NUR253 Exam 2 V1 | NUR 253 Mental
Health Nursing Exam Q&A | Galen College
of Nursing
1. A nurse is caring for a client with schizophrenia who is experiencing auditory
hallucinations. Which is the most appropriate initial nursing response?
A. ‘I do not hear the voices, but I understand they are real to you.’
B. ‘You should try to ignore the voices and focus on this task.’
C. ‘What are the voices telling you to do right now?’
D. ‘The voices are just part of your illness and are not real.’
Answer: C
Rationale: The nurse’s priority is to assess for command hallucinations to ensure safety.
This response helps determine if the client is being told to harm themselves or others.
Acknowledging the client’s reality while presenting the nurse’s reality comes after safety
assessment.
2. A client is prescribed Clozapine for treatment-resistant schizophrenia. Which laboratory
value is the most critical for the nurse to monitor?
A. Serum creatinine and BUN
B. White blood cell count
C. Liver function tests
,D. Platelet count
Answer: B
Rationale: Clozapine carries a significant risk of agranulocytosis, which is a severe
decrease in white blood cells. Clients must have regular blood draws to monitor their
Absolute Neutrophil Count (ANC). This monitoring is mandatory to prevent life-threatening
infections.
3. The nurse observes a client with schizophrenia standing in the same position for hours,
resembling a statue. This behavior is documented as:
A. Waxy flexibility
B. Echolalia
C. Akathisia
D. Anhedonia
Answer: A
Rationale: Waxy flexibility is a condition where a person remains in a fixed position for
long periods. It is often seen in catatonic schizophrenia. The nurse should provide physical
care and nutrition to these immobile clients.
4. Which of the following is considered a negative symptom of schizophrenia?
A. Delusions
B. Flat affect
, C. Hallucinations
D. Disorganized speech
Answer: B
Rationale: Negative symptoms represent a loss of normal functions, such as emotional
expression. Flat affect involves a lack of visible emotion or facial expression. Positive
symptoms, by contrast, add abnormal behaviors like delusions and hallucinations.
5. A client taking Haloperidol develops high fever, muscle rigidity, and tachycardia. Which
condition should the nurse suspect?
A. Serotonin syndrome
B. Neuroleptic malignant syndrome (NMS)
C. Agranulocytosis
D. Tardive dyskinesia
Answer: B
Rationale: Neuroleptic malignant syndrome is a rare but life-threatening reaction to
antipsychotic drugs. It is characterized by hyperpyrexia, severe muscle rigidity, and
autonomic instability. This condition requires immediate medical intervention and
discontinuation of the medication.
Health Nursing Exam Q&A | Galen College
of Nursing
1. A nurse is caring for a client with schizophrenia who is experiencing auditory
hallucinations. Which is the most appropriate initial nursing response?
A. ‘I do not hear the voices, but I understand they are real to you.’
B. ‘You should try to ignore the voices and focus on this task.’
C. ‘What are the voices telling you to do right now?’
D. ‘The voices are just part of your illness and are not real.’
Answer: C
Rationale: The nurse’s priority is to assess for command hallucinations to ensure safety.
This response helps determine if the client is being told to harm themselves or others.
Acknowledging the client’s reality while presenting the nurse’s reality comes after safety
assessment.
2. A client is prescribed Clozapine for treatment-resistant schizophrenia. Which laboratory
value is the most critical for the nurse to monitor?
A. Serum creatinine and BUN
B. White blood cell count
C. Liver function tests
,D. Platelet count
Answer: B
Rationale: Clozapine carries a significant risk of agranulocytosis, which is a severe
decrease in white blood cells. Clients must have regular blood draws to monitor their
Absolute Neutrophil Count (ANC). This monitoring is mandatory to prevent life-threatening
infections.
3. The nurse observes a client with schizophrenia standing in the same position for hours,
resembling a statue. This behavior is documented as:
A. Waxy flexibility
B. Echolalia
C. Akathisia
D. Anhedonia
Answer: A
Rationale: Waxy flexibility is a condition where a person remains in a fixed position for
long periods. It is often seen in catatonic schizophrenia. The nurse should provide physical
care and nutrition to these immobile clients.
4. Which of the following is considered a negative symptom of schizophrenia?
A. Delusions
B. Flat affect
, C. Hallucinations
D. Disorganized speech
Answer: B
Rationale: Negative symptoms represent a loss of normal functions, such as emotional
expression. Flat affect involves a lack of visible emotion or facial expression. Positive
symptoms, by contrast, add abnormal behaviors like delusions and hallucinations.
5. A client taking Haloperidol develops high fever, muscle rigidity, and tachycardia. Which
condition should the nurse suspect?
A. Serotonin syndrome
B. Neuroleptic malignant syndrome (NMS)
C. Agranulocytosis
D. Tardive dyskinesia
Answer: B
Rationale: Neuroleptic malignant syndrome is a rare but life-threatening reaction to
antipsychotic drugs. It is characterized by hyperpyrexia, severe muscle rigidity, and
autonomic instability. This condition requires immediate medical intervention and
discontinuation of the medication.
