NSG 322/NSG322 Exam 3 V1 | Behavioral
Health Nursing Q&A with Rationale |
Grand Canyon University
1. A nurse is assessing a client who has been taking Lithium for two weeks for Bipolar
Disorder. The client reports blurred vision and a coarse hand tremor. Which action should the
nurse take first?
A. Withhold the next dose and request a serum lithium level.
B. Prepare to administer a dose of benztropine immediately.
C. Advise the client to drink more fluids to dilute the medication.
D. Document the findings as expected side effects of early therapy.
Answer: A
Rationale: Blurred vision and coarse hand tremors are advanced signs of lithium toxicity,
which can be life-threatening if ignored. The nurse must stop the medication to prevent
further toxicity while confirming the blood level. This ensures client safety and follows the
protocol for managing narrow therapeutic index drugs.
2. A client diagnosed with Schizophrenia is experiencing auditory hallucinations and states,
‘The voices are telling me to hurt my roommate.’ What is the nurse’s priority intervention?
A. Initiate one-to-one observation to ensure safety.
B. Tell the client that the voices are not real and are just a symptom.
,C. Ask the client why they want to hurt their roommate.
D. Administer an as-needed dose of a benzodiazepine.
Answer: A
Rationale: Safety is always the primary concern in psychiatric nursing when command
hallucinations involve harm to others. One-to-one observation provides the highest level of
supervision to prevent an assault. This intervention allows the nurse to monitor the client’s
behavior closely while providing a therapeutic presence.
3. A client with Major Depressive Disorder is being started on Phenelzine, an MAOI. Which
food choice indicates the client understands the dietary restrictions?
A. A grilled chicken breast with a side of steamed broccoli.
B. A pepperoni pizza with extra mozzarella cheese.
C. A smoked ham sandwich with aged cheddar.
D. A glass of red wine and a bowl of chicken liver.
Answer: A
Rationale: Clients taking MAOIs must avoid foods high in tyramine, such as aged cheeses,
cured meats, and fermented products. Consuming tyramine while on an MAOI can lead to a
hypertensive crisis, which is a medical emergency. Fresh meats and vegetables like grilled
chicken and broccoli are safe, low-tyramine options.
, 4. A nurse is caring for a client with Borderline Personality Disorder who is using splitting
behavior. Which nursing action is most effective in managing this behavior?
A. Allowing the client to choose their favorite nurse for each shift.
B. Holding a staff meeting to ensure a consistent approach by all team members.
C. Explaining to the client that their behavior is manipulative.
D. Limiting the client’s social interactions with other patients.
Answer: B
Rationale: Splitting involves the client seeing staff as either ‘all good’ or ‘all bad,’ which
often creates conflict among the care team. Consistency and limit-setting among all staff
members are crucial to neutralize this defense mechanism. By presenting a united front,
the team prevents the client from playing staff members against one another.
5. Which clinical finding is most characteristic of Anorexia Nervosa rather than Bulimia
Nervosa?
A. The presence of dental caries and parotid gland swelling.
B. Emotional distress related to body image and weight.
C. Reporting episodes of binge eating followed by compensatory behaviors.
D. A body weight significantly below the expected minimum for age/height.
Answer: D
Health Nursing Q&A with Rationale |
Grand Canyon University
1. A nurse is assessing a client who has been taking Lithium for two weeks for Bipolar
Disorder. The client reports blurred vision and a coarse hand tremor. Which action should the
nurse take first?
A. Withhold the next dose and request a serum lithium level.
B. Prepare to administer a dose of benztropine immediately.
C. Advise the client to drink more fluids to dilute the medication.
D. Document the findings as expected side effects of early therapy.
Answer: A
Rationale: Blurred vision and coarse hand tremors are advanced signs of lithium toxicity,
which can be life-threatening if ignored. The nurse must stop the medication to prevent
further toxicity while confirming the blood level. This ensures client safety and follows the
protocol for managing narrow therapeutic index drugs.
2. A client diagnosed with Schizophrenia is experiencing auditory hallucinations and states,
‘The voices are telling me to hurt my roommate.’ What is the nurse’s priority intervention?
A. Initiate one-to-one observation to ensure safety.
B. Tell the client that the voices are not real and are just a symptom.
,C. Ask the client why they want to hurt their roommate.
D. Administer an as-needed dose of a benzodiazepine.
Answer: A
Rationale: Safety is always the primary concern in psychiatric nursing when command
hallucinations involve harm to others. One-to-one observation provides the highest level of
supervision to prevent an assault. This intervention allows the nurse to monitor the client’s
behavior closely while providing a therapeutic presence.
3. A client with Major Depressive Disorder is being started on Phenelzine, an MAOI. Which
food choice indicates the client understands the dietary restrictions?
A. A grilled chicken breast with a side of steamed broccoli.
B. A pepperoni pizza with extra mozzarella cheese.
C. A smoked ham sandwich with aged cheddar.
D. A glass of red wine and a bowl of chicken liver.
Answer: A
Rationale: Clients taking MAOIs must avoid foods high in tyramine, such as aged cheeses,
cured meats, and fermented products. Consuming tyramine while on an MAOI can lead to a
hypertensive crisis, which is a medical emergency. Fresh meats and vegetables like grilled
chicken and broccoli are safe, low-tyramine options.
, 4. A nurse is caring for a client with Borderline Personality Disorder who is using splitting
behavior. Which nursing action is most effective in managing this behavior?
A. Allowing the client to choose their favorite nurse for each shift.
B. Holding a staff meeting to ensure a consistent approach by all team members.
C. Explaining to the client that their behavior is manipulative.
D. Limiting the client’s social interactions with other patients.
Answer: B
Rationale: Splitting involves the client seeing staff as either ‘all good’ or ‘all bad,’ which
often creates conflict among the care team. Consistency and limit-setting among all staff
members are crucial to neutralize this defense mechanism. By presenting a united front,
the team prevents the client from playing staff members against one another.
5. Which clinical finding is most characteristic of Anorexia Nervosa rather than Bulimia
Nervosa?
A. The presence of dental caries and parotid gland swelling.
B. Emotional distress related to body image and weight.
C. Reporting episodes of binge eating followed by compensatory behaviors.
D. A body weight significantly below the expected minimum for age/height.
Answer: D
