NUR 253 Final Exam V3 | 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. Walking with the nurse on the unit.
B. Participating in a group volleyball game.
C. Playing a competitive game of chess.
D. Watching a high-action movie in the dayroom.
Correct Answer: A
Expert Explanation: Clients in a manic phase require activities that use gross motor skills
but are not overly stimulating or competitive. Walking with a staff member provides a
physical outlet while maintaining a calm environment. This intervention helps manage
energy levels without increasing agitation or conflict with other patients.
2. A client is prescribed Lithium Carbonate for Bipolar Disorder. Which of the following should
the nurse include in the teaching?
A. Limit sodium intake to less than 2 grams per day.
B. Expect a weight loss of 5 to 10 pounds initially.
,C. Stop taking the medication if fine hand tremors occur.
D. Maintain a consistent intake of sodium and fluids.
Correct Answer: D
Expert Explanation: Lithium is a salt, and its excretion is closely tied to sodium levels in
the body. If sodium intake drops, the kidneys retain lithium, leading to toxicity. Therefore,
the client must maintain a steady intake of both salt and water to keep lithium levels within
the therapeutic range.
3. Which defense mechanism is a client using when they state, ‘I only drink because my
spouse is so demanding’?
A. Displacement
B. Projection
C. Reaction Formation
D. Rationalization
Correct Answer: D
Expert Explanation: Rationalization involves creating logical-sounding excuses to justify
unacceptable behavior. By blaming the spouse, the client avoids taking responsibility for
their alcohol consumption. This helps the individual maintain self-esteem while continuing
maladaptive habits.
, 4. A client with Schizophrenia is hearing voices telling them that the food is poisoned. What is
the nurse’s best response?
A. I don’t hear any voices, but I can see that you are scared.
B. The food is fine; I saw the chef prepare it myself.
C. Why do you think someone would want to poison you?
D. Let’s ignore the voices and go to the dining room.
Correct Answer: A
Expert Explanation: The nurse should acknowledge the client’s feelings without validating
the hallucination. By stating ‘I don’t hear any voices,’ the nurse presents reality. This
approach focuses on the emotional distress of the client while maintaining a factual
perspective.
5. A client is being admitted for alcohol detoxification. Which medication should the nurse
anticipate administering first?
A. Disulfiram
B. Methadone
C. Naltrexone
D. Chlordiazepoxide
Correct Answer: D
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. Walking with the nurse on the unit.
B. Participating in a group volleyball game.
C. Playing a competitive game of chess.
D. Watching a high-action movie in the dayroom.
Correct Answer: A
Expert Explanation: Clients in a manic phase require activities that use gross motor skills
but are not overly stimulating or competitive. Walking with a staff member provides a
physical outlet while maintaining a calm environment. This intervention helps manage
energy levels without increasing agitation or conflict with other patients.
2. A client is prescribed Lithium Carbonate for Bipolar Disorder. Which of the following should
the nurse include in the teaching?
A. Limit sodium intake to less than 2 grams per day.
B. Expect a weight loss of 5 to 10 pounds initially.
,C. Stop taking the medication if fine hand tremors occur.
D. Maintain a consistent intake of sodium and fluids.
Correct Answer: D
Expert Explanation: Lithium is a salt, and its excretion is closely tied to sodium levels in
the body. If sodium intake drops, the kidneys retain lithium, leading to toxicity. Therefore,
the client must maintain a steady intake of both salt and water to keep lithium levels within
the therapeutic range.
3. Which defense mechanism is a client using when they state, ‘I only drink because my
spouse is so demanding’?
A. Displacement
B. Projection
C. Reaction Formation
D. Rationalization
Correct Answer: D
Expert Explanation: Rationalization involves creating logical-sounding excuses to justify
unacceptable behavior. By blaming the spouse, the client avoids taking responsibility for
their alcohol consumption. This helps the individual maintain self-esteem while continuing
maladaptive habits.
, 4. A client with Schizophrenia is hearing voices telling them that the food is poisoned. What is
the nurse’s best response?
A. I don’t hear any voices, but I can see that you are scared.
B. The food is fine; I saw the chef prepare it myself.
C. Why do you think someone would want to poison you?
D. Let’s ignore the voices and go to the dining room.
Correct Answer: A
Expert Explanation: The nurse should acknowledge the client’s feelings without validating
the hallucination. By stating ‘I don’t hear any voices,’ the nurse presents reality. This
approach focuses on the emotional distress of the client while maintaining a factual
perspective.
5. A client is being admitted for alcohol detoxification. Which medication should the nurse
anticipate administering first?
A. Disulfiram
B. Methadone
C. Naltrexone
D. Chlordiazepoxide
Correct Answer: D
