NUR 253 Final Exam V1 | Mental
Health Nursing Q&A with Rationale
| Galen College of Nursing
1. A nurse is caring for a client who is experiencing a manic episode. Which of the following
activities is most appropriate for the client?
A. Watching a movie in the dayroom with other clients
B. Walking around the facility with a nurse
C. Working on a large, complex jigsaw puzzle
D. Joining a competitive game of basketball
Correct Answer: B
Expert Explanation: A client in a manic state requires activities that are physical but low
in stimulation to help manage hyperactivity. Walking provides a safe outlet for energy
without the overstimulation found in group or competitive settings. This intervention also
allows the nurse to maintain supervision and provide therapeutic support during the
activity.
2. A nurse is assessing a client for lithium toxicity. Which of the following findings should the
nurse identify as an early sign of toxicity?
A. Fine hand tremors and nausea
B. Seizures and cardiac arrhythmias
,C. Confusion and coarse tremors
D. Polyuria and blurred vision
Correct Answer: A
Expert Explanation: Early signs of lithium toxicity typically occur at levels between 1.5
and 2.0 mEq/L and include gastrointestinal upset and fine tremors. These symptoms
indicate that the lithium levels are beginning to exceed the therapeutic window. The nurse
should immediately report these findings to prevent progression to severe toxicity such as
seizures or coma.
3. A client with schizophrenia is experiencing auditory command hallucinations. What is the
nurse’s priority assessment?
A. Whether the voices are male or female
B. How long the client has been hearing the voices
C. The content of the voices and if they are telling the client to hurt someone
D. The client’s ability to ignore the voices
Correct Answer: C
Expert Explanation: Command hallucinations pose a significant safety risk to the client
and others because the voices may instruct the client to perform dangerous acts. Safety is
the highest priority in mental health nursing according to Maslow’s hierarchy and the risk-
assessment framework. Determining what the voices are saying allows the nurse to
implement necessary safety precautions immediately.
, 4. A nurse is preparing to administer clozapine to a client. Which laboratory result must the
nurse review before giving the medication?
A. Serum glucose levels
B. White blood cell (WBC) count
C. Blood urea nitrogen (BUN)
D. Troponin levels
Correct Answer: B
Expert Explanation: Clozapine carries a high risk for agranulocytosis, which is a severe
and potentially fatal decrease in white blood cells. National protocols require weekly or bi-
weekly blood monitoring to ensure the client’s absolute neutrophil count is within a safe
range. The medication must be withheld if the WBC count drops below the threshold
required by the Clozapine Risk Evaluation and Mitigation Strategy (REMS) program.
5. A nurse is caring for a client with Borderline Personality Disorder who is ‘splitting’ staff
members. How should the nurse respond?
A. Agree with the client that some staff members are better than others
B. Hold a staff meeting to ensure a consistent approach to the client’s care
C. Rotate the staff assigned to the client frequently
D. Explain to the client why their behavior is manipulative
Correct Answer: B
Health Nursing Q&A with Rationale
| Galen College of Nursing
1. A nurse is caring for a client who is experiencing a manic episode. Which of the following
activities is most appropriate for the client?
A. Watching a movie in the dayroom with other clients
B. Walking around the facility with a nurse
C. Working on a large, complex jigsaw puzzle
D. Joining a competitive game of basketball
Correct Answer: B
Expert Explanation: A client in a manic state requires activities that are physical but low
in stimulation to help manage hyperactivity. Walking provides a safe outlet for energy
without the overstimulation found in group or competitive settings. This intervention also
allows the nurse to maintain supervision and provide therapeutic support during the
activity.
2. A nurse is assessing a client for lithium toxicity. Which of the following findings should the
nurse identify as an early sign of toxicity?
A. Fine hand tremors and nausea
B. Seizures and cardiac arrhythmias
,C. Confusion and coarse tremors
D. Polyuria and blurred vision
Correct Answer: A
Expert Explanation: Early signs of lithium toxicity typically occur at levels between 1.5
and 2.0 mEq/L and include gastrointestinal upset and fine tremors. These symptoms
indicate that the lithium levels are beginning to exceed the therapeutic window. The nurse
should immediately report these findings to prevent progression to severe toxicity such as
seizures or coma.
3. A client with schizophrenia is experiencing auditory command hallucinations. What is the
nurse’s priority assessment?
A. Whether the voices are male or female
B. How long the client has been hearing the voices
C. The content of the voices and if they are telling the client to hurt someone
D. The client’s ability to ignore the voices
Correct Answer: C
Expert Explanation: Command hallucinations pose a significant safety risk to the client
and others because the voices may instruct the client to perform dangerous acts. Safety is
the highest priority in mental health nursing according to Maslow’s hierarchy and the risk-
assessment framework. Determining what the voices are saying allows the nurse to
implement necessary safety precautions immediately.
, 4. A nurse is preparing to administer clozapine to a client. Which laboratory result must the
nurse review before giving the medication?
A. Serum glucose levels
B. White blood cell (WBC) count
C. Blood urea nitrogen (BUN)
D. Troponin levels
Correct Answer: B
Expert Explanation: Clozapine carries a high risk for agranulocytosis, which is a severe
and potentially fatal decrease in white blood cells. National protocols require weekly or bi-
weekly blood monitoring to ensure the client’s absolute neutrophil count is within a safe
range. The medication must be withheld if the WBC count drops below the threshold
required by the Clozapine Risk Evaluation and Mitigation Strategy (REMS) program.
5. A nurse is caring for a client with Borderline Personality Disorder who is ‘splitting’ staff
members. How should the nurse respond?
A. Agree with the client that some staff members are better than others
B. Hold a staff meeting to ensure a consistent approach to the client’s care
C. Rotate the staff assigned to the client frequently
D. Explain to the client why their behavior is manipulative
Correct Answer: B
