and non-
confrontational. Validating the hallucination or arguing with the patient can increase their
anxiety and distrust.
2. Which lab value is most critical for a nurse to monitor in a patient taking Lithium
carbonate?
A. Serum potassium levels
B. Blood glucose levels
,C. Serum sodium levels
D. White blood cell count
Correct Answer: C
Expert Explanation: Lithium is a salt, and its excretion is closely tied to sodium levels in
the body. If sodium levels drop, the kidneys retain lithium, leading to toxicity. Maintaining a
consistent intake of sodium and fluids is essential for safety during therapy.
3. A patient is admitted for a major depressive episode and expresses feelings of
worthlessness. What is the priority nursing assessment?
A. Ability to perform activities of daily living
B. Assessment of suicidal ideation and intent
C. Sleep patterns and quality
D. Nutritional intake and weight changes
Correct Answer: B
Expert Explanation: Safety is always the primary concern in mental health nursing for
patients with depression. Feelings of worthlessness are a high-risk factor for self-harm and
suicidal behavior. The nurse must directly ask the patient if they have a plan to hurt
themselves.
, 4. A nurse is caring for a patient who is experiencing a panic attack. What should be the
nurse’s first action?
A. Teach the patient deep breathing techniques.
B. Stay with the patient and provide a calm environment.
C. Administer an ordered PRN benzodiazepine immediately.
D. Ask the patient to explain what triggered the attack.
Correct Answer: B
Expert Explanation: Presence is the most effective intervention during the height of a
panic attack to ensure the patient’s safety. Short, simple instructions are necessary because
the patient cannot process complex information during severe anxiety. Providing a low-
stimulus environment helps to decrease the physiological symptoms of panic.
5. Which side effect of first-generation antipsychotics is characterized by involuntary
movements of the tongue and face?
A. Akathisia
B. Pseudoparkinsonism
C. Dystonia
D. Tardive Dyskinesia
Correct Answer: D
