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 who is experiencing a manic episode.
Which nutritional intervention is most appropriate?
A. Offer high-calorie, high-protein finger foods.
B. Provide a large, three-course meal in the dining hall.
C. Restrict fluid intake to prevent water intoxication.
D. Instruct the client to remain seated until they finish their meal.
Answer: A
Rationale: Clients in a manic state are often too hyperactive to sit down for a full meal.
Finger foods allow the client to consume necessary nutrients while moving around the unit
safely. This intervention prioritizes meeting the high caloric demands caused by physical
agitation and prevents weight loss during a manic phase.
2. A client is prescribed Lithium Carbonate for the treatment of Bipolar I Disorder. Which
laboratory value should the nurse monitor most closely to prevent toxicity?
A. Serum Sodium
B. Serum Potassium
C. Serum Calcium
,D. Serum Glucose
Answer: A
Rationale: Lithium is a salt, and its excretion is closely tied to sodium levels in the body.
When sodium levels are low, the kidneys retain lithium, which significantly increases the
risk of lithium toxicity. The nurse must educate the client on maintaining a consistent salt
and fluid intake to keep lithium levels within the therapeutic range.
3. A client with Schizophrenia is hearing voices that say, ‘Kill the person in the next room.’
Which action is the nurse’s priority?
A. Initiate one-on-one observation for safety.
B. Ask the client to describe what the voices look like.
C. Administer a PRN dose of Lorazepam.
D. Tell the client that the voices are not real.
Answer: A
Rationale: Command hallucinations that involve harming others represent a high-risk
psychiatric emergency. Safety is the priority, so the nurse must ensure constant
supervision to prevent the client from acting on the command. After ensuring safety, the
nurse should further assess the client’s ability to resist the commands and notify the
provider.
, 4. A nurse is monitoring a client who recently started Haloperidol. The client is experiencing
muscle rigidity, a temperature of 103°F (39.4°C), and autonomic instability. What should the
nurse suspect?
A. Neuroleptic Malignant Syndrome (NMS)
B. Extrapyramidal Symptoms (EPS)
C. Serotonin Syndrome
D. Anticholinergic Toxicity
Answer: A
Rationale: Neuroleptic Malignant Syndrome is a rare but life-threatening reaction to
antipsychotic medications like Haloperidol. Key clinical features include ‘lead-pipe’ muscle
rigidity, high fever, and tachycardia. The nurse must immediately stop the medication,
notify the physician, and prepare for emergency supportive care.
5. A client is being discharged on Phenelzine, an MAOI. Which food choice indicates the client
understands the dietary restrictions?
A. Smoked salmon on a sourdough bagel.
B. Pepperoni pizza with extra cheese.
C. A glass of red wine and aged cheddar.
D. Grilled chicken with steamed broccoli.
Answer: D
Health Nursing Exam Q&A | Galen College
of Nursing
1. A nurse is caring for a client with Bipolar Disorder who is experiencing a manic episode.
Which nutritional intervention is most appropriate?
A. Offer high-calorie, high-protein finger foods.
B. Provide a large, three-course meal in the dining hall.
C. Restrict fluid intake to prevent water intoxication.
D. Instruct the client to remain seated until they finish their meal.
Answer: A
Rationale: Clients in a manic state are often too hyperactive to sit down for a full meal.
Finger foods allow the client to consume necessary nutrients while moving around the unit
safely. This intervention prioritizes meeting the high caloric demands caused by physical
agitation and prevents weight loss during a manic phase.
2. A client is prescribed Lithium Carbonate for the treatment of Bipolar I Disorder. Which
laboratory value should the nurse monitor most closely to prevent toxicity?
A. Serum Sodium
B. Serum Potassium
C. Serum Calcium
,D. Serum Glucose
Answer: A
Rationale: Lithium is a salt, and its excretion is closely tied to sodium levels in the body.
When sodium levels are low, the kidneys retain lithium, which significantly increases the
risk of lithium toxicity. The nurse must educate the client on maintaining a consistent salt
and fluid intake to keep lithium levels within the therapeutic range.
3. A client with Schizophrenia is hearing voices that say, ‘Kill the person in the next room.’
Which action is the nurse’s priority?
A. Initiate one-on-one observation for safety.
B. Ask the client to describe what the voices look like.
C. Administer a PRN dose of Lorazepam.
D. Tell the client that the voices are not real.
Answer: A
Rationale: Command hallucinations that involve harming others represent a high-risk
psychiatric emergency. Safety is the priority, so the nurse must ensure constant
supervision to prevent the client from acting on the command. After ensuring safety, the
nurse should further assess the client’s ability to resist the commands and notify the
provider.
, 4. A nurse is monitoring a client who recently started Haloperidol. The client is experiencing
muscle rigidity, a temperature of 103°F (39.4°C), and autonomic instability. What should the
nurse suspect?
A. Neuroleptic Malignant Syndrome (NMS)
B. Extrapyramidal Symptoms (EPS)
C. Serotonin Syndrome
D. Anticholinergic Toxicity
Answer: A
Rationale: Neuroleptic Malignant Syndrome is a rare but life-threatening reaction to
antipsychotic medications like Haloperidol. Key clinical features include ‘lead-pipe’ muscle
rigidity, high fever, and tachycardia. The nurse must immediately stop the medication,
notify the physician, and prepare for emergency supportive care.
5. A client is being discharged on Phenelzine, an MAOI. Which food choice indicates the client
understands the dietary restrictions?
A. Smoked salmon on a sourdough bagel.
B. Pepperoni pizza with extra cheese.
C. A glass of red wine and aged cheddar.
D. Grilled chicken with steamed broccoli.
Answer: D
