NUR253 Final Exam V1 | NUR 253 Mental
Health Nursing Exam Q&A | Galen College
of Nursing
1. A patient who recently started taking clozapine (Clozaril) reports a sore throat and fever.
What is the nurse’s priority action?
A. Administer an antipyretic as ordered.
B. Request a prescription for a STAT white blood cell count.
C. Advise the patient to increase fluid intake.
D. Document the findings as common side effects.
Answer: B
Rationale: Clozapine can cause agranulocytosis, which is a life-threatening decrease in
white blood cells. A sore throat and fever are early signs of infection that must be
investigated immediately. Obtaining a white blood cell count is the essential first step to
ensure patient safety.
2. Which statement by a patient indicates the ‘orientation phase’ of the nurse-patient
relationship?
A. ‘Can we set a time for our daily meetings?’
B. ‘I want to work on my coping skills today.’
C. ‘I am feeling much more confident about going home.’
,D. ‘I appreciate everything you did for me this week.’
Answer: A
Rationale: The orientation phase involves establishing the parameters of the relationship,
such as meeting times and goals. This stage focuses on building trust and defining the
contract between the nurse and the patient. Setting a schedule is a classic task of this initial
phase.
3. A nurse is caring for a patient with bipolar disorder experiencing acute mania. Which meal
choice is most appropriate?
A. A bowl of vegetable soup and a salad.
B. A steak and baked potato dinner.
C. A bowl of spaghetti with meat sauce.
D. A ham and cheese wrap and an apple.
Answer: D
Rationale: Patients in a manic state often have high energy levels and cannot sit still long
enough to eat a full meal. ‘Finger foods’ that are high in protein and calories allow the
patient to eat while moving. A wrap and an apple provide nutrition that can be consumed
on the go.
4. The nurse is assessing a patient for lithium toxicity. Which of the following findings should
the nurse report immediately?
A. Mild thirst and dry mouth.
, B. Occasional fine hand tremors.
C. Coarse hand tremors and ataxia.
D. Mild nausea after taking the medication.
Answer: C
Rationale: Coarse hand tremors and ataxia are signs of moderate to severe lithium toxicity.
Mild thirst and fine tremors are common side effects that usually do not require
discontinuation of the drug. The nurse must prioritize signs that indicate a dangerously
high blood level of lithium.
5. A patient is admitted after a suicide attempt. Which question is most important for the
nurse to ask during the initial assessment?
A. ‘Does your family know about your attempt?’
B. ‘Why did you try to hurt yourself?’
C. ‘How long have you been feeling this way?’
D. ‘Do you have a plan to harm yourself right now?’
Answer: D
Rationale: Assessing for immediate risk and the presence of a current plan is the highest
priority for safety. Open-ended questions are helpful, but direct questions about self-harm
are necessary to determine the level of precaution needed. This assessment guides the
immediate plan of care for the patient’s protection.
Health Nursing Exam Q&A | Galen College
of Nursing
1. A patient who recently started taking clozapine (Clozaril) reports a sore throat and fever.
What is the nurse’s priority action?
A. Administer an antipyretic as ordered.
B. Request a prescription for a STAT white blood cell count.
C. Advise the patient to increase fluid intake.
D. Document the findings as common side effects.
Answer: B
Rationale: Clozapine can cause agranulocytosis, which is a life-threatening decrease in
white blood cells. A sore throat and fever are early signs of infection that must be
investigated immediately. Obtaining a white blood cell count is the essential first step to
ensure patient safety.
2. Which statement by a patient indicates the ‘orientation phase’ of the nurse-patient
relationship?
A. ‘Can we set a time for our daily meetings?’
B. ‘I want to work on my coping skills today.’
C. ‘I am feeling much more confident about going home.’
,D. ‘I appreciate everything you did for me this week.’
Answer: A
Rationale: The orientation phase involves establishing the parameters of the relationship,
such as meeting times and goals. This stage focuses on building trust and defining the
contract between the nurse and the patient. Setting a schedule is a classic task of this initial
phase.
3. A nurse is caring for a patient with bipolar disorder experiencing acute mania. Which meal
choice is most appropriate?
A. A bowl of vegetable soup and a salad.
B. A steak and baked potato dinner.
C. A bowl of spaghetti with meat sauce.
D. A ham and cheese wrap and an apple.
Answer: D
Rationale: Patients in a manic state often have high energy levels and cannot sit still long
enough to eat a full meal. ‘Finger foods’ that are high in protein and calories allow the
patient to eat while moving. A wrap and an apple provide nutrition that can be consumed
on the go.
4. The nurse is assessing a patient for lithium toxicity. Which of the following findings should
the nurse report immediately?
A. Mild thirst and dry mouth.
, B. Occasional fine hand tremors.
C. Coarse hand tremors and ataxia.
D. Mild nausea after taking the medication.
Answer: C
Rationale: Coarse hand tremors and ataxia are signs of moderate to severe lithium toxicity.
Mild thirst and fine tremors are common side effects that usually do not require
discontinuation of the drug. The nurse must prioritize signs that indicate a dangerously
high blood level of lithium.
5. A patient is admitted after a suicide attempt. Which question is most important for the
nurse to ask during the initial assessment?
A. ‘Does your family know about your attempt?’
B. ‘Why did you try to hurt yourself?’
C. ‘How long have you been feeling this way?’
D. ‘Do you have a plan to harm yourself right now?’
Answer: D
Rationale: Assessing for immediate risk and the presence of a current plan is the highest
priority for safety. Open-ended questions are helpful, but direct questions about self-harm
are necessary to determine the level of precaution needed. This assessment guides the
immediate plan of care for the patient’s protection.
