NUR253 Exam 2 V1 | NUR 253 Mental
Health Nursing Exam Q&A | Galen College
of Nursing
1. A client diagnosed with schizophrenia is experiencing auditory hallucinations and tells the
nurse, ‘I hear voices telling me I am a bad person.’ Which response by the nurse is most
therapeutic?
A. ‘I do not hear the voices, but I believe they are real to you.’
B. ‘Why do you think the voices are saying that to you?’
C. ‘Don’t listen to them; they are just part of your illness.’
D. ‘What are the voices telling you to do right now?’
Answer: A
Rationale: The nurse should acknowledge the client’s experience without validating the
hallucination as reality. This approach helps maintain a relationship based on trust while
gently presenting reality. Acknowledging the client’s feelings about the hallucination is a
key step in hallucination management.
2. Which of the following is considered a negative symptom of schizophrenia?
A. Delusions of grandeur
B. Auditory hallucinations
C. Avolition
,D. Disorganized speech
Answer: C
Rationale: Negative symptoms represent a loss or diminution of normal functions.
Avolition, or a lack of motivation or ability to complete tasks, is a classic negative symptom.
Positive symptoms include hallucinations, delusions, and disorganized thinking.
3. A client is prescribed Clozapine for treatment-resistant schizophrenia. Which laboratory
value is most critical for the nurse to monitor?
A. Blood Urea Nitrogen (BUN)
B. White Blood Cell (WBC) count
C. Serum Potassium
D. Liver Function Tests (LFTs)
Answer: B
Rationale: Clozapine carries a high risk for agranulocytosis, a potentially fatal drop in
white blood cell counts. Regular monitoring of the WBC and Absolute Neutrophil Count
(ANC) is mandatory for clients taking this medication. This monitoring ensures early
detection of bone marrow suppression.
4. The nurse observes a client with schizophrenia pacing the hall and talking to the wall.
Which action should the nurse take first?
A. Ignore the behavior unless the client becomes aggressive.
, B. Ask the client to go to their room for a time-out.
C. Administer a PRN dose of Haloperidol.
D. Assess the client for the presence of hallucinations.
Answer: D
Rationale: Assessment is the first step of the nursing process. The nurse must determine if
the client is experiencing hallucinations, particularly command hallucinations, which may
pose a safety risk. This helps determine the appropriate subsequent intervention.
5. A client taking Haloperidol develops high fever, muscle rigidity, and tachycardia. What is
the priority nursing intervention?
A. Administer the next dose of Haloperidol as scheduled.
B. Provide a cooling blanket and encourage oral fluids.
C. Stop the medication and notify the healthcare provider immediately.
D. Apply soft restraints to prevent injury from rigidity.
Answer: C
Rationale: These symptoms are indicative of Neuroleptic Malignant Syndrome (NMS), a
life-threatening complication of antipsychotic therapy. The priority is to stop the causative
agent immediately and initiate emergency medical support. NMS is characterized by ‘lead-
pipe’ rigidity, hyperpyrexia, and autonomic instability.
Health Nursing Exam Q&A | Galen College
of Nursing
1. A client diagnosed with schizophrenia is experiencing auditory hallucinations and tells the
nurse, ‘I hear voices telling me I am a bad person.’ Which response by the nurse is most
therapeutic?
A. ‘I do not hear the voices, but I believe they are real to you.’
B. ‘Why do you think the voices are saying that to you?’
C. ‘Don’t listen to them; they are just part of your illness.’
D. ‘What are the voices telling you to do right now?’
Answer: A
Rationale: The nurse should acknowledge the client’s experience without validating the
hallucination as reality. This approach helps maintain a relationship based on trust while
gently presenting reality. Acknowledging the client’s feelings about the hallucination is a
key step in hallucination management.
2. Which of the following is considered a negative symptom of schizophrenia?
A. Delusions of grandeur
B. Auditory hallucinations
C. Avolition
,D. Disorganized speech
Answer: C
Rationale: Negative symptoms represent a loss or diminution of normal functions.
Avolition, or a lack of motivation or ability to complete tasks, is a classic negative symptom.
Positive symptoms include hallucinations, delusions, and disorganized thinking.
3. A client is prescribed Clozapine for treatment-resistant schizophrenia. Which laboratory
value is most critical for the nurse to monitor?
A. Blood Urea Nitrogen (BUN)
B. White Blood Cell (WBC) count
C. Serum Potassium
D. Liver Function Tests (LFTs)
Answer: B
Rationale: Clozapine carries a high risk for agranulocytosis, a potentially fatal drop in
white blood cell counts. Regular monitoring of the WBC and Absolute Neutrophil Count
(ANC) is mandatory for clients taking this medication. This monitoring ensures early
detection of bone marrow suppression.
4. The nurse observes a client with schizophrenia pacing the hall and talking to the wall.
Which action should the nurse take first?
A. Ignore the behavior unless the client becomes aggressive.
, B. Ask the client to go to their room for a time-out.
C. Administer a PRN dose of Haloperidol.
D. Assess the client for the presence of hallucinations.
Answer: D
Rationale: Assessment is the first step of the nursing process. The nurse must determine if
the client is experiencing hallucinations, particularly command hallucinations, which may
pose a safety risk. This helps determine the appropriate subsequent intervention.
5. A client taking Haloperidol develops high fever, muscle rigidity, and tachycardia. What is
the priority nursing intervention?
A. Administer the next dose of Haloperidol as scheduled.
B. Provide a cooling blanket and encourage oral fluids.
C. Stop the medication and notify the healthcare provider immediately.
D. Apply soft restraints to prevent injury from rigidity.
Answer: C
Rationale: These symptoms are indicative of Neuroleptic Malignant Syndrome (NMS), a
life-threatening complication of antipsychotic therapy. The priority is to stop the causative
agent immediately and initiate emergency medical support. NMS is characterized by ‘lead-
pipe’ rigidity, hyperpyrexia, and autonomic instability.
