NUR253 Exam 2 V3 | NUR 253 Mental
Health Nursing Exam Q&A | Galen College
of Nursing
1. A nurse is caring for a client with Bipolar Disorder experiencing acute mania. Which
nutritional intervention is most appropriate?
A. Offer high-protein, high-calorie finger foods.
B. Provide a large, high-calorie meal in the quiet dining room.
C. Schedule the client for three standard meals a day with others.
D. Restrict fluid intake to prevent polyuria.
Answer: A
Rationale: Clients in acute mania are often too hyperactive to sit down for a full meal.
Finger foods allow them to eat while moving, ensuring they receive necessary calories and
protein. This intervention supports physical health while accommodating manic behavior.
2. A client is prescribed Lithium Carbonate for Bipolar I Disorder. Which laboratory value
should the nurse monitor most closely to prevent toxicity?
A. Serum Potassium
B. Serum Sodium
C. Serum Calcium
,D. Serum Magnesium
Answer: B
Rationale: Lithium is a salt, and its excretion is closely tied to sodium levels. When sodium
levels are low, the kidneys retain lithium, leading to toxicity. Therefore, the nurse must
ensure the client maintains a consistent sodium intake and monitor for dehydration.
3. A client with Schizophrenia tells the nurse, ‘The FBI is tracking me through the TV.’ Which
response by the nurse is therapeutic?
A. ‘I don’t see any FBI agents here; you are safe.’
B. ‘Why would the FBI want to track a person like you?’
C. ‘It must be frightening to feel like you are being watched.’
D. ‘The TV is just a machine; it cannot track people.’
Answer: C
Rationale: This response acknowledges the client’s feelings without validating the
delusion. It focuses on the emotional impact of the thought, which is a key component of
therapeutic communication. Avoiding direct confrontation of the delusion helps maintain
the nurse-client relationship.
4. A client started taking Fluoxetine (an SSRI) two weeks ago. The client reports a sudden
surge in energy but still feels ‘sad.’ What is the nurse’s priority assessment?
A. Assess for signs of Serotonin Syndrome.
, B. Monitor for weight gain.
C. Evaluate the client’s sleep patterns.
D. Assess for suicidal ideation and intent.
Answer: D
Rationale: When antidepressants begin to work, energy levels often improve before the
depressed mood lifts. This ‘window’ is high-risk because the client may now have the
physical energy to carry out a suicide plan. Safety is always the priority in psychiatric
nursing during this phase of treatment.
5. The nurse is preparing to administer Haloperidol to a client. The nurse should monitor for
which of the following extrapyramidal symptoms (EPS)?
A. Hypertension and tachycardia
B. Excessive thirst and urination
C. Increased appetite and weight gain
D. Muscle rigidity, tremors, and shuffling gait
Answer: D
Rationale: Haloperidol is a first-generation antipsychotic that frequently causes EPS.
These symptoms include pseudoparkinsonism, characterized by rigidity and shuffling gait.
Early identification allows for the administration of anticholinergic medications like
benztropine.
Health Nursing Exam Q&A | Galen College
of Nursing
1. A nurse is caring for a client with Bipolar Disorder experiencing acute mania. Which
nutritional intervention is most appropriate?
A. Offer high-protein, high-calorie finger foods.
B. Provide a large, high-calorie meal in the quiet dining room.
C. Schedule the client for three standard meals a day with others.
D. Restrict fluid intake to prevent polyuria.
Answer: A
Rationale: Clients in acute mania are often too hyperactive to sit down for a full meal.
Finger foods allow them to eat while moving, ensuring they receive necessary calories and
protein. This intervention supports physical health while accommodating manic behavior.
2. A client is prescribed Lithium Carbonate for Bipolar I Disorder. Which laboratory value
should the nurse monitor most closely to prevent toxicity?
A. Serum Potassium
B. Serum Sodium
C. Serum Calcium
,D. Serum Magnesium
Answer: B
Rationale: Lithium is a salt, and its excretion is closely tied to sodium levels. When sodium
levels are low, the kidneys retain lithium, leading to toxicity. Therefore, the nurse must
ensure the client maintains a consistent sodium intake and monitor for dehydration.
3. A client with Schizophrenia tells the nurse, ‘The FBI is tracking me through the TV.’ Which
response by the nurse is therapeutic?
A. ‘I don’t see any FBI agents here; you are safe.’
B. ‘Why would the FBI want to track a person like you?’
C. ‘It must be frightening to feel like you are being watched.’
D. ‘The TV is just a machine; it cannot track people.’
Answer: C
Rationale: This response acknowledges the client’s feelings without validating the
delusion. It focuses on the emotional impact of the thought, which is a key component of
therapeutic communication. Avoiding direct confrontation of the delusion helps maintain
the nurse-client relationship.
4. A client started taking Fluoxetine (an SSRI) two weeks ago. The client reports a sudden
surge in energy but still feels ‘sad.’ What is the nurse’s priority assessment?
A. Assess for signs of Serotonin Syndrome.
, B. Monitor for weight gain.
C. Evaluate the client’s sleep patterns.
D. Assess for suicidal ideation and intent.
Answer: D
Rationale: When antidepressants begin to work, energy levels often improve before the
depressed mood lifts. This ‘window’ is high-risk because the client may now have the
physical energy to carry out a suicide plan. Safety is always the priority in psychiatric
nursing during this phase of treatment.
5. The nurse is preparing to administer Haloperidol to a client. The nurse should monitor for
which of the following extrapyramidal symptoms (EPS)?
A. Hypertension and tachycardia
B. Excessive thirst and urination
C. Increased appetite and weight gain
D. Muscle rigidity, tremors, and shuffling gait
Answer: D
Rationale: Haloperidol is a first-generation antipsychotic that frequently causes EPS.
These symptoms include pseudoparkinsonism, characterized by rigidity and shuffling gait.
Early identification allows for the administration of anticholinergic medications like
benztropine.
